Name(s): lispro, aspart (Novolog), glulisine; rapid inhalation powder

Onset: 5-15 mins

Peak: 30-90 mins, Afreeza- ~50 min

Duration: 3-6 hrs

Nursing considerations:

• admin 15 mins before meal once food has arrived
• increased risk for hypoglycemia- make sure pt has food at bedside
• mixing- can be mixed w intermediate acting insulin (NPH)- clear before cloudy

Names: Regular insulin (Humulin R, Novolin R)

Onset: 30 min-1 hr

Peak: 2-4 hr

Duration: 4-12 hr

Nursing considerations:

• admin 30-60 mins before meals- make sure meal tray is on the floor
• only insulin that can be administered IV

Names: NPH (Humulin N, Novolin N), isophane

Onset: 1-2 hr

Peak: 4-12 hr

Duration: 14-24 hr

Nursing considerations:

• food should be taken around the time of onset + peak
• mixing - can be mixed w rapid or short acting insulins

Names: glargine, levemir, detemir

Onset:60-90 mins

peak: no peak

duration: 18-24 hr

Considerations: used as a basal insulin- dont mix w any other insulins

Action: Cellular uptake of glucose, converts glucose to glycogen stores, moves K+ into cells

Uses:

• glycemic control of DM
• if oral antdiabetic meds, diet, and exercise unable to control blood glucose
• emergency tx of dbx complications (DKA, HHNS)
• tx of hyperK
• surgery, stress, trauma/infx

Complications: 

• hypoglycemia (blood glucose <70) 
  • monitor pts for hypoglycemia (s/s: SNS-tachycardia, palpitations, sweating, shakiness; PNS- headache tremors weakness lethargy)
  • admin glucose (conscious- 15 g concentrated sugar [OJ, grape juice, 8 oz milk, gluc tabs], unconscious- IV glucose [D50] or IM glucagon)
  • have pt wear Medi bacelet + carry candy/snack at all times
• hypoK- insulin downs blood levels of K+
  • monitor pts taking large doses or continued doses of insulin
• lipohypertrophy- tell pt to rotate sites + allow 1 in between injection sites

Interactions:

• sulfonylureas, meglitinides, beta blockers + ETOH -hypoglycemia effects
• thiazide diuretics, glucocorticoids- counteract insulin and raise blood glucose
• beta blockers- mask s/s of hypoglycemia (tremors, tachycardia) + impair body's ability to breakdown glycogen stores to raise glucose (HYPOGLYCEMIA)
  • monitor glucose levels + dont rely on classic s/s of hypogly
  • maintain reg eating schedule to ensure adequate blood glucose

1. Adjust insulin dosage to meet insulin needs
2. ↑ insulin when- increase in caloric intake, infx/stress, growth spurts + 2nd and 3rd trimester of pregnancy
3. ↓ insulin- level of exercise, 1st trimester of pregnancy
4. mixing insulin- inject air first in NPH, but draw up clear (short or rapid) before cloudy (NPH)
5. gently rotate the vial to mix an insulin, NEVER SHAKE!
6. only NPH and premixed insulins should be cloudy – don't administer other insulins if they're cloudy or discolored, or have precipitates
7. admin short acting insulins (lispro, aspart, glulisine) + regular insulin by sub Q injection, continuous subQ infusion, and IV route
8. admin NPH by subQ route
9. Encourage diet + activity to enhance diabetes medication therapy
10. Ensure proper storage of insulin:
11. Unopened vials can be stored in the fridge until their exp date
12. Premixed insulins can be stored for up to 3 mos if refrigerated
    • premixed insulins in syringes - 1-2 weeks in refrigerator
    • Keep syringes vertical, w needles pointing up
    • Prior to admin, resuspend the insulin by gently moving the syringe
    • Vial in use should be stored at room temperature, avoiding proximity to sunlight + intense heat. Discard after 1 mo
    • Inhaled human insulin available as dry powder, packed in cartridges for use in an inhaler.
      • Cartridges available in 4, 8, or 12 units
      • multiple cartridges might be required to administer full prescribed dose 
13. Regular insulin is most common type of insulin administered in hospital setting- typical concentration is 100 units/100 mL of 0.9% NS
14. rapid acting (aspart, glulisine, and lispro) are the only other insulins appropriate for IV admin
15. When administering insulin via IV infusion, allow 50 mL of solution to flow through the IV tubing and waste (Insulin binds to the tubing, so do this to make sure the fluid pt receives will have right concentration of insulin

Prototype: glipizide; glyburide, glimepiride

Action: stimulate beta cells to produce more insulin; increase tissue sensitivity to insulin

Side effects:

liver/kidney dysfunction, decay, hypersensitivity, Type 1 diabetes

Alcohol produces disulfiram or Antabuse reaction (flushing, headache, sweating, nausea, and vomiting weakness)

Complications:

• NOT FOR pt w sulfa allergies
• hypoglycemia- make sure pt knows how to tx hypoglycemia (tachycardia, sweaty, shakiness, weakness) or that glucagon is available
• GI upset
• weight gain

Pt teaching:

• photosensitivity- wear sunscreen
• take 30 mins before a meal, avoid ETOH

• Prototype: Metformin
• Action:
  • decreases breakdown of glycogen stores- lowers glucose production, ↑ glucose uptake by fat/skeletal muscle,
  • ↓ glucose absorption by the gut
  • 1st choice med for Type II
• Contraindications: Hypersensitivity, DKA, renal failure
• Considerations:
  • doesnt cause hypoglycemia- can take w a sulfonylurea
  • not for ppl w ↓ renal fx
• Side effects
  • GI upset, metallic taste
  • lactic acidosis (s/s diarrhea dizziness hypotension weakness bradycardia)
  • megaloblastic anemia
• Pt teaching- take w a meal, no ETOH, discontinue 24-48 hrs before and after procedures using contrast

Prototype: Acarbose

Action: inhibits glucose absorption in GI 

Considerations:

• side effects
  • GI upset, hepatotoxicity, not for GI disorders
  • if pt experience hypoglycemia- simple sugar (glucose only-will inhibit breakdown of more complex carb)

Prototype: Glucagon 

Action: stimulates glycogen breakdown the liver to release glucose

Use:  for severe hypoglycemia in unconscious pt at home, when other methods not available

Considerations:

• Admin IM or IV - blood glucose begins to rise w in 10 mins
• Once pt is awake, provide food afterward
• Pt teaching- keep glucagon in the home, teach family members how to administer subq or IM injections during emergency

Other: Diazoxide

Action: stimulates epinephrine release + inhibits insulin release by beta cells = overall effect is ↑blood glucose - for hyperinsulinemia (not hypoglycemic rxn) 

Use: for chronic hypoglycemia caused by hyperinsulinism