Rapid onset (roughly 15 minutes)

Peak 1-2 hours

Subcutaneous, take within 15 minutes of mealtime

Only short-acting

IV bolus, IV infusion, or IM

Onset 30 - 60 minutes

Peak 2.5 hours

Only Intermediate-acting insulin

Zinc Insulin crystals and protamine sulfate in buffered water for injection

Onset 1-2 hours

Peak 4-8 hours

Duration 10-18 hours

Long-acting insulin and also called Basal Insulin

Absorber over 24 hours

Normally clear, colorless solution w/ pH of 4.0

Long-acting insulin

Low doses given twice daily

Higher doses given once daily

130/80 mm Hg

less than 100mg/dL

Metformin, which is classified as a Biguanide

Especially used for patients with a BMI over 25

Metformin

MOA

Decrease glucose production by the liver

Decrease intestinal absorption of glucose

Improve insulin receptor sensitivity

Increase peripheral glucose uptake and use

Decrease production of triglycerides and cholesterol

Does not stimulate insulin secretion

Not associated with weight gain and significant hypoglycemia when used alone

Metformin

Adverse Effects

Biguanide

Most common are gastrointestinal, bloating, nausea, cramping, feeling of fullness, and diarrhea.

Weight loss early in course

Long-term use, reduction in Vitamin B12

Metformin

Interactions

iodinated radiologic contrast media

discontinue day of and 48 hours after

Glipizide, glyburide, and glimepiride

Stimulate the release of insulin and decrease the secretion of glucagon

Must have functioning beta cells in the pancreas

Used for early stages of type 2

Sulfonylureas

Indication

Glipizide, glyburide, and glimepiride

Second-step drug when A1C levels remain elevated with use of Metformin

Used in conjunction with Metformin or Thiazolidinediones

Not used in patients with advanced diabetes or insulin dependent patients

Once insulin is started, sulfonylureas are stopped

Sulfonylureas

Contraindications and

Adverse Effects

Hypoglycemia, reduced calorie intake, ethanol use, or advanced age, and Sulfonamide antibiotic allergy

Hypoglycemia, hepatic or renal disease, weight gain, rash, nausea, epigastric fullness, and heartburn

Repaglinide and Nateglinide

Increases insulin secretion from the pancreas

Shorter duration of action and must be given with meals

Glinides

Indication

Treat type 2 diabetes

Particularly useful for diabetics with high postprandial glucose levels who have low levels of circulation insulin

Used with Metformin and Thiazolidinediones, but not Sulfonylureas due to similar MOA

Glinides

Adverse Effects

Hypoglycemia, especially if not taken with meal.

weight gain

Pioglitazone

Decreases insulin resistance by enhancing the sensitivity of insulin receptors

Directly stimulates peripheral glucose uptake and storage

Inhibits glucose and triglyceride production by liver

Slow onset of several weeks and maximal activity may not be evident for several months

Slows progression in type 2 Diabetes

Thiazolidinediones (Glitazones)

Indication

For patients who cannot tolerate or achieve glucose control with metformin or the sulfonylureas

Can be used with Insulin

Thiazolidinediones (Glitazones)

Contraindication

Class III or IV heart failure

Used with caution with liver or kidney disease

Thiazolidinediones (Glitazones)

Adverse Effects

Can increase risk of heart failure

Commonly causes peripheral edema and weight gain

Associated with reduced bone mineral density and increased risk of fractures

Thiazolidinediones (Glitazones)

Interactions

If hypoglycemia is developed while taking Acarbose or Miglitol, what would be the treatment?

IV or Oral glucose must be administered

Complex carbohydrates cannot be used because alpha-glucosidase is blocked

Reversibly inhibits the enzyme A-glucosidase found in the small intestines

Delays glucose absorption

Must be taken with food

Excessive postprandial blood glucose elevates(spike)

Alpha-Glucosidase Inhibitors (Acarbose and Miglitol)

Contraindication

Alpha-Glucosidase Inhibitors (Acarbose and Miglitol)

Adverse Effects

Alpha-Glucosidase Inhibitors (Acarbose and Miglitol)

Interactions

Dipeptidyl Peptidase IV (DPP-IV) Inhibitor

(Gliptins)

Delays breakdown of incretin hormones

Reduces fasting and postprandial glucose concentration

Sitagliptin, Saxagliptin, and Linagliptin

Dipeptidyl Peptidase IV (DPP-IV) Inhibitor

(Gliptins)

Indications

Dipeptidyl Peptidase IV (DPP-IV) Inhibitor

(Gliptins)

Interactions

Sitagliptin may increase digoxin levels

Rifampin may decrease the efficacy of Linagliptin

Alpha Glucosidase inhibitor

Blunts the elevation of blood glucose levels after meals

Taken with first bite of a meal

C/I DKA, cirrhosis, IBS, colonic ulcerations, partial intestinal obstruction or chronic intestinal disease

Sulfonylurea

Best given 30 minutes before breakfast

Very rapid onset, short duration

Functions much like body normally does in response to meals when greater levels of insulin are required rapidly to deal with the increased glucose in the blood

Rapidly stimulates pancreas to release insulin

Not C/I in renal failure

Only Biguanide

C/I hepatic or renal disease, alcoholism, or cardiopulmonary disease

Thiazolidinedione

Decreases insulin resistance

Can worsen or precipitate heart failure

DPP-IV inhibitor

Especially helpful in the treatment of patients who have erratic eating habits because drug dose is skipped when meals are missed

Pramlintide

Natural hormone secreted by the beta cells of the pancreas

Slows gastric emptying

Supresses secretion and hepatic glucose production

Increases satiety(sense of having eaten)

Given before major meals, subcutaneous

Amylin Agonist

Contraindication

Amylin Agonist

Interactions

Reduce Insulin by 50%

Delay absorption of other drugs if taken at the same time

Take 1 hour before other drugs

Amylin Agonist

Indications

Type 1 or type 2 Diabetes

Who have failed first line drug therapy

Exenatide and Liraglutide

Hormone that is secreted by the gastrointestinal tract in response to food

Stimulates insulin secretion

reduce postprandial glucagon production

Slow gastric emptying

Increase satiety

Exenatide and Liraglutide

Indication

Incretin mimetics

Long-acting

subcutaneous

Type 2 diabetes

Cannot be used with insulin

Best given 60 min before meals

Exenatide and Liraglutide

Adverse Effects

Incretin mimetics

Hemorrhagic or necrotizing pancreatitis

Weight loss of 5 to 10 pounds

Exenatide and Liraglutide

Interactions

Incretin Mimetics

Delays absorption of other orally administered drugs by slowing gastric emptying

Below 50 mg/dL

Early Symptoms: confusion, irritability, tremor, and sweating

Later Symptoms: hypothermia and seizures

Without adequate restoration of glucose, coma and death can occur