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177 Cards in this Set
- Front
- Back
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Where is glucagon secreted?
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From the alpha cells of the pancreas
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What is the function of glucagon?
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Increases hepatic glucose output -->increases blood glucose concentration
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What triggers glucagon release?
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Released in direct response to low blood glucose levels
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What mechanism does glucagon use to increase blood glucose concentration?
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Breaks down glycogen
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What is the name of the area where alpha and beta cells occur in the pancreas?
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Islets of Langerhans
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What cells secrete insulin?
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Pancreatic Beta Cells
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What two circumstances is insulin secreted?
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-Basally in small amounts between meals and overnight
-Boluses in response to food |
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What is the function of insulin?
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Promotes the uptake, utilization, and storage of glucose --> lowers plasma glucose concentration
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What percentage of insulin is released from the pancreas as Basal?
As bolus? |
50% Basal
50% Bolus |
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During fasting, is the insulin level in the body zero?
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No, at no time is the insulin level at zero in the body
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What is Basal Insulin?
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Small amounts of the insulin are released by the body every 24 hours
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How much insulin in released in adults every hour?
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About 1 unit
-Basal Insulin |
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What is Bolus Insulin?
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-Used to limit postprandial hyperglycemia by stimulating glucose uptake by peripheral tissue
-In response to food. |
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List the other names for Bolus Insulin.
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-premeal
-mealtime -prandial -nutritional insulin |
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What determines the resting membrane potential in pancreatic B-cells?
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the ATP-sensitive K channels
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What is the mechanism for insulin release?
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-Glucose enter B cells Via GLUT-2
-K(atp) is blocked causing depolarization and Ca++ to rush in. -Ca++ signal induces insulin secretion. |
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What is Type I DM?
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Immune response or viral attack on Beta cells. Body does not produce insulin
-These pts will always require insulin injections |
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Describe Type II DM?
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-Pts produce insulin, but it is usually not enough
-Pts on oral anitbiotics and encouraged to diet and exercise |
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Define hypoglycemia.
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A pathologic state produced by a lower than normal amount of sugar (glucose) in the blood
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What is the clinical term for a condition in which an excessive amount of glucose is in the blood?
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Hyperglycemia
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What two sources were used to create animal insulin?
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beef or pork
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Which technique is utilized in the production of human insulin?
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recombinant DNA using E. coli or yeast
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Why is human insulin preferred over animal insulin?
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Human insulin is less likely to have antibodies, reaction or allergy
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Can insulin be administered orally?
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No`
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How long is the half-life of insulin?
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Only a few minutes due to rapid removal by the liver and kidneys
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What is the administration route for all insulin medications?
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Sub-Q
-Short acting can be given IV as well |
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What location offers the most rapid absorption for insulin?
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the abdomen
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What is lipodystrophy?
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Hardening of the injection site when a pt does not rotate sides between injections
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If a pt is on insulin, but is still hyperglycemic, what is a possible reason?
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Pt not rotating injection sites
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List the 3 rapid acting insulin drugs.
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-insulin aspart (Novolog)
-insulin lispro (Humalog) -Insulin glulisine (Aprida) |
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What is the onset of action for rapid acting insulin?
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2-15 mins
-very fast |
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What is the duration of Rapid Acting Insulins?
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1-5 hours
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What is the peak for Rapid Acting insulin?
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30 mins to 3 hours
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When do you administer rapid acting insulin?
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Immediately before meals
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Give an example of a short acting insulin
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Insulin Regular (Humulin R)
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Which form of insulin can be administered via IV?
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Short acting insulin
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What is the onset and peak for short acting insulin?
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onset: 1-2 hours
peak: 2-4 hours |
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When should short acting insulins be administered and what are their duration of action?
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-30 to 45 minutes before meals
-DOA: 8-12 hours |
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What is an example of intermediate acting insulin?
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NPH (Humulin N)
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What is the onset of action and Duration for NPH?
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Onset: 1-1.5 hours
DOA: 12 to 16 hours |
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Which insulin appears cloudy?
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NPH (Humunlin N)
Intermediate acting Insulin |
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Can you use NPH for emergency IV use?
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NO, only Humulin R
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How would you mix Humulin N and Humulin R in one syringe?
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Add R first and then N
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What are the long acting insulin drugs?
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-Glargine (Lantus)
-Detemir (Levenir) |
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What is the onset of action and duration of Long acting Insulin?
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Onset: 1-2 hours
Duration: 24 hours |
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Which insulin does not have a peak
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Glargine
-It never gets to hypoglycemic point |
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What is the peak time for detemir?
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6-8 hours
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How often are long acting insulins administered?
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only Once daily
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In general, what are rapid/short acting insulins used for?
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-Used for mealtime coverage
-Bolus dose |
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What determines the onset, peak and duration of each insulin drug?
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The form of insulin administered
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In general, when do we use intermediate and long acting insulins?
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-Used to treat basal needs
-Not intended for mealtime use |
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What insulin drug is considered a combination product?
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-Novolin or Humulin 70/30
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How would you describe the dosing for insulin?
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It is really trial and error based on
-total body weight -Dosed in units |
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What should you instruct your pt to avoid when administering insulin?
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Avoid exercise close to administration period
-Do not rub injection site -heat accelerates absorption |
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List the administration sites from best to worst
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abdomen>buttocks>arm/leg
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Which tool allows for more accurate and faster and easier dosing of insulin?
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Portable pen injectors
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Why is the insulin infusion pump considered invasive?
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Because a needle is implanted in the skin for long periods of time
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Which type of DM is most likely to use an Infusion pump?
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Type I
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What type of insulin is delivered with using the infusion pump?
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short acting insulin
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How should insulin not being used be stored?
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in the refrigerator
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How long can you use insulin at room temperature that has been opened?
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28 days
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What are the adverse effects of insulin?
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*hypoglycemia*
-insulin allergy: rare -Lipohypertrophy |
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What are the signs and symptoms of hypoglycemia?
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-Tachycardia
-confusion -vertigo -diaphoresis |
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What should you do for a conscious patient who is suffering from hypoglycemia?
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you can give them juice or a chocolate bar.
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If your patient is so hypoglycemic that they are unconscious, what should you do?
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Treat them with 20-50mL of 50% dextrose by IV
-or 1mg glucagon either Sub Q or IM |
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Should a nurse shake the vial before administering it?
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No, never! They should roll it.
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List the First generation of Sulfonylureases?
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-Chlorpropramide (Diabinese)
-Tolbutamide (Orinase) -Tolazamide (Tolinase) |
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List the Second Generation of Sulfonylureases?
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-Glyburide (DIaBeta, MIcronase, Glynase Pres Tab)
-Glipizide (Glucotrol, Glucotrol XL) -Glimepiride (Amaryl) |
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What types of patients can be perscribed sulfonylureases?
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Only Type II.
-effective only in pts with functioning B cells. |
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What is the primary effect of sulfonylureas?
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Increases secretion of insulin from B-cells of the pancreas
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What are two secondary effects of sulfonylureas?
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1. Increases insulin receptor sensitivity
2. Decreases hepatic glucose output |
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Where are sulfonylurea absorbed?
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In the GI
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How are sulfonylurea metabolized?
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90-100% hepatic metabolism
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What is unique about glyburide?
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Unlike other sulfonylurea that have nearly 100% hepatic metabolism, glyburide is metabolised 50% by liver and excreted 50% by the kidneys
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Which sulfa pts must you be cautious with?
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-Hepatic or renal disease
-Elderly (kidney funciton is not as good) -Pts with a "sulfa" allergy. |
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What should you educate your pt on sulfonlyureas to do?
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Where SPF because sulfas cause sun sensitivity
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What are the adverse effects of sulfonylureas?
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*Hypoglycemia*
-dermatologic reaction: rash, photosensitivity, hypersensitivity -GI disturbances: NV, abnormal liver function -weight gain (not ideal, want pt to lose weight) |
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Which drug option is ideal for pts with sulfa allergies?
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Meglitinides
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What are the 2 drugs under the category of meglitinides?
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-Repaglininde (Prandin)
-Nateglinide (Starlix) |
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What is the MOA of meglitinides?
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Increase secretion of insulin from B-cells
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How are meglitinides like sulfas?
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They are structurally related to sulfas but have no sulfa moiety
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What is the onset of action and duration for repaglinide and nateglinide?
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OOA: 15-30 mins
DOA: <4 hours |
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Where are meglitinides metabolized?
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CYP 3A4 and CYP 2C9
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What are 3 potential advantages for meglitinides?
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1. Rapid onset oand short duration of action
2. May be used in the elderly 3. May be useful to patients who skip meals |
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What are the adverse effects of meglitinides?
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-hypoglycemia
-weight gain |
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Give an example of a Biguanide
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metformin (glucophage)
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What is the MOA of metformin
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-Decrease hepatic glucose output
-increase peripheral glucose uptake and untilization |
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What are the advantages of metformin (glucophage)?
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-Does not cause hypoglycemia (doesn't effect insulin release)
-Weight loss |
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How are biguanides excreted? Where are they metabolized?
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100% through kidneys
-Not metabolized through the liver? |
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What are the adverse effects of biguanides?
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-Diarrhea
-lactic acidosis -increase lactate in the body |
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What are the contraindications for metformin?
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-Renal impairment
-men creatinine ≥1.5 -women creatinine ≥ 1.4 -Hepatic impairment |
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What must you do if you must administer a biguanide with an iodinated contrast material?
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-You must have pt stop the biguanide for 24 hours prior to ICM and stay off of meds 4 hours after
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What drugs are known as α- Glucosidase inhibitors?
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-Acarbose (Precose)
-Miglitol (Glyset) |
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Which drugs are potent competitive inhibitors of the brush border cells?
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α- Glucosidase inhibitors
-They stop the breakdown of carbohydrates |
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Are α- Glucosidase inhibitors absorbed well in the body?
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No
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What is the onset of action for α- Glucosidase inhibitors and how are they metabolized?
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-6 hours
-metabolized by intestinal bacteria |
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What are the adverse effects of α- Glucosidase inhibitors?
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-Abdonminal pain, flatulence, diarrhea
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What can occur at high doses of Acarbose?
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Hepatotoxicity
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Patients suffering significant GI disorders are contraindicated from which drug class>?
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α- Glucosidase inhibitors
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Name 2 examples of Thiazolidinediones
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-Rosiglitazone (Avandia)
-Pioglitazone (Actos) |
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What the the MOA of Thiazolidinediones?
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Binds to the NUCLEAR STEROID HORMONE RECEPTOR and promotes glucose uptake into skeletal and muscle/adipose tissue
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What is the primary advantage of using drugs such as rosiglitazone?
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There is no hypoglycemia!~
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What are the adverse effects of Pioglitazone and Rosiglitazone?
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--Thiazolidinediones
-Hepatotoxicity -Edema (which can worsen if combined with insulin) |
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Which pts must you take caution with when administering Thiazolidinediones>
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-Pts with hepatic disease or failure
-CHF because edema can worsen if combined with insulin!! |
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What are incretins?
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Intestinal hormones released in response to glucose
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What is GLP-1 and when is it released?
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-Glucagon-like peptide-1
-rapidly rises within minutes of food ingestion |
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What is DDP-4 and what is its natural purpose in the body?
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-dipeptidyl peptidase-4
-rapidly degrades GLP-1 in the body |
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What actions do GLP-1s have in the body naturally?
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-Enhance glucose-dependent insulin secretion (β)
-Suppress glucagon secretion (α) -Slow the rate of gastric emptying -Reduces appetite |
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What class does Exenatide (Byetta) fall under?
What is its function? |
Incretin Mimetics
-GLP-1 AGONIST! |
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How is exenatide administered?
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Pre-filled pens for Sub-Q injeciton
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List some adverse effects of INCRETIN MIMETICS
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-Hypoglycemia (esp is combined with sulfa)
-Nausea and diarrhea -headache -Pancreatitis |
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List the DPP4-Inhibitors
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--Sitagliptin (Januvia)
-Saxagliptin (Onglyza) |
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MOA of DPP4 INHIBITORS?
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Stops the breakdown of GLP-1 by inhibiting DPP4
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What adverse effects are associated with DPP4 inhibitors?
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-GI effects
-NO evidence of HYPOGLYCEMIA -(This medicine is new) |
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What drug falls under Amylin Analogue?
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Pramlintide (Symlin)
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What is the MOA for Amylin Analogues?
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-Slows gastric emptying
-Suppresses glucagon secretion -Decreases glucose output by the liver |
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Which patients can be give Pramlintide?
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Both Type I and II
-Those that have failed other types of meds |
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What are the adverse effects of Pramlintide and why are they odd?
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-Severe hypoglycemia
*this is odd because the drug doesn't actually alter the insulin concentration, but drops the blood sugar* -GI disturbances |
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List all the classes of meds that cause hypoglycemia!!
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-Amylin Analogues
-Incretin Mimetics -Meglitinides -Sulfonlyurea -Insulin |
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Which DM drugs do not cause Hypoglycemia?
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-Biguanides
-Thiazolidinediones -DPP4-inhibitors |
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What hormones are released by the Thyroid Gland?
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T3-active form
T4 (thyroxine)-inactive form |
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What element is essential in Thyroid Hormone production?
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Iodine
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How often is T3 and T4 created and stored?
How often are they released? |
T3 and T4 are constantly formed and stored.
Not a constant release |
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What % of T4 and T3 is secreted from the Thyroid gland?
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T4= 100%
T3= <20% is secreted from Thyroid Gland |
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Where can we find Thyroid Hormone regulation?
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Hypothalamus: neg feedback on TRH
-Anterior pituitary: neg feedback on TSH |
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What is Thyrotoxicosis?
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Hyperthyroidism
-excessive amount of thyroid hormone |
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What general class of drugs are used to treat Hyperthyroidism?
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Anthithyroid medications
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What drugs fall under Thioamides?
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-Antithyroid Meds
-Propylthiouracil (PTU) -Methimazole (Tapazole) aka MMI |
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What is the MOA of Thioamides?
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Inhibits the iodination of tyrosine and the coupling of iodotyrosines
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What additional mechanism does PTU have on T4 and T3?
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it inhibits the peripheral conversion of T4 to T3
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Thioamides do NOT?
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effect the release of performed T4 and T3
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What are the adverse effects of Thioamides?
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-Rash
-Edema -Decreased WBC count; reverses on discontinuation if caught early |
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What must you do as a nurse if your pt on thioamides has a drop in WBC?
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conduct a CBC on the pt every 6 months
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How long does thioamides require for a pt to become euthyroid?
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1-2 months
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What is the duration for Thioamides?
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They have a short half life but accumulate in the thyroid gland to exert longer effects
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What is hypothyroidism?
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Under active thyroid: does not produce enough TH
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List the Natural Thyroid Hormones.
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-Thyroid (Armour Thyroid)
-Thyroglobulin |
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Why is Armour Thyroid not used as much?
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Because it is derived from desiccated hog, beef or sheep thyroid it can cause a lot of ALlERGIES!
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Where does thyroglobulin come from?
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Purified hog gland extract that contains a standard amount of T4 and T3 in ration of 25:1
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In general, why are Natural Thyroid hormones not readily used?
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-Bioavailability is unpredictable
-Allergies |
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List the Synthetic Thyroid Hormones
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-Levothyroxine (T4)
-Liothyronine (T3) -Liotrix (T4 and T3 ratio of 4:1) |
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Which of the synthetic TH is used most often?
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Levothryoxine
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Which Synthetic TH is considered a prodrug?
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Levothyroxine
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What is the onset for Levothyroxine and how does it benefit the pt?
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2-3 week onset
-gives the body time to adjust |
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What are the adverse effects of LEVOTHYROXINE?
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-Heart Failure
-Angina -MI -Hyperthyroidism |
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How should the nurse administer Levothyroxine?
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-Consistently every morning before meals
-With a large glass of water |
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What is the function of osteoblasts?
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To encourage bone deposit
-To build bone |
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Which cells are responsible for breaking down bone?
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Osteoclasts
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Which hormones are involved in the control of calcium?
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-Vitamin D
-Parathyroid Hormone PTH -Calcitonin |
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Vitamin D has what effect on the body?
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It stimulates Ca absorption from the GI tract
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What is the positive method that PTH uses to increase Ca?
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-Decreases Ca excretion by the kidneys
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Which method used by PTH to increase Ca is not favorable?
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-Increasing bone resorption by stimulating osteoclast activity
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Calcitonin has what effect on Ca levels?
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Released in response to increased plasma calcium levels and it acts to inhibit bone resorption
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In general, what medications are used to treat Bone Disorders?
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-Ca and Vit D suppliments
-Bisphosphonates -Calcitonin |
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How is Ca absorbed?
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Absorption from the gut is incomplete even in the presence of Vit D
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Which for of Calcium supp requires stomach acid?
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Calcium carbonate
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What is unique about Calcium citrate?
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It does NOT require stomach acid for absorption
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If a pt is on multiple medications, when would you want to administer their Ca suppliment?
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2 hours before or after their other meds
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What is the adverse effect of Ca?
|
Constipation
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Which pts have the highest likelihood for Vit D deficiency?
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Those with malabsorption syndrome
-Those not exposed to sunglight |
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How do we get Vit D?
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-Through our Diet
-Through direct UV sunlight |
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What is an adverse effect of Vit D?
|
Increased levels of Calcium
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Which form of Vit D is obtain from diet and the sun?
Is this active? |
D3 or cholecalciferol
-No it is not active until it goes through the liver and kidney |
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What is the active form of Vit D?
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1,25-dihydroxyvitamin D3 or calcitriol
converted in the kidney |
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Which form of Vit D is obtain from diet and the sun?
Is this active? |
D3 or cholecalciferol
-No it is not active until it goes through the liver and kidney |
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What is the active form of Vit D?
|
1,25-dihydroxyvitamin D3 or calcitriol
converted in the kidney |
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Which form of Vit D is obtain from diet and the sun?
Is this active? |
D3 or cholecalciferol
-No it is not active until it goes through the liver and kidney |
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What is the active form of Vit D?
|
1,25-dihydroxyvitamin D3 or calcitriol
converted in the kidney |
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Describe the Conversion of inactive Vit D from sunlight to the active form.
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List all the Bisphosphonates.
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-Pamidronate (Aredia): IV
-Alendronate (Fosamax): oral -Risedronate (Actonel): oral -Ibandronate (Boniva): oral |
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What is the mechanism of action for Bisphosphonates?
|
Prevents bone resorption by inhibiting osteoclast activity
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How do the pharmokinetics of bisphosphonates dictate its administration?
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Because only 5% are absorbed on an empty stomach, the pt must take med in morning 30-45 mins prior to eating.
-Take with a big glass of water |
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What should you as a nurse instruct your pt that is on bisphosphonates to do?
|
Sit upright or stand for 30-45 mins after taking becuase it causes esophageal erosions
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What are some adverse effects of bisphosphonates?
|
-esophogeal erosion
-GI disturbances -Constipation -Diarrhea |
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What is the MOA of calcitonin?
|
Inhibits Osteoclasts
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Why is calcitonin not given as much?
|
Its admin routes cause pain
Nasal: sores Inj: painful |
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Adverse effects of calcitonin?
|
GI upsets and pain at injection site
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