Medication Education - Diabetes

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VASUpharm14
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280641
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Medication Education - Diabetes
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2014-08-15 15:05:52
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DI, counseling, and pearls - Ch. 21
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  1. Diabetes Ch. 21
  2. Biguanide - metformin
    • DI: ETOH = INC lactic acidosis (renal impairment and advanced heart dx)
    • - Iodinated contrast dye = INC lactic acidosis (hold 48 hours and check renal prior to restart)
    • - DEC vit B-12 absorption and folic acid (supplement)
    • Counseling: 1. take BID with morning and evening meals, daily with evening ER
    • 2. upset stomach - food will help
    • 3. rare - life-threatening condition called lactic acidosis (weakness, SOB, stomach pain, slow heart rate, sleepy)
    • 4. Glumetza, Fortamet, Glucophage XR - ghost shell
    • 5. X-ray or CT scan with dye injection - temporarily stop metformin and let doctor know
  3. Sulfonyureas - glipizide, glimepiride, glyburide
    • DI: insulin - stop SU = hypoglycemia
    • - reduce dose SU with TZD, GLP-1 agonist, DDP-4 inhibitors, canagliflozin
    • - caution 2C9 ind/inh
    • - Glyburide avoid CRCL < 50 ml/min
    • Counseling: 1. Glipizide XR with first meal, IR 30 mins before breakfast and dinner, Glimepiride QD with first meal
    • 2. watch for sx of hypoglycemia (shaky, hungry, confused, dizzy, sweat, fast heartbeat)
  4. Meglitinides - repaglinide, nateglinide
    • DI: insulin = hypoglycemia
    • - reduce dose of meg with TZD, GLP-1 agonist, DDP-4 inhibitors, canagliflozin
    • - Gemfibrozil INC Prandin (repa) and DEC BG = choose fenofibrate instead
    • - caution with drugs cause hypoglycemia (IQ FLOP)
    • Counseling: 1. 30 mins prior to meals (skip if forget)
    • 2. skip meal = skip dose
    • 3. watch for sx of hypoglycemia (shaky, hungry, confused, dizzy, sweat, fast heartbeat)
  5. TZD - pioglitazone, rosiglitazone
    • DI: can reduce amount of insulin or SU/meg required
    • - CYP2C8 - caution with rifampin and gemfibrozil
    • Counseling: 1. QD w/wo food
    • 2. takes several weeks to work = monitor
    • 3. check up to rule out CHF, heart issues, fluid retention, bladder cancer, hx of MI, stroke, liver dx
    • 4. Contact doctor - a) liver damage (dark colored urine, pale stools, skin or eyes are yellow), b) water retention (ankles swell, trouble breathing), c) women = bone fractures
  6. Alpha- glucosidase inhibitors - acarbose, miglitol
    • Counseling: 1) take with full glass of water with first bite of food (no food, no drug)
    • 2) gas, diarrhea, abdominal pain that goes away with time
    • 3) hypoglyemic - use glucose tabs ONLY (sugars won't work)
  7. DPP-4 inhibitors - sitagliptin, saxagliptin, linagliptin, alogliptin
    • DI: reduce insulin or SU/megs required
    • - saxagliptin (Onglyza) - major 3A4 substrate = lower dose 2.5 mg with strong inhibitors
    • - linagliptin (Tradjenta) - major 3A4 and P-gp substrate = DEC levels cause by strong inducers
    • Counseling: 1) QD in AM w/wo food
    • 2) Contact doctor - trouble breathing, sx of pancreatitis (severe stomach pain, radiate from abdomen to back)
  8. Sodium glucose co-transporter-2 inhibitor (SGLT2) - canagliflozin
    • DI: reduce insulin or SU/megs required
    • - UGT inducers (rifampin) reduce level of SGLT2 = dose increase SGLT2 to 300 mg
    • - INC digoxin AUC
    • - contraindicated in renal CRCL <30 ml/min, ESRD, dialysis
  9. Glucagon-like peptide-1 (GLP-1) agonists - exenatide, liraglutide
    • DI: reduce insulin or SU/megs required
    • - can slow gastric emptying and reduce absorption of PO drugs
    • - Byetta (exenatide) - OC DEC = take OC 1 hour prior
    • Counseling: 1) Administer with fresh needle by SC injection in stomach area, thigh, back of upper arm (count to 5)
    • 2) store in fridge or RT (30 days), not freeze
    • 3. nausea decreases over time (drink fluids)
    • 4. Contact doctor - sx of pancreatitis (severe stomach pain, radiate from abdomen to back), dec ETOH use
    • Byetta: 1) inject BID within 60 mins before morning and evening meals (meals 6 hours apart) - after meals = hypoglycemia
    • 2) expect in 1 month - no nausea = INC dose
    • 3) toss after 30 days
    • Bydureon: 1) once every 7 days (weekly), missed dose - at least 3 days from next dose
    • 2) inject immediately after mixing
    • Victoza: 1) inject QD 
    • 2) expect dose inc after 1 week
    • Note: not with thyroid cancer, contact doctor - swelling in neck, trouble swallowing, SOB
  10. Pramlintide
    DI: slows gastric emptying which can reduce absorption of PO drugs
  11. Bile acid binding resins - colesevelam
    • DI: Separate 4 hours AFTER with certain drugs
    • - monitor INR with warfarin
    • - 4-6 hours BEFORE Niaspan
    • Counseling: 1) constipation = laxatives (senna), stool softener (docusate), fluid intake
    • 2) DEC ADEK vitamins = take multivitamin at other time
  12. Bromocriptine
    • DI: CYP 3A4 - watch inducers and inhibitors
    • - do NOT use other ergot medications 
    • - adjust with SU
  13. Insulin
    • Counseling: 1) store unused in fridge and used in RT
    • 2) wash hands and prepare
    • 3) check insulin - color, crystals, lumps
    • 4) roll bottle gently in hand (don't shake) or invert pen 4-5 times
    • 5) clean injection site and insulin top with alcohol swab (let dry)
    • 6) abdomen is preferred injection site
    • 7) alter sites (avoid inflammation and atrophy) and make sure 1 inch from navel and last site
    • 8) pinch skin, insert 90 degree , and count to 5-10 seconds
    • 9) proper disposal
  14. hypoglycemia
    • sx: dizziness, h/a, anxiety, shakiness, diaphoresis (sweating), excessive hunger, confusion, clumsy or jerky movements, tremors, palpitations, fast hear rate, blurred vision
    • Treatment: conscious - 15-20 grams of glucose, 1/2 cup (4 oz) of any juice or regular (non-diet) soda, 1 cup (8 oz) milk, 1 tablespoon of sugar or honey, 2 tablespoons of raisins, 4-5 saltine crackers, 3 or 4 glucose tabs, 1 servicing of glucose gel 
    • then - retest in 15 minutes, repeat if necessary and eat a meal when BG back to normal
    • - unconscious = glucagon 1 mg SC/IM/IV 
    • - alternative: Dextrose 25%, 50%

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