Pharmacology. Kacy Aderhold, MSN, APRN-CNS, CMSRN

Transcription

1 Pharmacology Kacy Aderhold, MSN, APRN-CNS, CMSRN

2 Biguanides Decreases hepatic glucose production and improves insulin sensitivity (increases number of insulin receptors) Common Adverse Reaction: diarrhea Should be taken with food Can take 7 to 10 days to reach therapeutic levels Black Box Warning: lactic acidosis can occur Use cautiously with liver disease, IV dye studies, renal insufficiency Hold the day of procedures that involve IV dyes & 48 hours following Examples: metformin (Glucophage) metformin XR (Glucophage XR, Glumetza, Fortamet)

3 Thiazolidinediones (TZDs) Increases insulin sensitivity (improves receptivity of receptors) Black Box Warning: TZDs cause or exacerbate CHF, Avandia risk of MI Increase risk of peripheral fractures Onset of action = 3 weeks May take up to 12 weeks for maximum effect Examples: pioglitazone (Actos) Rosiglitazone (Avandia)

4 Sulfonylureas Stimulate beta cells of pancreas to release more insulin Hypoglycemia can occur Patients should not skip meals Examples: glyburide (Micronase, Glynase, DiaBeta)- daily with first meal glimipiride (Amaryl)-daily with first meal glipizide (Glucotrol)- daily or BID with food

5 Alpha-Glucosidase Inhibitors Slows breakdown of carbs in intestine Taken TID, at start of each meal SE: flatulence, bloating, abdominal pain May subside over time Examples: acarbose (Precose) miglitol (Glyset)

6 DPP-4 Inhibitors Inhibits dipeptidyl peptidase-4, slowing incretin metabolism, increasing insulin synthesis/release, decreasing glucagon levels Incretin enhancers, slows gastric emptying Given daily Examples: sitagliptin (Januvia) saxagliptin (Onglyza) linagliptin (Tradjenta) alogliptin (Nesina)

7 Meglitinides Stimulates pancreatic islet beta cell insulin release rapid insulin burst Hypoglycemia can occur Must be taken before meals Examples: repaglinide (Prandin) nateglinide (Starlix)

8 SGLT2 Inhibitors Inhibits sodium-glucose cotransporter 2 (SGLT2) in the proximal nephron, reducing glucose reabsorption and increasing urinary glucose excretion Taken daily before first meal Contraindicated in renal impairment CrCl<45 SE: UTI, yeast infection Example canagliflozin (Invokana) dapagliflozin (Farxiga) empagliflozin (Jardiance)

9 Best Practice Oral Agents (OAs) OAs are inappropriate in most hospitalized patients Continued use may be appropriate in selected stable patients who consume meals at regular intervals Injectable noninsulin therapies such as exenatide and pramlintide have limitations similar to OAs ( Moghissi et al., 2009) Consider precautions for each component when using combination oral agents

10 Injectable Medications Non-Insulin Incretin Mimetics or GLP-1 Receptor Agonists Amylin Mimetics

11 Incretin Mimetics GLP-1 Receptor Agonists Activates glucagon-like-peptide-1 receptors, increases insulin secretion, decreases glucagon secretion, and slows gastric emptying (incretin mimetic), increasing satiety Injection SE: nausea, indigestion, weight loss Examples: exenatide (Byetta)- Taken bid with am and pm meal exenatide (Bydureon)- taken weekly liraglutide (Victoza)- daily

12 Amylin Mimetic Activates insulin receptors, increases glucose secretion, slows gastric emptying, increase satiety Injection Taken before meals SE: nausea, weight loss Example pramlintide (Symlin)

13 Other: Bile acid sequestrant, colesevelam (Welchol) is a cholesterol lowering medication that also reduces blood glucose levels in patients with diabetes. Binds bile acid in intestinal tract, increasing hepatic bile acid production Bromocriptine (Cycloset) is a dopamine 2 agonist that activates neurotransmitters centrally, decreasing hyperglycemia without increasing insulin sensitivity Afrezza is a rapid-acting inhaled insulin that improves glycemic control in adults with diabetes mellitus, administered at the beginning of each meal.

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15 Insulin

16 Types of Insulin Basal Insulin controls blood glucose in the fasting state glargine (Lantus) detemir (Levemir) NPH (Humulin N or Novolin N) (Intermediate Acting) Prandial or Nutritional Insulin blunts the rise in blood glucose following nutritional intake Short Acting Regular (R) (Humulin R or Novolin R) Rapid Acting lispro (Humalog) glulisine (Apidra) aspart (NovoLog) Correctional Insulin corrects hyperglycemia due to mismatch of nutritional intake and/or illness related factors and scheduled insulin administration Should be same as prandial insulin

17 The Discovery of Insulin Diabetes Video

18 Basal Insulin The pancreas secretes a small amount of insulin into the bloodstream every few minutes to match the liver s secretion of glucose. This allows a steady supply of glucose into the cells. Suppresses glucose production by the liver between meals and overnight % of daily insulin needs (TDD total daily dose) targets fasting BG Basal insulin available: detemir (Levemir) glargine (Lantus) NPH (Novolin N, Humulin N)

19 Basal Insulin: Pharmacokinetics Lantus (Glargine) Levemir (Detemir) NPH (Humulin N or Novolin N) Action Long acting Long acting Intermediate Onset 1 hour 1 hour 1-2 hours Peak Relatively peakless Relatively peakless 4-14 hours Duration hours* 6-23 hours* hours Color Clear Clear Cloudy Dosing 1-2 times/day 1-2 times/day 1-3 times/day *Dose dependent (Epocrates, 2015)

20 INSULIN EFFECT Glargine/Detemir B L S HS B Time

21 Bolus Insulin Provides a fast/rapid response to elevations in BG levels. Nutritional/prandial insulin- also referred to as Y covers carbohydrates intake (food, liquids, IVs,TPN,TF), limits hyperglycemia after intake. Correctional insulin- also referred to as X decreases elevations in BG, corrects for hyperglycemia % of daily insulin needs (TDD) targets post-prandial BG levels Bolus insulin available: aspart (NovoLog) lispro (Humalog) glulisine (Apidra) regular (Humulin R, Novolin R)

22 Nutritional and Correctional Insulin: Pharmacokinetics Regular (Humulin R or Novolin R) Humalog (Lispro) Novolog (Aspart) Apridra (Glulisine) Action Fast acting Rapid acting Rapid acting Rapid acting Onset minutes 5-15 minutes minutes 5-15 minutes Peak 2-4 hours minutes 1-3 hours 55 minutes Duration 5-6 hours 3-4 hours 3-5 hours 3-4 hours Color Clear Clear Clear Clear Dosing minutes before a meal Right before or immediately after a meal, acts as basal insulin when used in an insulin pump with frequent delivery (Epocrates, 2015)

23 Bolus Insulin

24 INSULIN EFFECT Basal/Bolus Insulin Regimen Morning Afternoon Evening Night RAA* RAA* RAA* Glargine/Detemir B L S HS B MEALS RAA* = Rapid Acting Analog (Lispro/Aspart)

25 INSULIN EFFECT Natural Insulin Secretion Morning Afternoon Evening Body s post prandial insulin secretion in response to carb intake Night Body s basal insulin secretion B L S HS B MEALS

26 Insulin Mixtures Contain a pre-mixed combination of intermediate acting basal insulin and short/rapid bolus insulin, stated as %/% Have double peaks of action Types: Humulin 70/30, 50/50 and Novolin 70/30 contain NPH and regular insulin in stated percentages. Should be given minutes before meal Humalog mix 75/25, 50/50 and NovoLog mix 70/30 contain a long and rapid insulin in stated percentages. May be given right before meal to immediately after meal

27 Insulin Mixtures Humulin 70/30, 50/50 or Novolin 70/30 Novolog mix 70/30 Humalog mix 75/25, 50/50 B L S BT B L S BT Onset: minutes Peak: 2 to 12 hours (double peak) Lasts: hours Onset: 5-15 minutes Peak: 1-6 hours (double peak) Lasts: hours

28 Sliding Scale Insulin Prolonged Sliding Scale Insulin (SSI) as the sole regimen is ineffective in the majority of patients. SSI increases risk of both hyperglycemia and hypoglycemia. SSI is associated with adverse outcomes in general surgery patients with T2DM. SSI is potentially dangerous in T1DM. Corrective Insulin or the use of additional short or rapid acting insulin in conjunction with scheduled insulin doses to treat BG levels above desired targets, is preferred. (ADA, 2015)

29 Timing of Insulin Rapid acting insulin like Novolog may be given right before meal to immediately after meal Insulin doses given late can cause the next FSBS reading to be high since the insulin did not have enough time to fully work before we are taking the FSBS again FSBS should be taken 30 minutes or less before patient eats FSBS taken early can result in high FSBS readings due to the insulin not having time to complete duration before FSBS taken

30 Insulin Stacking Insulin stacking occurs when short or rapid acting S.Q. insulin doses are given too close together. Consider: Rapid insulin SQ should not be dosed any closer than 3 hours apart. Consider: Regular insulin SQ should not be dosed any sooner than 4 hours apart.

31 Insulin Alert Insulin is a high-alert, high-risk drug. Verify patient s BG before calculation of dose is completed. Verify dose calculation with another RN, LPN or clinical pharmacist. To prevent hypoglycemia from an insulin overdose, never give an IV insulin bolus by increasing the infusion rate temporarily via the infusion pump. Don t confuse NovoLog.. Novolin Humalog.. Humulin Novolin 70/30. NovoLog mix 70/30 Humulin 50/50.Humalog mix 50/50 INTEGRIS Health's policy on Insulin Administration

32 To Hold or Not to Hold? Oral Agents: What to do: Secretagogues Sulfunylureas, Prandin, Starlix Hold if not tolerating meals Metformin Hold if dehydrated, N&V, compromised renal or cardiac status, dye study, sepsis, any serious illness, immediate post-op Thiazolidinediones Insulin: May be given unless patient is unable to swallow or strict NPO What to do: Basal Insulin Glargine (Lantus), Detemir (Levemir) Do not HOLD NPO, patient should always have full dose without regard to food intake Basal Insulin - NPH Do not HOLD If NPO, patient will need ½ to 2/3 of their usual dose Bolus Insulin Regular, lispro(humalog), aspart(novalog), apidra IF NPO, hold meal doses and give only correction doses for hyperglycemia

33 Insulin Infusion Insulin infusions are a physician s order. There are several insulin infusions that may be ordered at INTEGRIS Health: Intensive Insulin Infusion, Maintenance Insulin Infusion, or as part of the DKA protocol (low-dose insulin infusion). Some indications for insulin infusion include: Critical Care Illness MI Carcinogenic Shock Perioperative care Surgical illness Corticosteroid therapy

34 Transitioning from Insulin Infusion to Subcutaneous Insulin Why? Volume resuscitated Pressor support discontinued Ready to resume eating How? Initiate subcutaneous insulin injections Give a dose of subcutaneous basal insulin 2 hours before discontinuing insulin infusion to prevent hyperglycemia

35 Insulin Pen Use in the Hospital Benefits: Decrease nursing time needed to prepare an insulin injection Decrease dosing errors Decrease accidental needle sticks Alerts: DO NOT share pens with more than one patient. Studies have shown that biological contamination of insulin occurred in up to half of all insulin pen cartridges that were reused with multiple patients. DO NOT use pen cartridges as a multi-dose vial. Insulin should not be withdrawn from the pen with a syringe- this will result in inaccurate measurement of future doses. How to Use Insulin Pen Video Insulin Pen Safety Video Insulin Pen Instructions

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37 Insulin Multi-dose Vial in Omnicell What is the process? Levemir, Aspart, and Regular insulin will be kept in the Omnicell. 1. Bring alcohol swabs and a syringe with you to the Omnicell. 2. Select your patient and the correct insulin from the Omnicell screen. 3. Enter the amount of units you are withdrawing from the vial as quantity. So, if you are giving an 8 unit dose, remove quantity of When the drawer opens, swab the insulin vial with alcohol, draw up the correct dose, replace the insulin vial in the drawer, select a barcode from the pocket, attach barcode to your syringe, shut the drawer, and log out.

38 How to Label the Insulin Syringe The Omnicell will contain barcodes to attach to the insulin syringe. Call your satellite pharmacist if you ever run out of labels. Attach the barcode to the syringe lengthwise so the barcode can be scanned. Do not cover the graduations on the syringe. The dose needs to be readable at all times. Do not wrap the label around the syringe. This will make it impossible to scan the barcode.

39 Remember! When giving an insulin injection using a syringe, pinch the skin using your thumb and index finger. Insert the needle quickly and firmly at a 90 angle.

40 Insulin Expiration Date Insulin can be stored at room temperature up to 28 days after opening. Pharmacy will label all vials stored in the Omnicell with the proper expiration date.

41 Insulin Pumps Consists of a pump, reservoir, and infusion set that delivers insulin through plastic tubing subcutaneously Allows flexibility in lifestyle and better glucose control Mimics normal functioning pancreas Patients may self-manage in the hospital if mentally and physically capable (physician s order) Nursing must document basal and bolus doses Before pump is removed, ensure subq insulin is initiated DKA can develop within 4-6 hours without insulin Insulin Pump sign should be hung in patient s room INTEGRIS Health's Insulin Pump Policy We must check FSBS with our glucometers!

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43 High Potency Insulin U-500 Usually insulin is 100 units/ml, U-500 is 500 units/ml (very concentrated)=u-500 insulin is 5 times as strong as regular insulin Used for treatment of patients with high daily insulin requirements Regular Insulin ONLY Requires special dosing calculation Given twice - three times daily before meals U-500 Policy U-300 Insulin glargine (Toujeo) Concentrated Doses preadjusted

44 Survival Skills Discharge Education Provider who will manage DM after discharge Assess need for HH or outpatient DM education Diagnosis SMBG & home goals Information on consistent eating patterns When & how to take BG lowering medications Sick day management Proper use & disposal of needles & syringes (ADA, 2015)

45 Patient Teaching-Insulin Administration Start patient teaching as soon as you know patient will go home on insulin. Have patient demonstrate! Discuss dosage, timing, and peaks of insulin they use Discuss site selection & rotation Safe injection practices!

46 Patient Teaching- Insulin Administration Includes: site selection, drawing insulin from a vial, mixing insulin, using insulin pens, and throwing away supplies

47 Safe Injection Practices

48 One Pen, One Person

49 References American Diabetes Association. Standards of Medical Care in Diabetes 2010 (Position Statement). Diabetes Care, 33(1), S11-S61. American Diabetes Association (2015). Standards of Care. Diabetes Care 38 (1), S1-S99. Bode, B., Braithwaite, S., Steed, D., Davidson, P., (2004). Ace Inpatient Diabetes and Metabolic Control Consensus Conference. Intravenous insulin infusion therapy: indications, methods, and transition to subcutaneous insulin therapy. Endocrine Practice, 10(2), Diabetes Blog Site (2015). What did dogs teach humans about diabetes? Retrieved from Fonseca, V. A., (Ed.). (2006). Clinical diabetes: Translating research into practice. Philadelphia: Saunders Elsevier. Garber, A. J., Handelsman, Y., Einhorn, D., Bergman, D. A., Bloomgarden, Z. T., Fonseca, V., et al. (2008). Diagnosis and management of prediabetes in the continuum of hyperglycemia when do the risks of diabetes begin? A consensus statement from the American College of Endocrinology and the American Association of Clinical Endocrinologists. Endocrine Practice 14(7), Greenspan, F. S., Gardner, D. G. (Eds.). (2001). Basic and clinical endocrinology (6th ed.). New York: Lange/McGraw Hill Insulin. (201). In Epocrates Essentials for Apple ios (Version 5.1) [Mobile application software]. Retrieved from International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy, (2010). Diabetes Care, 33(3), ). Kruger, D. F., Aronoff, S. L., Edelman, S. V., Current and future perspectives on the role of hormonal interplay in glucose homeostasis. The Diabetes Educator. 33(S2), 32S-46S. Moghissi, E. S., Korytkowski, M. T., DiNardo, M., Einhorn, D., Hellman, R., Hirsch, I. B., et al. (2009). American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on inpatient glycemic control. Endocrine Practice, 15(4), 1-15.