Diabetes medications

There are many diabetes pills on the market.  Below is a list of the different diabetes pills you might see your patients taking and what you need to know about them:

This information is provided by  Joslin Diabetes

Diabetes Pills	How to Take	How They Work	Side Effects	Of Note
Biguanides Metformin (Glucophage) Metformin liquid ( Riomet) Metformin extended release  (Glucophage XR, Fortamet, Glumetza)	Metformin:usually taken twice a day with breakfast and evening meal. Metformin extended release:usually taken once a day in the morning.	Decreases amount of glucose released from liver.	Bloating, gas, diarrhea, upset stomach, loss of appetite (usually within the first few weeks of starting). Take with food to minimize symptoms. Metformin is not likely to cause low blood glucose. In rare cases, lactic acidosis may occur in people with abnormal kidney or liver function.	Always tell healthcare providers that it may need to be stopped when you are having a dye study or surgical procedure.
Sulfonylureas Glimepiride (Amaryl) Glyburide  (Diabeta, Micronase) Glipizide (Glucotrol, Glucotrol XL) Micronized glyburide (Glynase)	Take with a meal once or twice a day.	Stimulates the pancreas to release more insulin, both right after a meal and then over several hours	Low blood glucose, occasional skin rash, irritability, upset stomach	Because these medicines can cause low blood glucose, always carry a source of carbohydrate with you. Follow your meal plan and activity program. Call your healthcare provider if your blood glucose levels are consistently low. If there is an increase in your activity level or reduction in your weight or calorie intake, the dose may need to be lowered.
Meglitinides Repaglinide (Prandin) D-Phenylalanine Derivatives Nateglinide (Starlix)	Both of these medications should be taken with meals. If you skip a meal, skip the dose.	Stimulate the pancreas to release more insulin right after a meal.	Effects diminish quickly and they must be taken with each meal; may cause low blood glucose.	These work quickly when taken with meals to reduce high blood glucose levels. However, they are less likely than sulfonylureas to cause low blood glucose.
Thiazolidinediones Pioglitazone (TZDs) Pioglitazone (Actos)	Usually taken once a day; take at the same time each day.	Makes the body more sensitive to the effects of insulin.	May cause side effects such as swelling (edema) or fluid retention. Do not cause low blood sugar when used alone. Increased risk of congestive heart failure in those at risk.	Increases the amount of glucose taken up by muscle cells and keeps the liver from overproducing glucose; may improve blood fat levels. Talk with your healthcare provider if you have the following symptoms: nausea, vomiting, fatigue, loss of appetite, shortness of breath, severe edema or dark urine.
DPP-4 Inhibitors Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin ( Tradjenta)	Take once a day at the same time each day.	Improves insulin level after a meal and lowers the amount of glucose made by your body.	Stomach discomfort, diarrhea, sore throat, stuffy nose, upper respiratory infection. Do not cause low blood glucose.	Can be taken alone or with metformin, a sulfonylurea or Actos. Tell your healthcare provider if you have any side effects that bother you or that don’t go away.
Alpha-glucosidase Inhibitors Acarbose (Precose) Miglitol (Glyset)	Take with first bite of the meal; if not eating, do not take.	Slows the absorption of carbohydrate into your bloodstream after eating.	Gas, diarrhea, upset stomach, abdominal pain	Take with meals, to limit the rise of blood glucose that can occur after meals; these do not cause low blood glucose. Side effects should go away after a few weeks. If not, call your healthcare provider.
Bile Acid Sequestrants Colesevelam (Welchol)	Take once or twice a day with a meal and liquid.	Works with other diabetes medications to lower blood glucose.	Constipation, nausea, diarrhea, gas, heartburn, headache (may interact with glyburide, levothyroxine and contraceptives)	Primary effect, when used either alone or with a statin, is to lower LDL cholesterol; has blood glucose-lowering effect when taken in combination with certain diabetes medications. Before taking this medication, tell your healthcare provider if you have high triglycerides (blood fats) or stomach problems. If you take thyroid medication or glyburide, take them 4 hours before taking Welchol. Tell your healthcare provider if you have side effects that bother you or that don’t go away.
Combination Pills Pioglitazone & metformin) (Actoplus Met)  Glyburide & metformin (Glucovance) Glipizide & metformin (Metaglip) Sitagliptin & metformin (Janumet) Saxagliptin & metformin (kombiglyze ) Repaglinide & metformin (Prandimet) Pioglitazone & glimepiride (Duetact)	Check with your provider; usually taken once a day.	Combines the actions of each pill used in the combination.	Side effects are the same as those of each pill used in the combination. Some combination pills may lead to low blood glucose levels if one of the medications contained in the combination has this effect.	May decrease the number of pills you need to take.

Insulin pumps

 Many of you may have had a patient in your care with an insulin pump.  Insulin pumps and how they are used are foreign to many nurses. 

An insulin pump is a device that delivers insulin to a patient.  Inside most insulin pumps, there is a refillable syringe with insulin in it.  Attached to the syringe is tubing which leads to a small catheter which is placed in the subcutaneous tissue of the patient and taped down.

The insulin pump delivers insulin in two ways. By bolus and/or basal rate.

Bolus-  The patient would give themselves a “bolus” of insulin before eating a meal or to correct a high blood glucose.  They program the information into their insulin pump and then the pump delivers the insulin.

Basal rate- A basal rate is a tiny dose of insulin that is given usually hourly to keep the patients blood glucose in range.  The basal rate acts as the patients long acting insulin.  For example: instead of the patient receiving 10 units of lantus every night, the insulin pump would be programed to give 0.5 units of Novalog every hour for 24 hours.  The fascinating thing about using the basal rate method instead of one dose of long lasting insulin is that you can program the pump each hour to give a different amount of insulin to mimic the bodies normal cycle.  If a patient happens to chronically run a low blood glucose early in the morning, then the basal rate can be set to give less insulin during those morning hours.

What you need to know as a nurse?

- The insulin pump can be removed for short periods of time. If necessary, the patient can unhook the pump and tubing from the catheter site. 

-If your patient is experiencing hyperglycemia with ketones, chances are, their pump or insertion site is malfunctioning and needs to be changed out.

-If you patient is experiencing hypoglycemia, the pump can be unhooked to ensure that the patient is not getting additional insulin.

-Your best resource for knowing the in’s and out’s of using a pump usually lies with the patient.  They should usually be able to tell you anything you need to know about the pump.  A person who is not capable or responsible for working their pump should have a responsible adult who does know how to work their pump at all times.  Otherwise, there should be a phone number on the pump to call if you have any questions.

Great resources about insulin pumps:

Medtronic

Diabetes - How do insulin pumps work

Highs and Lows

Lows:

Symptoms:

Hunger

Shakiness

Sweaty

Pale face

Headache

Confusion

Drowsiness

Behavior changes

Double vision

Loss of consciousness

Seizure or convulsion

How to treat it:

For a mildly low glucose (below 70): give 2-8 oz sugary fluid. Recheck blood glucose in 10-20 min.  If BG is still below 70, repeat sugary fluid and recheck in 10-20 min. When BG is above 70, give a solid snack (10-20g complex carb. Crackers with peanut butter work great)

* The above treatment is a good rule of thumb but many diabetes know exactly what they need to take in order treat their lows. Just ask the patient what they normally use to treat their lows! *

I know oftentimes the first thing you want to do is start shoving sugar down the person’ throat! Beware, that if you over treat with sugar, your patient’s blood sugar will rise quickly then drop again.

*The most important thing I was taught about treating a low blood glucose is to treat, then wait a full 15 min to retest and re-treat if needed. Often, the body just needs enough time to replenish its glucose after being treated for a low blood sugar reading.*

The problem with lows:  The reason low blood sugar is bad is because your brain’s main source of nutrients comes from sugar.  Low sugar = low brain function.  If severe lows happen often, this can result in brain damage.

Highs:

Symptoms:

Hot

Irritable

Headache

Stomache ache

If a patient has a high blood glucose, they should take insulin to correct it as directed by their physician if they are prescribed insulin.  Many Type II Diabetics do not take insulin and therefore would just need to watch their blood sugars more often if they experience hyperglycemia.

In the pain procedure setting, we often cancel patients if they have a high blood sugar.  The reason for this is the steroid that we often use.  Steroids will increase the blood glucose even more which can be very dangerous for the patient.  Educating your patient on this is very important.  This can help them understand why their blood sugar is higher after they have a procedure.

A great resource that I used for this post is called Understanding Diabetes by H. Peter Chase, MD from the University of Colorado