4/9/2018 HOW TO REGULATE DIABETES MEDICATIONS. By Sarah Froemsdorf MSN, RNC, CDE, FNP DISCLOSURES NONE. Diagnosis

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1 HOW TO REGULATE DIABETES MEDICATIONS By Sarah Froemsdorf MSN, RNC, CDE, FNP DISCLOSURES NONE Diagnosis 1

2 NORMAL BODY The normal pancreas releases one unit of insulin every hour all day. The normal pancreas releases 5-7 units of insulin at meals. Impacted by weight and age. Age related changes. Increased glucose --- Reduction of insulin Research that changed history. Diabetes Control and Complications Trial (DCCT 1993) United Kingdom Prospective Diabetes Study (UKPDS 1998) Kummamoto Diabetes Study (2000) DIABETES CARE. 2

3 Diabetes medications: THEN Before 1993: 1ST Generation sulfonylureas beef/pork insulins, NPH, UL, Lente, and Reg (R) insulin. ============================== After 1993: 9 categories of oral antidiabetes medications. Human insulin analogs, PLUS. Diabetes medications: 1. 1st generation Sulfonylureas 2. 2nd generation sulfonylureas 3. Biguanides 4. Thiozolidindiones (TZD) 5, Meglitinides 6. Amino acid derivative 7. Alpha-glucosidase inhibiters. 8. DPP4 S 9. GLP-1 S 10. SGLT-2 S Where meds work. 3

4 First generation sulfonylureas Drug: Orinase, diabinese, dymelor, tolinase s/e: lots Not used anymore. 2nd generation sulfonylureas. Drugs: Glyburide (Micronase, diabeta, glynase), Glipizide(glucatrol) Glimepiride (amaryl) Dose: Glipizide is taken 30 min AC Glipizide start 5 mg bid, titrate up to 20 mg bid. Glimepiride is 4 or 8 mg daily in a.m. Action: Stimulates insulin production from the pancreas. Excretion: hepatic and renal. s/e: hypoglycemia & weight gain. Contains a sulfa base. BIGUANIDES Drug: Metformin (Glucophage) XR, ER, SA Dose: Titrate to max 2550 mg (2000 mg) a day with food. (weight neutral) Action: prevents glucose production from the liver. S/E: Upset stomach, diarrhea, bloating, metallic taste, Stimulates ovulation. Used in PCOS. Stop when having tests requiring dye injection. Excretion via kidneys. GFR < 60 = 500 mg bid GFR < 50 = 500 mg daily GFR < 30 or 40 = stop metformin 4

5 Meglitinides and amino acid derivatives. Drug: Repaglinide (Prandin) Dose: 0.5, 1 mg, 2mg ac tid ( max 16 mg/day) Excretion: renal Drug: Nateglinide (Starlix) Dose: 120 mg ac tid (max of 360 mg / day) Excretion: hepatic Action: stimulate insulin secretion from the pancreas S/E: hypoglycemia. Thiazolidinediones (TZD S) Drug: ACTOS (Pioglitazone) Dose: 15 mg, 30 mg, 45 mg daily. Excretion: liver. Action: works at the cellular level to prevent insulin resistance. S/E: H/A, fluid retention, weight gain, bone loss, ***Stimulates ovulation, risk of bladder cancer. ***Contraindicated in CHF or Bladder cancer. Alpha glucosidase inhibitors Drug: Precose (acarbose) 25 or 50 mg up to 100 mg/meal. Miglitol (glyset) 25/50/100 tid and titrate up. Action: slows digestion of food. Good with gastroparesis or dumping syndrome. Excretion: hepatic S/E: Causes lots of flatulence. *** Hypoglycemia will not respond to traditional treatment. *** Must use oral gel to treat hypoglycemia. 5

6 Dipeptidyl peptidase 4 inhibitors (DPP-4 S) Drugs: oral agents. Allogliptin (nesina), 6.25, 12.5, 25 mg daily Linagliptin (tradjenta), 5 md dly Sitagliptin (Januvia), 25, 50, 100 mg dly Saxagliptin (onglyza) 2.5 and 5 mg daily Action: pancreas, liver, postprandial. Excretion: renal. S/E: URI, H/A, pancreatitis, renal, joint pain. Januvia: Stevens-Johnson s syndrome. GLUCAGON LIKE PEPTIDE 1 RECEPTOR AGONISTS (GLP-1 S). Drugs: injections Albiglutide (Tanzeum), 30 or 50 mg weekly Dulaglutide (Trulicity), 0.75, 1.0 mg/0.05 ml daily **** Exenatide (Byetta), 5 or 10 mcg bid Exenatide ER (Bydureon) 2 mg weekly. Liraglutide (Victoza) 0.6, mg/day Action: pancreas, liver, post-prandial. Excretion: renal. Victoza is renal and hepatic. S/E: Nausea, Pancreatitis, Papillary thyroid cancer. Sodium-glucose cotransporter 2 inhibitor (SGLT2 S). Drugs: Canagliflozin (Invokana), 100mg, 300 mg. Dapagliflozin (Farxiga), 5 mg, 10 mg. Empagliflozin (Jardiance). 10 mg, 25 mg. Action: renal excretion of glucose. S/E: UTI, yeast infection, DKA, hypotension, acute renal injury. 6

7 Combination drugs Contains 2 of the current oral agents we currently have on the market. -These are more expensive. -? Synergistic effect. -Can be taken separately which may lower the cost. Example: meta-glip: metformin + glipizide. Start with metformin 500 mg bid. Intensify to 1000 mg bid. B fast lunch supper HS. Add: glipizide, TZD, DPP4, SGLT2 GLIPIZIDE GLIPIZIDE METFORMIN DPP4/SGLT2 B fast lunch supper HS 7

8 Medications that alter glcuose Raise the glucose Atenolol, amlodipine Caffeine Lasix, HCTZ, Thiazides Steroids, prednisone Estrogen, thyroid meds Niacin Tobacco Seizure or TB medications. Lower the glucose Alcohol Allopurinol Testosterone Coumadin or aspirin Tagamet MAOI S, potassium salts. Probenecid, propranolol Sulfa drugs/ Bactrim. Supplements. Supplements are medicine Supplements have side effects that could be detrimental to health Encourage patients to bring all supplements to visits Do not take supplements unless recommended by their provider. HOW TO REGULATE INSULIN BY SARAH FROEMSDORF MSN, RNC, FNP, CDE 8

9 Normal insulin glucose excursion If your body can t MAKE IT. You just have to TAKE IT. Replaced insulin excursion 9

10 Insulin analogs Basal: Lantus (glargine) Levemir (detemir) is a slow release used to suppress excessive glucose production by the liver. < 40 units daily 12 hours. > 40 units daily 24 hours. Bolus: Novalog (aspart) is a fast release. Novalog is for food. Hormones Glucose rises overnight because of the rise in hormones. Growth hormone. Epinephrine Norepinephrine Cortisol. Normally the FBS is the highest glucose of the day. Step Get the glucose in control overnight. start low doses of lantus at bedtime. Lantus is only changed every 4-7 days. NOT daily. 10

11 LANTUS SET RIGHT? So how do we know if the Lantus is set right? Remember, Sugar rises overnight. Lantus is basal insulin Lantus holds the glucose steady overnight. Lantus is for when you are not eating. SET RIGHT IF. 11

12 TOO MUCH NOT ENOUGH Step 2. Bedtime glucose: high. If they are going to bed in the s, they are going to bed too high. If the glipizide is maxed, start novalog at supper. Novalog works at HS novalog: starts 15 minutes peaks 1 hour last 4 hours. 12

13 Continue oral agents. Leave glipizide at breakfast and lunch, no glipizide with novalog at supper. Leave metformin at breakfast and supper Leave any other background oral agent. SUPPER NOVALOG Step 3 If glucose is NOT coming down with glipizide, stop the glipizide and start novalog at every meal. Leave the metformin, pioglitazone and/or saxagliptin if they are on these. 13

14 BASAL / BOLUS Review Step 4. 14

15 Special Situation # 1. NOVALOG ONLY. 1. Pigging out! Ate a whole pie: glucose 400 What to do???? What to do? Take additional insulin to cover the high glucose and drink plenty of water. SHOULD HAVE taken the insulin with the pie to prevent the high glucose. Special Situation # 2 2. Low sugar. glucose 50 Do you or do you not take the insulin? 15

16 Special situation rebound to 250 hepatic glucose production and people over treat. Special Situation Low glucose. Yes, take the insulin but take less and take it immediately after treating and eating. Special Situation # 3 3. More activity than usual. Work low of 50 rebound high 250. How do we prevent this? 16

17 Special Situations. More activity than usual If you can anticipate the activity, cut the novalog or glipizide by half. If you have already taken your novalog, carry fast acting glucose and a snack with you. Goal Hgb A1c: 6.5-8% Depends on 1. Risk of severe hypoglycemia. 2. Comorbidities and life expectancy. 3. Disease duration and diabetes complications. 4. Cognition. 5. Resources and social support. Cases 17

18 High FBS Date B fast Lunch Supper HS Comments 10/ / / Yard work 2 hours. 10/ / Low FBS Date B fast Lunch Supper HS Comments 2/ / Awoke in middle of night at 54 2/ / / High HS Date B fast Lunch Supper HS Comments 5/ / / Large supper 5/ /

19 High supper and bedtime Date B fast Lunch Supper HS Comments 7/ / / / / Highs and Lows. Date Bfast Lunch Supper HS Comments 1/ / / Low of 57 overnight. 1/ / / / Sick days Date B fast Lunch Supper HS Comments 11/ Lantus 25 11/ / / Lantus 11/ /water 11/ Getting sick 11/ sick 11/ Extra novalog 11/ Extra novalog 11/ Extra novalog 19

20 ? Date B fast Lunch Supper Bed Comments 11/ / / / / / / / Advanced education. RULE OF 1800: (1700) Also called the insulin sensitivity or correction factor divided by the TOTAL insulin per day (60) divided by 60 = 30 So one unit of insulin moves the glucose approximately 30 points. Example. Glucose 300 Goal Difference 150. If one unit moves the glucose 30 points, This person needs 5 extra units of novalog to bring the glucose down 150 mg/dl. 20

21 example Glucose 50 Goal 100 Difference -50 So we subtract 2 units to get the glucose back to normal. Advanced eduation: RULE OF 500: Carb ratio (CHO ratio) 500 divided by 60 = 8 So one unit of novalog is needed for every 8 grams of carbohydrates eaten. example 1/8 slice of pecan pie = 75 grams of cho s. 75 divided by 8 = 9 units of extra novalog is needed to cover the 75 grams of carbs in 1/8 slice of pecan pie. 21

22 THE END OF THE BEGINNING WITH DIABETES. 22