Diabetes Mellitus (DM) Medication Guide
Insulin
Overview of Insulin Therapy
Purpose: Exogenous insulin is required when the pancreas cannot produce sufficient insulin to meet metabolic demands.
o Type 1 Diabetes Mellitus (T1DM): Requires insulin for survival due to absolute insulin deficiency.
o Type 2 Diabetes Mellitus (T2DM): May need insulin during stress (e.g., illness, surgery) or as the disease
progresses and oral agents (OAs) or noninsulin injectable agents fail to maintain glycemic control.
Administration:
o Type 1 DM: Requires multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) via a pump.
Basal with Bolus = multiple doses or pump
o Type 2 DM: May require up to four injections per day or insulin pump therapy for tight glucose control.
o Bolus – for after meals (rapid)
o Basal – continuous supply
Always want 70 – 100 glucose
Types of Insulin
Diabetes Mellitus (DM) Medication Guide
Memorize this information
Table 53.4-page 1291 for types of insulin
Insulin Plans
1. Basal-Bolus Plan:
o Basal Insulin (long- or intermediate-acting): Maintains glucose levels between meals and overnight.
1. Long-Acting Insulin: Preferred for basal control; lower risk of hypoglycemia due to no significant peak.
o Bolus Insulin (rapid- or short-acting): Controls postprandial (after meals = AC) glucose surges.
1. Rapid-Acting Insulin: Ideal for flexible mealtime coverage.
o Goal: Mimic endogenous insulin release and maintain “time in range” as close to normal as possible (Table 53.5-
page 1292) .
2. Combination Therapy:
o Premixed formulations combine basal and bolus insulin for fewer injections per day.
o Examples: 70/30 (70% NPH and 30% regular insulin).
o Less flexibility in dosing; often used for patients with limited dexterity or complex regimens.
Diabetes Mellitus (DM) Medication Guide
o Combination Insulin: Simplifies regimens but lacks flexibility.
Administration Essentials
Subcutaneous Injection:
o Sites: Abdomen (fastest absorption), arms, thighs, buttocks.
o Rotate sites within the same region to prevent lipodystrophy (e.g.,
atrophy or hypertrophy of fat tissue).
o Use short needles for most patients (5 mm or 8 mm).
o Angle: 90° for most patients, 45° for thin individuals.
o Insulin Pens
Portable
Consistent and accurate
Poor vision (hear click)
Smart pens
Insulin Pump:
o Delivers continuous basal insulin and allows bolus dosing at meals.
o Advantages: Tighter glucose control, flexibility with meals and activities.
o Challenges: Risk of infection, cost, and device dependence.
IV Insulin:
o Only regular insulin can be given intravenously, often used in emergencies (e.g., diabetic ketoacidosis).
Storage and Handling
At Room Temperature: Insulin vials and pens in use can be kept at room temperature (up to 86°F or 30°C) for 4 weeks.
Refrigeration: Unopened insulin should be stored in the refrigerator. Avoid freezing or exposure to direct sunlight.
Diabetes Mellitus (DM) Medication Guide
Prefilled Syringes:
o Stable for 1 week (if mixed) or 30 days (single insulin type) when refrigerated.
o Store vertically with needles pointing up.
Common Problems and Solutions
1. Hypoglycemia:
o Causes: Excess insulin, missed meals, unplanned activity.
o Symptoms: Tremors, confusion, sweating.
o Management: Immediate carbohydrate intake or glucagon for severe cases.
2. Lipodystrophy:
o Cause: Repeated use of the same injection site.
o Prevention: Rotate injection sites.
3. Somogyi Effect:
o Cause: Rebound hyperglycemia due to nocturnal hypoglycemia.
o Solution: Decrease evening insulin dose or add a bedtime snack.
4. Dawn Phenomenon:
o Cause: Early morning hyperglycemia due to increased growth hormone and cortisol.
o Solution: Increase evening insulin or adjust timing.
Patient Education
1. Include the following direction when teaching about insulin:
o Wash hands thoroughly.
o Always inspect insulin bottle before using it. Make sure that it is the right type and
concentration, expiration date has not passed, and top of bottle is in perfect
Diabetes Mellitus (DM) Medication Guide
condition. Insulin solutions (except for NPH, lispro protamine, aspart protamine) should look clear and colorless.
Discard if it appears discolored or you see particles in the solution.
o For intermediate-acting insulins (which are normally cloudy), gently roll the insulin bottle between the palms of
hands to mix the insulin.
1. Do not agitate clear insulins.
2. Do not shake insulin to minimize introduction of air bubbles.
o Choose the right injection site.
o Ensure that the site is clean and dry.
o Push the needle straight into the skin (90-degree angle). If you are very thin, muscular, or using an 8- or 12-mm
needle, you may need to pinch the skin and/or use a 45-degree angle.
o Push the plunger all the way down, leave needle in place for 5 sec to ensure that all insulin is injected, and then
remove needle.
o Destroy and dispose of single-use syringes safely.
2. Self-Monitoring:
o Frequent blood glucose monitoring (at least 4x/day or per HCP instructions).
o Use Continuous Glucose Monitoring (CGM) systems when available.
3. Storage:
o Teach patients to protect insulin from extreme temperatures.
o Instruct on warming prefilled syringes by rolling them between the palms before use.
Oral DM Medication
Insulin resistance
Decreased insulin production
Increased liver glucose production
Can be combined with insulin as needed.
Diabetes Mellitus (DM) Medication Guide
Class MOA Nursing Hypoglyce Wt Chronic Heart Atherosclerot
Mediatio Considerations mia Kidney Failure ic CVD
n
Biguanide Hold 48 hours before and after
procedures with IV contrast.
s
Reduces liver glucose Avoid in kidney, liver, or heart
Metformin production failure.
0 ↓ Loss No No
enhances insulin sensitivity Can cause lactic acidosis;
improves glucose uptake monitor for symptoms.
Contraindicated with excess
alcohol use.
Sulfonylur Risk of hypoglycemia; monitor
glucose closely.
eas Stimulates insulin release Take with meals to avoid lows.
Glimepiride, from beta cells ↑High ↑Gain No Yes 0
Glipizide,
Glyburide
Thiazolidi Monitor for cardiovascular side
effects (e.g., heart failure, MI).
nediones
Improves insulin Increased risk of bladder cancer
Pioglitazone (pioglitazone).
sensitivity, transport, and 0 ↑ Gain Yes No ? Benefit
, usage at target tissues. Avoid in patients with heart
Rosiglitazon failure.
e
SGLT-2 Monitor for urinary tract
infections and dehydration.
Inhibitors
Helps with weight loss.
canagliflozi Cardiovascular and renal
n Blocks glucose protective effects.
reabsorption in the
dapagliflozi kidneys, increasing glucose
↑Low 0 No Yes Benefit
n excretion in urine.
empagliflozi
n
ertugliflozin
GLP-1 Administer subcutaneously
(most forms).
Analogues
Avoid in patients with a history
albiglutide of medullary thyroid cancer or
dulaglutide Increases insulin synthesis, pancreatitis.
inhibits glucagon secretion, Can cause nausea and weight
exenatide slows gastric emptying,
0 ↓ NO Yes Liraglutide
loss.
exenatide and increases satiety.
liraglutide
semaglutid
e
DPP-4 Enhances incretin activity, Lower hypoglycemia risk due to ↑Low 0 Yes No 0
increasing insulin secretion glucose-dependent action.
Inhibitors
and decreasing liver Does not cause weight gain.
alogliptin glucose production.
linagliptin
Diabetes Mellitus (DM) Medication Guide
saxagliptin
sitagliptin
