GLP-1Glucagon-like peptide-1 receptor agonist / What it does / More common side effects /caution / Good to know
ExanatideBYETTA 5-10 mcg BID
Extanatide ER BYDUREON,
LiraglutideVICTOZA0.6,1.2, 1.8 mg QD
AlbiglutideEPERZAN/
TANZEUM 30-50mg qwk
DulaglutideTRULICITY 0.75mg qwk, to 1.5mg / -Incretin mimetic
- insulin release while eating
-slows gastric emptying
-suppresses glucagon
-promotes satiety. / GI nausea, vomiting, diarrhea that resolves over time; increased heart rate; acute pancreatitis; increased risk for C-cell thyroid tumors
Not recommended in individuals with Hx GI problems or pancreatitis.
Reinforce to pts to report abdominal pain (pancreatitis) / rarehypoglycemia unless combined with sulfonureas or insulin; weight loss;lower post prandial blood glucose which lowers A1C
Injected
Prefilled injection devices
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Need missed dose plan for weekly
DPP-4 inhibitors: Dipeptidyl peptidase 4
SitagliptinJANUVIA100 mg qd
SaxagliptinONGLYZA2.5-5mg qd
LinagliptinTRAJENTA 5mg qd
AlogliptinNESENA25mg qd
All combined with metformin under different names / Lowerspost prandial blood glucose by stopping DPP-4 from breaking down the GLP-1 hormone. This means that GLP-1 is available for a longer period to signal the pancreas to release insulin while eating.
Adjust dose for renal pts / allergy to medication, acute pancreatitis, increased risk of heart failure, severe joint pain
Reinforce to pts to report abdominal pain, weight increase and SOB / Reduce dose of insulin or sulfonurea may be needed; well tolerated, more effective during early years of T2DM when GLP-1 levels are sufficient and the pancreas is able to respond. Takenpo daily, with or without food.
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SGLT2 Inhibitors Sodium-glucose transporter 2:CanagliflozinINVOKANA 100-300mgqd
Dapagliflozin FARXIGA 5-10mg qd
EmpagliflozinJARDIANCE10-25mg qd
Also combo with metformin under various names ieInvokanmet / Glucose is excreted in urine or reabsorbed into the blood because of SGLT2. SGLT2 inhibitors lower the renal threshold,block the glucose from returning into the blood, causing extra glucose to be eliminated in the urine.
Adjust dose based on eGFR.
Can give with other DM meds / GU yeast infections, (stop until yeast infection resolved and restart medication. If reoccurs, consider discontinuation.increased urination especially with higher BG, dehydration, low BP, increase in LDL, temporary increase in creatinine.
Rare risk of DKA in Type 2, increase in amputations (prior hx) / no hypoglycemia; weight loss; lower post prandial glucose; can be used in mild to moderate kidney disease
assess for fluid balance(CHF, CKD, dehydration risks)
Taken po first meal of the day. “what floz in, flows out”
Increased urination post high carb meal; increase hydration, daily foot care; FDA reduced CHF,CVD $$$
New insulins- $$$$ / Side Effects
Hypoglycemia with all! / Good to know !
Afreeza inhaled insulin powder:ON HOLD BY DRUG COMPANY Rapid acting insulin given prior to meals via cartridges that are loaded and inhaled. Repeat for full dose.Available color coded in 4 units(blue) or 8 units(green) or mix of 4/8unit cartridge blister cards. / Refrigerate: good to expiration date. Room temp 10 minutes before use.
Room temperature and in sealed foil package: use within 10 days.
Opened foil: use within 3 days. / Black box warning: bronchospasm
Contraindicated in pts with chronic lung disease such as asthma or COPD because of risk of acute bronchospasm. / FEV1/spirometry needed prior to ordering. If OK, repeat at 6 months then annually. Not recommended for patients who smoke or recently stopped smoking. Not to be used for DKA.
2 inhalers with every box, good for 15 days each.
Humalog Kwikpen U200 Rapid acting insulin in a concentrated form of U200. 200 units/ml. / 600units insulin in a pen. Amount dialed is amount units to be given, just the volume would be different. / Smaller volumes less lipodystrophy.
Less frequent pen changes. / May need PA. .
ToujeoSolostar penlongacting concentrated insulin glargine U300. 300 units/1 ml versus usual 100 units/ml. / Available only pen, contains 450 units. Smaller volume, less weight gain. No peak effect with duration of 36 hours.
Amount dialed is amount units to be given, just the volume would be different. / Less nocturnal hypoglycemia and wt gain than Lantus.
Deceased risk of lipodystropy affecting absorption
Less waste
Less frequent pen changes.
ONCE a day dosing preferably at same time. Titration q 3-4 days. Seems to need higher dose (14%) than Lantus / Coach Program and copay card: no more than $15 a month for private insurance or cash paying pts. Good option for Group Health patients where prior auth (PA)needed for Lantus. These patients would otherwise need to be on NPH or pay the $450 out of pocket for Lantus.
BG may go up first 3 days
PA needed Apple health
Tresiba Flexpen
LongactingDegludecU100 or U200 insulin / Available in U100, dials to 80 or U200 dials to 160. Stable at room temp for longer: 56 days. Duration 36 hrs. / ONCE a day dosing preferably at same time. Titration q 3-4 days. / Approval pending for combo with Victoza
BG may go up first 3 days
BasaglarKwikpen / Biosimilar of glargine / Works like lantus / Available Dec 2016
Cost less than lantus,
Humulin R U 500 pen / 5 unit increments, 1500units / BID/TID dosing; think NPH / Safer than U 500 vial
Humulin R U 500 concentrationVial
Starts to work quickly but can have a long duration, usually 8-14 hrs(up to 24 hr, think of NPH )
Does not work like Humulin R U 100 which lasts 6-8 hrs
5 times more concentrated than U100
Used when over 200 units/day needed
Insulin resistance/ high calorie / 20 ml bottle $1200, 10000 units
Taken 30 minutes before meal BID or TID
Rarely take at HS unless over than 600 units per day
High risk for prolonged hypoglycemia when ill because of decreased caloric intakeie 4000 calories at home, 1800 calories in hospital
potential for stacking if used like Humulin R U100 ac/HS
Now available in a pen!! 5 unit increments
Precautions / Safe Dosing / Dosing Formulas / examples
Patient taught to report that they are on U500.
Ask what they are actually taking at home, when they take it. / TB syringe by volume preferred but less common.
Ask pt to show where they draw up to on the insulin syringe. / U-100 syringe: divide prescribed dose(actual units of U500) by 5=markings in a U100 syringe
Volume: Divide prescribed dose (actual U500 units) by 500= volume in TB/allergy syringe / 25 units of Humulin R U500
Divided by 5 = 5 unit marking in a U100 syringe
Divided by 500 = 0.05 ml TB syringe
Patient more likely to state/show they take 40 units on U100 syringe / Multiply Unit marking on syringe by 5 to determine U 500 amount / 40 unit mark x 5 = 200 units U500
Pt usually will need to be converted to U100 basal/premeal with correction while in hospital. The total daily dose of U500 is calculated out, then split 50% basal and the other 50% in 3 for acTID.with custom correction scale. The dose may need to be decreased by 20% as their caloric intake may be dramatically different. However, if they are on steroids, a dose reduction may not be necessary. Do not use with other insulins.
Line Goulet, RN, BSN,M.Ed. CDE WhidbeyHealth 01/2017