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49 Cards in this Set
- Front
- Back
- 3rd side (hint)
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two types of action for insulin
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2 types of action:
– Glucoregulatory – Anti-lipolytic |
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The principal indication for using insulin is for _________ of diabetes mellitus
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The principal indication for using insulin is for all types of diabetes mellitus
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Insulin is also used for _______, to drive
______ into the cells along with ________ |
Insulin is also used for hyperkalemia, to drive
potassium into the cells along with glucose |
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The immediate precursor of insulin is called
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pro-insulin,
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pro-insulin consists of two component
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and consists of the insulin molecule plus C-peptide (connecting peptide)
In the final step of insulin biosynthesis, Cpeptide is enzymatically clipped off Commercial insulin preparations do not have Cpeptide attachments |
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People with T1DM can't produce insulin, how about T2DM
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People with T2DM are resistant to insulin
• For the type 2 diabetic who produces insufficient quantities. |
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Type I diabetes
Failure of Beta Cells: |
•Causes
•Inheritance •Auto-immunity •Environmental damage ---Illness (viral?) ---Chemical ---Injury |
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•Insulin resistance is also an adaptive mechanism that is normal in some parts of the lifespan.
For example, all pregnant women are insulin resistant in order to ensure nutrients go to the developing fetus. |
•Insulin resistance is also an adaptive mechanism that is normal in some parts of the lifespan.
For example, all pregnant women are insulin resistant in order to ensure nutrients go to the developing fetus. |
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Complication:
Hyperglycemia Which leads to: |
Complication:
Hyperglycemia Which leads to: •Hypoglycemia •Ketoacidosis •Macrovascular damage •Microvascular damage •Retinopathy •Nephropathy •Sensory/motorneuropathy •Autonomic Neuropathy •Gastric paresis •Amputations •Erectile DysfunctionGlucagon |
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glucagon produce by
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Produced by alpha cells of pancreas
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glucagon action
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Action is opposite of insulin
–Catabolic –Promotes breakdown of glycogen, reduces glycogen synthesis, promotes glucose biosynthesis –Promotes relaxation in GI smooth muscle Prevent hypoglycemia in patients NPO long time waiting for GI procedures. |
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short duration: rapid acting insulin
onset, peak, duration of name |
lispro (Humalog), 15-30 mins, 0.5-2.5hr, duration 3-6.5hrs
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short duration: slower actinginsulin
onset, peak, duration of name |
Regular insulin, 30-60mins, 1-5hrs, duration 6-10 hrs
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intermediate durationinsulin
onset, peak, duration of name |
NPH insulin, 60-120min, 6-14hrs, duration 16-24 hrs
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long durationinsulin
onset, peak, duration of name |
Insulin glargine, 70mins , none, duration 24hrs
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color of regular insulin and things to know
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Always a crystal clear solution
if there is any clouding >>>>discarded Only insulin administered IV –SQ acts in 15 minutes •Refrigeration not necessary –but it should be kept away from warm temperatures, and out of direct sunlight, as this will simply denature the insulin protein |
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the action of lispro
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the onset of action is very fast so This means given within five minutes of eating!
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Things to know about NPH insuline
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Neutral Protamine Hagedorn Insulin
–This is regular insulin with a large protein called protamine attached to it •Protamine decreases the solubility of NPH which retards its absorption, which accounts for the onset and lengthy duration of action –NPH is considered an intermediate-acting insulin –Cloudy solution –Typically given twice a day |
Given with a short acting to cover breakfast
•It peaks about 4-8 hours later. –So it covers lunch OK –Problem is around 3-4 pm especially if skip lunch –Driving home and get hypoglycemic •Needs mid-afternoon snack •Peaks and valleys are not the best for fatty acid production and glucagon rescue efforts |
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things to know about Glargine
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24 hour duration of action (Basal)
–Advantage: very stable blood levels which minimizes the risk for hypoglycemia and hyperglycemia –Can only be given SQ –Cannot be mixed with other insulin speciesMust use two syringes •Is used with other types, just not together |
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insline can only be give SQ
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glargine
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only insuline can given through IV
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Regular insuline
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nursing consideration for insulin concentration
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Insulin is available in two concentrations
•100 units/ml and 500 units/ml •The U-100 form is the most common, •U-500 form is by special order only from pharmaceutical companies for patients who need more than 200 units of insulin per day •Insulin syringes are calibrated for U 100 –Come in 50 unit and 100 unit sizes, with stubby little needles attached to the barrel, so that you can’t give more than a SQ injection |
DO NOT GET mL’SMIXED UP WITH UNITS—THEY ARE NOT EQUIVALENT AND THE ERROR CAN BE FATAL!
•Think before you act. –If this person needs more than 100 units something is probably wrong or need U -500 insulin –If use U-500 insulin its not the same easy dosing calcuation. For this course, remember that and ask the pharmacist for help!!!!!! |
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nursing consideration for combo insulin
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–Have premixed solutions of regular or short acting insulins with NPH
•70/30 is 70% NPH and 30% Regular –Must be rolled gently to get even distribution prior to giving it –Fixed ratio does not allow carb counting or easy alteration based on most recent blood surgars |
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nursing consideration for insulin dosing
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Conventional Therapy is fixed
•2/3 of total daily dose is in AM, 1/3 in PM •Implications: no flexibility in timing, meals, or composition of the insulin species •Intensive therapy –B, L, D = Regular or short acting based on BS –Bedtime = Basal Insulin like Glargine |
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Pt has blood blucose 50mg/dl and feel shaky. the best treatment?
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if conscious then drink orange juice
if not conscious then give patient D50 |
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your pt in the ICU is on an insulin drip but doesn't have diabete. the question you need to ask >
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what is the Pt's potassium level
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things to know about insuline pens and cartridge
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Insulin pens
–Don’t have to draw up in syringe, just dial in number you want and shoot. –Cartridge so when its empty, toss and simply load another cartridge –Needle so could conceivably get dull so can change •3ml cartridge ( 100 units per ml) or 10 ml vials –Could be more expensive for the pens |
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Hypoglycemia Causes
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–Imbalance between calories and insulin
•If not eating, don’t take insulin –n/v (i.e. have the flu) –Not matching insulin to exercise requirements (when one exercise then one is more sensitive to insulin) –Dieting •Where suddenly drop intake and not change insulin dose |
either we get too much insulin or we give insulin but they don't eat
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S/S of Hypoglycemia
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Mild = HA, confusion, drowsiness, irritability
•Severe= Tachycardia, palpitations, sweating, nervousness •Hypoglycemia must be treated –If the patient is conscious and has a gag reflex: skim milk, regular Pepsi or Coke, OJ, sugar cubes, honey, corn syrup, glucose gel –If no gag reflex, glucagon injection or D50 IV |
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Oral Hypoglycemic Agents function
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Oral Hypoglycemic Agents
•Sulfonylureas •similar in structure to the sulfonamide antibiotics, but have no antibiotic activity •Can be used in combination with insulin or as a stand-alone drug –First generation agents differ from second generation agents only by a longer duration of action. 2ndgeneration agents in current use are: •Glymeperide/Amaryl •Glipizide/Glucotrol •Glyburide/micronase, Diabeta |
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Oral Hypoglycemic Agents
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•Sulfonylureas
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drug interactions for sulfonylureas
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Oral Hypoglycemic Agents
•Alcohol + drug = disulfram reaction •Alcohol + drug = hypoglycemia •Cimetidine + drug = hypoglycemia from potentiating of sulfonylurea •Beta blocker + drug = suppression of insulin release, masking the sympathetic reaction to hypoglycemia less obvious |
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sulfonylureas action and SE
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Stimulate the beta cells of the pancreas to produce more insulin,
–Principal side effect: •hypoglycemia from over-stimulation of the pancreas, |
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Biguanides
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Biguanides
•Metformin/Glucophage –Decreasing hepatic production of sugar and enhances peripheral utilization of glucose by skeletal muscle. –No insulin release from the pancreas, nor does it cause hypoglycemia –Monitoring renal function is vital –Can be used with insulin and sulfonylureas –Major problem: lactic acidosis •inhibits the metabolism of lactic acid, inducing a metabolic acidosis. 50 % mortality rate, occurs almost exclusively in people with renal insufficiency |
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thiazolidinedione
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•“The glitazones”
–Decreases insulin resistance or alternatively to re-sensitize peripheral cells (skeletal muscle and liver) to insulin, so they can take up more glucose –Can be combined with sulfonylureas, insulin, metformin –MAJOR Restriction in 2011 •Can cause fluid retention, edema, and weight gain… •cautious use in CHF, HTN –Monitor liver function tests! |
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incretin function
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GLP-1 has multiple effects on body
–Brain: increased satiety, reduced appetite, eat less, lose weight –Alpha cells of pancreas: decreased post-prandial glucagon secretion –Liver: decreased hepatic production of sugar –Beta cells: enhanced glucose-dependant insulin secretion –Stomach: decreased gastric emptying which translates into eating less food, lose weight |
Insulin production: signals the pancreas to make the right amount of insulin—then stops after blood sugar levels get closer to normal
•Sugar production: helps stop the liver from producing too much sugar when you don't need it —helping avoid high blood sugar levels •Sugar digestion: helps slow down the rate at which sugar enters the bloodstream —also helping to avoid high blood sugar spikes |
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IncretinMimetics
Exenitide/Byetta |
•Can be used in conjunction with sulfonylureas, metformin and now insulin ( new 2011)
•Injection, but is NOT insulin, –Synthetic analogue to human incretin, GLP-1 –Glucagon-like peptide-1, made by small intestine in response to food in GI tract –Augments insulin secretion so long as glucose is present –The “incretin effect” accounts for 60% of total insulin release following a meal –Endogenous incretins are rapidly degraded by GI enzyme, DDP-IV (dipeptidyl pepsidase-IV) |
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one big plus for incretin mimetics med
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possible weight loss
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nursing consideration for incretin mimetics
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taken SQ before breakfast and dinner.
–5mcg or 10 mcg BID –Check a finger-stick blood sugar 2 hours after these meals will help determine if the med is working. –On the + side, patients showed a nice weight loss with exenitide –Significant n/v as primary side effect –If taking with sulfonylurea, hypoglycemia possible |
Once a week exentide!
•Injection that must be reconstituted immediately before giving it –Cannot be pre-mixed! –Patient needs injection education •Perhaps even better HgA1C reduction than 2-3 x a day! •WEIGHT LOSS!!!! |
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incretin mimetics If taking with sulfonylurea, what is possible
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hypoglycemia
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when taking thiazolidineediones, we need to monitor what
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liver function tests
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IncretinEnhancers
DPP-4 Inhibitors |
•Sitagliptin/Januvia
–PO med 100mg/day –These drugs inhibit incretin breakdown by DPP-4 to enhance the activity of endogenous incretins –Can be used as monotherapy or added to metformin or glitazone –Lowers A1c 0.6-0.8% as monotherapy –Will not cause hypoglycemia, nausea, wt gain –No significant drug interactions –Able to be renally dosed with renal problems |
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function of Biguanides
•Metformin/Glucophage |
Decreasing hepatic production of sugar and enhances peripheral utilization of glucose by skeletal muscle.
–No insulin release from the pancreas, nor does it cause hypoglycemia |
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Biguanides
•Metformin/Glucophage monitory what |
renal function
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major problem
Biguanides •Metformin/Glucophage |
lactic acidosis
inhibits the metabolism of lactic acid, inducing a metabolic acidosis. 50 % mortality rate, occurs almost exclusively in people with renal insufficiency |
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drug interactions of sulfonylureas
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–Drug interactions
•Alcohol + drug = disulfram reaction •Alcohol + drug = hypoglycemia •Cimetidine + drug = hypoglycemia from potentiating of sulfonylurea •Beta blocker + drug = suppression of insulin release, masking the sympathetic reaction to hypoglycemia less obvious |
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function of sulfonylureas
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–Stimulate the beta cells of the pancreas to produce more insulin,
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SE of sulfonylureas
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–Principal side effect:
•hypoglycemia from over-stimulation of the pancreas, |
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function of Thiazolidinedione , the glitazones
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Decreases insulin resistance or alternatively to re-sensitize peripheral cells (skeletal muscle and liver) to insulin, so they can take up more glucose
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