Therapeutic care of diabetes ch 28

Question 1

3. Compare and contrast types of insulin, including onset, peak, and duration of action.

Answer 1

Bolus insulins

Basal insulins

Question 2

BOLUS insulins

Rapid-acting analogues aspart (Novorapid), glulisine (Apidra), lispro (Humalog)

Short-acting Humulin R/Novolin ge Toronto

Answer 2

• Intermediate-acting Humulin N/NPH
• Onset: 10 - 15 mins
• Peak: 1-2 Hours
• Duration: 3–5 hours
• Timing of injection: Given with one or more meals per day. To be
  given 0–15 minutes before or after meals.
• Short-acting Humulin R/Novolin ge Toronto
• Onset: 30 mins
• Peak: 2 - 3 hours
• Duration: 6.5 hours
• Timing of injection: Given with one or more meals per day. Should be injected 30–45 minutes before the start of the meal.

Question 3

BASAL insulins

Intermediate-acting Humulin N/NPH
Long-acting analogues Glargine (Lantus) Detemir (Levemir)

Answer 3

• Intermediate-acting Humulin N/NPH:
• Onset: 1 - 3 hours
• Peak: 1 - 2 hours
• Duration: up to 18 hours
• Timing: Often started once daily at bedtime. May be given once or twice daily. Not given at any time specific to meals.
• Long-acting analogues Glargine (Lantus) Detemir (Levemir)
• Onset: 90 mins
• Peak: N/A
• Duration: Lantus (up to 24 hr) and Levemir (16 to 24 hours)
• Timing: Lantus (Often started once daily at bedtime. ) Levemir (may be given once or twice daily. Not given at any time specific to meals.)

Question 4

4. Describe the signs and symptoms of insulin overdose and underdose.

Answer 4

Insulin overdose (Hypoglycemia):
- Low blood sugar less than 4
- Symptoms: shakiness, sweating, hunger, dizziness.
- Severe symptoms: Seizures, unconsciousness
- Treatment: Glucagon or IV glucose, If conscious dextrose tablets

• Insulin underdose:
• High glucose: above 7 - 12
• Symptoms: Thirst, frequent urination, fatigue
• Nausea, vomiting, fruity breath.
• IV fluids, insulin, electrolyte correction

Summary:
Insulin overdose causes hypoglycemia, with symptoms like shakiness, sweating, and confusion, progressing to seizures or coma if untreated.

Insulin underdose causes hyperglycemia, with symptoms like thirst, frequent urination, and fatigue, potentially leading to DKA if severe.

Both conditions require prompt recognition and treatment to prevent complications.

Question 5

5. Describe and compare the Somogyi phenomenon and morning hyperglycemia (Dawn) along with preventative measures for both.

Answer 5

• Somogyu Phenomenon: This is a rapid decrease in blood glucose, usually during the night, that stimulates the release of hormones that elevate blood glucose (epi-nephrine, cortisol, and glucagon), resulting in an elevated morning blood glucose level. Additional insulin above the client’s normal dose may produce rapid rebound hypoglycemia.

Preventative Measures:

Adjust insulin or medication doses (reduce evening doses).

Monitor blood sugar at bedtime and during the night (e.g., 2–3 AM).

Eat a bedtime snack to prevent nighttime hypoglycemia.

Use a continuous glucose monitor (CGM) to detect patterns.

• Dawn phenomenon: Between 4:00 a.m. and 8:00 a.m. the body naturally produces cortisol and growth hormone, both of which cause the blood glucose level to rise. Adjusting the insulin dose so that peak action occurs in the morning can help prevent hyperglycemicmia caused by the dawn phenomenon.

Preventative Measures:

Adjust insulin timing or type (e.g., use long-acting insulin or an insulin pump).

Increase evening insulin dose (if prescribed by a healthcare provider).

Eat a light, low-carb breakfast to avoid further spikes.

Exercise in the evening to improve insulin sensitivity.

Question 6

Key difference between Somogyri Phenomenon and Dawn phenomenon

Answer 6

Summary:
Somogyi phenomenon is caused by nighttime hypoglycemia and rebound hyperglycemia, while Dawn phenomenon is caused by natural hormonal changes.

Prevention: For Somogyi, focus on avoiding nighttime lows; for Dawn, adjust insulin or medication timing to counteract morning hormone effects.

Diagnosis: Monitor blood sugar at night (2–3 AM) to differentiate between the two.

Question 7

6. Compare and contrast the pharmacotherapy of the different types of diabetes.

Answer 7

• Type 1 Diabetes
  Primary Treatment:

Insulin therapy is mandatory (basal and bolus insulin).

Non-Insulin Options:

Limited to adjunct therapies like pramlintide or GLP-1 receptor agonists in some cases.

Focus:

Replacing insulin due to absolute insulin deficiency.

• Type 2 Diabetes
  First-Line Therapy:

Metformin (improves insulin sensitivity and reduces hepatic glucose production).

Second-Line Therapy:

Add GLP-1 receptor agonists (e.g., semaglutide) or SGLT2 inhibitors (e.g., empagliflozin).

Other options: DPP-4 inhibitors, sulfonylureas, thiazolidinediones, or meglitinides.

Insulin Therapy:

Added if oral or injectable agents fail to control blood sugar.

Focus:

Improving insulin sensitivity and reducing glucose production.

• Gestational Diabetes
  First-Line Therapy:

Lifestyle changes (diet and exercise).

Pharmacologic Therapy:

Insulin is the preferred treatment if lifestyle changes are insufficient.

Metformin or glyburide may be used in some cases.

Focus:

Managing glucose levels during pregnancy to protect maternal and fetal health.

Question 8

7. For each of the following drugs, the drug class suphonylureas,metformin, glyburide and sitagliptin explain its mechanism of action, therapeutic effects, and important adverse effects.

Answer 8

• Sulphonylureas
• Action: Stimulates insulin release; decreases insulin resistance
• Therapeutic effect: Lowers fasting/postprandial glucose.
• Adverse effects: Hypoglycemia, weight gain, drug interactions.
• Metformin
• Action: Decreases hepatic glucose production, improves insulin sensitivity.
• Therapeutic effect: Lowers glucose, weight-neutral, reduces CV risk.
• Adverse effect: GI issues, B12 deficiency, lactic acidosis.
• glyburide
• Action: Stimulates insulin secretion.
• Therapeutic effect: Lowers fasting/postprandial glucose.
• Adverse effect: Lowers fasting/postprandial glucose.
• Sitagliptin
• Action: Increases incretin levels, enhances insulin secretion, suppresses glucagon.
• Therapeutic effects: lowers postprandial glucose, weight-neutral.
• Adverse effects: nasopharyngitis, headache, pancreatitis (rare).

Question 9

Client education regarding Insulin administration. (Discussed in PP and listed in text)

Answer 9

Assessment
Obtain complete health history including allergies and drug history
Assess vital signs including signs of infection. Why?
Assess blood glucose levels
Assess ability and willingness of patient to have next meal. Why?
Assess subcutaneous areas for potential injection site