Fundamentals of Diabetes Care Module 5, Lesson 1

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1 Module 5, Lesson 1 Fundamentals of Diabetes Care Module 5: Taking Medications Healthy Eating Being Active Monitoring Taking Medication Problem Solving Healthy Coping Reducing Risks Foundations For Control Objectives 1. Explain the treatment effect of insulin 2. List guidelines for safe use of insulin 3. Recognize the names of the most common oral medications used for diabetes 4. Discuss the common complications of medication therapy for diabetes

2 Module 5, Lesson 1 Changes in Blood Glucose 350 Blood Glucose (mg/dl) Time (minutes) No Diabetes Diabetes Normal Glucose/Insulin Response Pattern The Diabetes Difference

3 Module 5, Lesson 1 Blood Glucose Goals ADA guidelines for good control in adults Near Normal Before eating: mg/dl After eating: Under 180 mg/dl A1C: no higher than 7% American Diabetes Association Standards of medical care in diabetes Diabetes Care 32:S13-S61. Lesson ONE ORAL MEDICATIONS FOR DIABETES CONTROL Need to Know Information Name of drug Dose of drug Time to take drug Common side effects What to do if a dose is missed What to do when sick When to call the clinician

4 Module 5, Lesson 1 Pills are not insulin Pills for Diabetes 1. Biguanides 2. Sulfonylureas 3. Meglitinides 4. Alpha glucosidase inhibitors 5. Thiazolidinediones 6. Incretin Mimetics 7. DPP-4 Inhibitors Burke, SD, and Cornell, SA Medication management in type 2 diabetes. Clinician Reviews, 18(3): Biguanides Generic Name Metformin Trade Name Glucophage, Glucophage SR Fortamet Glumetza Riomet Common Side Effects Diarrhea, Bloating, Gas Available in generic form Taken once or twice a day at mealtimes Dose is increased gradually to prevent common side effects Does not cause hypoglycemia

5 Module 5, Lesson 1 Generic Names Glyburide Glipizide Glimeperide Trade Names Diabeta, Micronase, Glynase Glucotrol Amaryl Common Side Effect Hypoglycemia Sulfonylureas Available in generic form Taken once or twice a day Must eat regular meals to prevent hypoglycemia Don t change dose without medical advice Koski, RR Practical review of oral antihyperglycemic agents for type 2 diabetes mellitus. The Diabetes Educator, 32(6): Glinides (Meglitinides) Generic Names Repaglinide Nateglinide Trade Names Prandin Starlix Common Side Effects Hypoglycemia Taken at mealtimes and only if eating Hypoglycemia is possible Don t change dose without medical advice No benefit to adding a glinide to an SFU Nathan, DM, et al Management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy. Diabetes Care. 29(8): Alpha-Glucosidase Inhibitors (AGIs) Generic Names Acarbose Miglitol Trade Names Precose Glyset Common Side Effects GI side effects Acarbose is available in generic form No risk of hypoglycemia when used alone Hypoglycemia can occur if used in combination with SFU or insulin Treat hypoglycemia with glucose tablets or gel Burke, SD, and Cornell, SA Medication management in type 2 diabetes. Clinician Reviews, 18(3):28-34.

6 Module 5, Lesson 1 Thiazolidinediones (TZD) Generic Name Pioglitazone Rosiglitazone Trade Name Actos Avandia Common Side Effects Water Retention Weight Gain Not available in generic No risk of hypoglycemia if taken alone No immediate effect on blood sugar Notify prescriber if gaining excessive weight AND feeling short of breath Koski, RR Practical review of oral antihyperglycemic agents for type 2 diabetes mellitus. The Diabetes Educator, 32(6): New Class: DPP-4 Inhibitor Generic Name Sitagliptin Trade Name Januvia Common Side Effects Headache, head cold like symptoms Main effect on postmeal blood sugar Not for type 1 diabetes Not for use in children Cautious use with kidney disease A Cholesterol Lowering Drug Generic Name Colesevelam Trade Name Welchol Common Side Effects Constipation, gas, upset stomach More commonly used to lower LDL cholesterol Now approved to lower blood sugar in type 2 diabetes Do not use in patients who have had blockage in bowel or certain types of pancreatitis Do not use in patients with triglyceride levels over 500

7 Module 5, Lesson 1 Check Your Knowledge Complete the following sentence. The most common side effects of metformin, which is often the first drug used in patients with type 2 diabetes, are: a) Weight gain b) Gastrointestinal c) Hypoglycemia d) Water retention Check Your Knowledge True or false? Because sulfonylureas (SFUs) and glinides cause the pancreas to release larger amounts of insulin into the bloodstream, hypoglycemia can result. a) True b) False Check Your Knowledge True or false? Patients should immediately stop taking a drug because of undesirable side effects. a) True b) False

8 Module 5, Lesson 2 Lesson TWO INSULIN AND OTHER INJECTABLES Insulin Shots Patients with type 1 diabetes depends on insulin to survive Patients with type 2 diabetes often need insulin for control Women with gestational diabetes may need insulin to protect the growing baby Insulin might be needed for some patients when they are sick, especially in the hospital Normal Glucose/Insulin Response Pattern

9 Module 5, Lesson 2 Duration of Action Rapid-acting Insulin lispro (Humalog ) Insulin aspart (NovoLog ) Insulin glulisine (Apidra ) Short-acting Regular insulin Intermediate-acting NPH (Humalin N, Novolin N) Long-acting Insulin glargine (Lantus ) Insulin detemir (Levemir ) Note: Trade names listed are available in the US and may vary internationally. Injection Sites How Fast Insulin Works Aspart, glulisine, lispro (Rapid) Regular NPH (Intermediate) Detemir (Long) Glargine (Long) Hours Adapted with permission from CADRE (Council for the Advancement of Diabetes Research and Education): Available at Burge MR, Schade DS. Endocrinol Metab Clin North Am. 1997;26: ; Barlocco D. Curr Opin Invest Drugs. 2003;4: ; Danne T et al. Diabetes Care. 2003;26:

10 Module 5, Lesson 2 Patients Needs are Different Single daily injection Two shots a day One type of insulin twice a day Two types of insulin, mixed together twice a day Three or four shots a day Long acting insulin once or twice a day Rapid acting insulin with meals Fixed Dose Insulin Combinations Fixed mixtures Premixed formulations of regular OR rapid insulin with intermediate insulin Commonly available mixtures (US) 75/25 = 75% intermediate / 25% rapid 70/30 = 70% intermediate / 30% short 70/30 = 70% intermediate / 30% rapid 50/50 = 50% intermediate / 50% rapid Insulin syringes 3/10, ½, 1 ml g needle Needle length 5/8, ½ Tools of the Trade American Association of Diabetes Educators Find an Educator tool: American Diabetes Association s Diabetes Forecast: Adapted from CADRE (Council for the Advancement of Diabetes Research and Education): Available at

11 Module 5, Lesson 2 Pens and Cartridges Insulin pens Faster and easier than syringes Single type or fixed mix only Do not share insulin pens or cartridges FYI: Insulin Pump Therapy Artificial Pancreas Continuous infusion Rapid- or short-acting insulin only Frequent blood sugar testing Carbohydrate counting Another Hormone Generic name Pramlintide Trade name Symlin Common side effects Hypoglycemia, nausea, weight loss, Less common side effects Fatigue, headache, dizziness, cough, injection site irritation For type 1 and type 2 diabetes Works with insulin to lower blood sugar Injectable only Given at mealtimes High risk for hypoglycemia, especially at first Kruger, DF and Gloster, MA Pramlintide for the treatment of insulin-requiring diabetes mellitus: Rationale and review of clinical data. Drugs. 64(13):14-32.

12 Module 5, Lesson 2 Gut Hormones (Incretins) Generic name Exenatide Trade name Byetta Common side effects Nausea, vomiting, diarrhea, weight loss, hypoglycemia Potential for acute pancreatitis Do not use in patients with Type 1 diabetes Do not use if patient has kidney failure Not approved for use in children Given by injection Taken at meals, twice a day Check Your Knowledge True or false? Patients with type 1 diabetes can take either insulin or pills to manage their disease. a) True b) False Check Your Knowledge Complete the following sentence. Rapidacting insulin should be taken: a) 1 hour before mealtime b) At mealtime c) 1 hour after mealtime d) 2 hours after mealtime

13 Module 5, Lesson 2 Check Your Knowledge If your patient tells you he is afraid of needles, which of the following is an appropriate response? a) The needles nowadays are very short and thin, so it shouldn t hurt at all! b) You should meet with your diabetes educator to learn how to give yourself a shot correctly. c) I suggest you check the American Diabetes Association s annual product review guide for more information and reviews. d) All of the above

14 Module 5, Lesson 3 Lesson THREE HELPING THE PATIENT USE MEDICINE SAFELY Hypoglycemia Blood sugar is under 70 mg/dl Need-to-know information What it feels like When to expect it How to correct it Symptoms Shaky Sweaty Hungry Irritable Dizzy Anxious Tired and weak Fast heartbeat Headache Levels of Severity Mild Patient can recognize and treat symptoms, with minimal interruption in daily activities Moderate Sleepiness, slow thinking, confusion, and personality changes Others may recognize the symptoms first, and person may need assistance with treatment Severe: This is an emergency. Call for Help! Patient may be unresponsive Glucagon by injection or intravenous glucose

15 Module 5, Lesson 3 Prolonged Symptoms If untreated, hypoglycemia progresses to changes in the level of consciousness: Weakness Confusion, personality changes Inability to reason Seizures Unconsciousness Death Food as Treatment Carbohydrate raises blood sugar Foods containing 15 grams of carbohydrate 3 or 4 glucose tablets 4 ounces juice or soda 8 ounces milk 1 Fruit Roll-Up 6-7 Lifesavers 1 small box or 2 tablespoons raisins Test Treat Wait 15 minutes Retest Eat or Re-Treat Rule of 15

16 Module 5, Lesson 3 In the Hospital or Nursing Home Check blood sugar levels before meals and at bedtime Know the symptoms of hypoglycemia and report them immediately Be alert for hypoglycemia in patients who are unconscious, sedated, or have dementia Find out when insulin is supposed to peak and check with patient during those times Getting Ready for an Appointment Current list of: Medications Over-the-counter drugs Herbals and Supplements Blood sugar records Questions for the clinician Medication List Drug Name Dose Frequency Long acting insulin (name) 28 units 10 pm daily Rapid acting insulin (name) 5 units Breakfast and Lunch Rapid acting insulin (name) 8 units Dinner (supper) Lipitor 20 mg once a day With dinner Lisinopril 20 mg once a day Before breakfast Multiple Vitamin 1 tablet once a day With breakfast Calcium 500 mg twice a day With breakfast and dinner Aspirin 81 mg once a day With Dinner Pain Reliever 500 mg; 2 tablets 2 or 3 times a week for arthritis pain or headache

17 Module 5, Lesson 3 For the Patient Read the label Take as directed Know when to call for help Know who to call for help Know what to ask the pharmacist Always be prepared to treat hypoglycemia Reading the Label The Patient s NEVER List Never put your pills into a bottle with a different label Never share your medications with someone else Never use someone else s medications Never be afraid to tell your doctor or nurse that you can t afford your medication

18 Module 5, Lesson 3 Ways to Lower the Cost of Medications Ask for generic medications Shop around Buy a 3-month supply Patient Assistance Programs Medicare Resource Partnership for Prescription Assistance Needy Meds Check Your Knowledge Which of the following is NOT an early symptom of hypoglycemia? a) Shakiness b) Sweatiness c) Irritability d) Personality changes

19 Module 5, Lesson 3 Check Your Knowledge According to the rule of 15, what is the order of events you should do when treating hypoglycemia? a) Test, treat, wait 15 minutes, retest, eat or retreat b) Test, wait 15 minutes, treat, retest, eat or retreat c) Treat, test, wait 15 minutes, eat or re-treat d) Wait 15 minutes, test, treat Check Your Knowledge Which of the following should you do with your patients with diabetes? a) Encourage them to create a medication list b) Help them understand their medication labels c) Talk about how to recognize and treat the symptoms of hypoglycemia d) All of the above

20 Module 5, Final Thoughts Lesson FIVE: FROM THE PATIENT S PERSPECTIVE Fear, Insecurity, Confusion

21 Module 5, Final Thoughts Resources National Diabetes Education Program American Association of Diabetes Educators American Diabetes Association

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