Rebecca Newberry APRN MS CDE

Transcription

1 Current Diabetes Medications Nursing Implications and Applications Rebecca Newberry APRN MS CDE Methodist Center for Diabetes and Nutritional Health Disclosures Objectives Speakers Bureaus/Consulting Board Astrazeneca, Boehringer-Ingelheim, Janssen, Novo Nordisk, Sanofi, Valeritas Explain diabetes medications to patients Apply medication information to various clinical settings, including surgical setting Identify various technologies used in diabetes management Physiology and Pathophysiology Basic Diabetes education process/program Use appropriate language Basis for understanding diabetes management Lifestyle - diet, activity, monitoring Medication adherence Follow up 1

2 Treating Physiology Medication Choices Addressing the various pathologies of diabetes leads to Combination Therapy Continue metformin when possible Do not mix drugs of same class/similar action Watch for side effects Be aware of cost issues Fab Four Metformin, Actos, GLP1, SGLT2 Patient centered approach should be used to guide choice of pharmaceutical agents Efficacy Hypoglycemia risk History of CV disease Impact on weight Potential side effects Renal effects Delivery method Cost Patient preferences Metformin Metformin Action Decreases hepatic glucose output Use First line med at diagnosis, continue Benefits No hypo or weight gain, approved for peds, 10 yrs+ Cost generic inexpensive. XR may be more Side effects nausea, bloating, gas, diarrhea, B12 deficiency with long term use To minimize GI effects, use XR, take with meals Considerations Obtain GFR before starting If <30, do not use If 30-45, use half maximum dose, evaluate risk/benefit For Dye study Stop on day of study, restart in 48 hours if renal function stable Risk for lactic acidosis Sulfonylureas Meglitinides Action Stimulates sustained insulin release from pancreas Use After metformin Benefits effective, available Cost - Low cost generic Side effects hypoglycemia and weight gain Considerations Must be taken with meal, timing very important, QD or BID Action Stimulates rapid insulin release from pancreas Use Before meals to affect post meal blood sugars Benefits Short duration of action, less hypoglycemia than long acting sfu Cost generic/branded Side effects hypoglycemia, weight gain 2

3 Thiazolidinediones (TZD) TZDs Action- Increases insulin sensitivity Use Black Box warning may cause or worsen CHF. Monitor for edema and weight gain. Increased risk for peripheral fractures, bladder cancer Benefits- Only med to work at receptor site Cost generic/low cost Side effects weight gain, edema Considerations takes 3 months for full effect, long duration of action when stopped GLP-1 Receptor Agonists GLP-1 Actions Increases insulin release with food, slows gastric emptying, promotes satiety, suppresses glucagon Use Black box warning Thyroid C-cell tumor Second line choice Benefits Decreased hypoglycemia, may help with weight loss, Victoza found to decrease risk of CV death, HA, stroke Cost Brand name only Side effects nausea, vomiting, weight loss, injection site reactions. Report signs of acute pancreatitis: severe abdominal pain, vomiting. Stop med Considerations Daily or weekly formulations. May decrease need for insulin, sulfonylureas DPP-IV Inhibitors DPP-IVs Actions- Prolongs action of gut hormones, increases insulin secretion, delays gastric emptying Uses Second line after metformin. Benefits No hypoglycemia or weight gain, few side effects Cost Branded only Side effects headache, flu-like symptoms Considerations- may decrease dose if renal function decreased (not Tradjenta). Can cause joint pain, report signs of pancreatitis. Some may increase risk of heart failure. 3

4 SGLT2 Inhibitors SGLT2s Action Decrease glucose reabsorption in the kidney Uses Second line, may be limitations to use if GFR decreased Benefits no hypoglycemia, may help with weight loss Cost Branded only Side Effects Genital mycotic infection, UTI, increased urination, hypotension, ketoacidosis Considerations Decrease risk of death from CV disease. Invokana may increase risk of amputation in high risk patients, don t use Farxiga in patients with bladder cancer. Need to increase fluid intake. Practice good genital hygiene Alpha Glucosidase Inhibitors Amylin Analog- Symlin Action Delays carbohydrate absorption Use Not commonly used Benefits Oral med, works with diet Cost Generic Side effects GI upset, gas, abdominal cramping Considerations Start low dose. Caution with liver/kidney problems. Hypoglycemia risk Actions Suppresses glucagon, slows gastric emptying, promotes satiety Use Type 1 or Type 2 diabetes, on insulin. Black box warning severe hypoglycemic risk, decrease insulin dose when starting Benefits Decreases insulin requirments, may help with weight loss Cost Branded only Symlin Dopamine Receptor Agonist Side Effects nausea, weight loss Considerations needs to be injected with insulin before meals Action Resets circadian rhythm, helping to decrease insulin resistance Use Not first or second line Benefits May decrease other medication doses Cost Branded (Quick Release bromocriptine) Side Effects Nausea, headache, fatigue, hypotension, dizziness 4

5 Cycloset Bile Acid Sequestrants Considerations Take 6 tabs within 2 hour of wakening Action Decreases cholesterol and blood glucose Use Not first or second line Benefits Dual action, lowers LDL 15-30% Cost Brand name Side effects GI issues, diarrhea. Can decrease absorption of certain meds, soluble vitamins Welchol Insulin Considerations Do not use if history of bowel obstruction, triglycerides over 500, or pancreatitis. Action Replaces insulin to take glucose into cell for metabolism Uses All types of diabetes, used first or second line. Usually effective in bringing blood sugars down. Benefits Works quickly, dosing can be individualized, many choices of formulations Insulin Technology in Diabetes Management Cost Are generics and biosimilars, but still not inexpensive. Many new formulations are Brand name. Side effects Hypoglycemia, weight gain Considerations Education is vital for patients to use appropriately. Injection technique, timing of dosing, etc. Need to be aware of different formulations, onset of action, duration. Meters for glucose testing Continuous Sensors Insulin Delivery Systems 5

6 Technology in Diabetes Management Technology in Diabetes Management Rapid evolution in recent years Patient driven Issues related to security, safety, privacy Clinicians need to be knowledgeable Systems set up to use newest technology Continuous Glucose Sensors Measures intracellular fluid glucose levels, correlates to blood glucose Consists of sensor, transmitter, display Sensors changed every 7-10 days Dexcom, Medtronic Enlite, Freestyle Flash Insulin Delivery Systems V-Go mechanical delivery device, takes the place of insulin injections. Device filled with insulin, changed every 24 hours. Set basal dosing, not able to be changed. Bolus dosing done per clicks on the device 6

7 Insulin Delivery Systems Insulin Pumps Omni Pod Tubeless, insulin delivered by pod attached to body, controlled by separate PDM (Personal Data Manager). Tandem uses tube, touchscreen display and adjustment. Updates done by computer. Medtronic 670-G system Pump and Sensor are connected, can be used in Automatic mode to deliver basal insulin automatically, based on blood sugar reading. Still need to bolus mealtime insulin. Use of Pump in Hospital Policies vary by institution Need to assure patient has ability to handle Continuous insulin dosing, using pump If possible, keep pump on patient May need to stop for safety Staff need to understand basic pump functions basal rates, bolus ratios etc 7

8 Peri-Operative Considerations Guidelines Goals Reduce overall morbidity/mortality Avoid severe hyper or hypo glycemia Maintain electrolyte/fluid balance Prevent ketoacidosis Vary per institution Surgery Research and Practice 2015: Guidelines for Perioperative Management of the Diabetic Patient Individualized based on medical history, glycemic control, procedure planned Pre Op Pre Op Oral meds stop day of surgery, resume when eating/drinking normally Injectables stop day of surgery, resume when appropriate Basal (Long acting) insulin Lantus, Levemir, Basaglar, Tresiba, Toujeo, NPH Partial dose day before/day of surgery, Bolus (rapid or mealtime) insulin Novolog, Humalog, Apidra, Regular Stop day of surgery Use as correction (sliding scale) when BS tested Resume appropriate dose when eating normally Cancelling Surgery Intra Op No evidence based guideline No surgery on patients in compromised metabolic state (DKA) mg/dl Variables patient, procedure, surgeon BG range lowest risk of adverse outcomes Monitor frequently IV insulin or Insulin infusion IV insulin active for 1 hour, serum half life of 7 minutes 8

9 Post Op Nursing Approach to Patient with Diabetes Variables affect glycemic control Physiologic stress, NPO status Diligent BG testing Use correction (sliding scale) based on BS results Resume basal insulin asap Resume orals/injectables as tolerated Non judgmental approach NOT a lifestyle disease understand physiology Assess issues regarding management Barriers to non adherence Treat with compassion Educate Use resources NEVER give up on a patient Nursing Approach to Patient with Diabetes References Educate yourself Diabetes field is rapidly changing Be open to new information Patient often great source of information Diabetes Resources ADA and ADA Pro Diabetes in Control Methodist Center for Diabetes and Nutritional Health 8111 Dodge Street, Suite Standards Of Medical Care in Diabetes. Diabetes Care 41:Supplement 1. American Diabetes Association, January Guideline for Perioperative Management of the Diabetic Patient. Sudhakaran, S, et al, Surgery Research and Practice 2015:294063, May 19, Questions? 9