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Home , Diabetes medication

Reference for Clinicians This table provides clinicians a brief overview of examples of used to treat diabetes. This is not a complete list and is not intended to be used as a sole reference. Nursing responsibilities with ALL diabetes medications: Emphasize importance of self-monitoring of glucose (SMBG); teach to be aware of signs/symptoms of allergic reactions; teach to be aware of possible side effects and contraindications; and monitor A1C levels.

Oral Medication Action Possible Side-effects Contraindications Nursing Responsibilities • Lowers glucose levels • Anorexia, , • Renal disease Patient education: • by decreasing the vomiting, diarrhea - • failure or • Take with food (Glucophage, amount of glucose usually occurs during alcohol abuse (can • Keep appointments Glucophage XR, produced by the liver initiation of the result in lactic for regular Glumetza, Fortamet, • Increases glucose • B-12 acidosis) function lab tests Riomet) uptake in muscle deficiency • Temporarily held on • Avoid alcohol • Multiple combinations cells • day of procedures • Report abnormal with other classes • Improves (severe but rare) with dye and glucose levels • First line therapy for & • Should not cause withheld 48 hours • Report s/s lactic ; hypertriglyceridemia as after the procedure; acidosis (weakness, current in obese patients monotherapy restart after drowsiness, malaise) recommendation is to with diabetes; may confirmation of renal start upon diagnosis promote weight loss function

This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National 1 Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-050216C Oral Medication Action Possible Side-effects Contraindications Nursing Responsibilities 2nd • Stimulates pancreatic • Hypoglycemia • Sulfa allergy • Assess for sulfa generation beta cells to release (especially with • Severe liver or kidney allergy • glyburide (DiaBeta, elderly and patients impairment Glynase, Micronase) with cardiovascular Patient education: • (Glucotrol, disease) • Take at same time Glucotrol XL) • of 2-3 kg daily 30 minutes • (Amaryl) • “Antabuse”-like before meal except response if consumed XL with alcohol • Take with food • Avoid alcohol

Alpha-glucosidase • Lowers postprandial • Flatulence • End-stage kidney Patient education: inhibitors (AGIs) rise in blood sugar by • Diarrhea disease • Take with first bite of • (Precose, delaying absorption • Abdominal distention • GI disorders main meal Glucobay) of carbohydrates • Be aware GI side • (Glyset) from intestines effects usually decrease with continued therapy • If used with other hypoglycemic agents, inform patient to treat hypoglycemia with faster acting glucose (glucose tabs or Lifesavers) instead of sucrose (white table sugar)

This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National 2 Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-050216C Oral Medication Action Possible Side-effects Contraindications Nursing Responsibilities Dipeptidyl Peptidase-4 • Reduces postprandial • Upper respiratory • Use with caution in Patient education: (DPP-4) Inhibitors rise in blood glucose tract patients with heart • Be aware of and • (Onglyza) by preventing the • Sore throat failure report s/s of • (Januvia) breakdown of GLP-1 • Headache • (Tradjenta) (GLP-1 reduces • Sitagliptin has been (abdominal pain, • (Nesina) glucose), which in associated with nausea/vomiting) • Multiple combinations turn stimulates pancreatitis • Inform that severe with other classes insulin synthesis and • Increased risk of and disabling decreases hypoglycemia when pain may occur secretion used in combination • Minimal to no weight with other diabetes gain • Increases insulin • Hypoglycemia • Caution with hepatic Patient education: • (Prandin) release in response to • Weight gain or renal impairment • Take within 15-30 • (Starlix) food ingestion minutes of a meal and skip/add dose if meal is skipped/ added • Keep appointments for regular kidney function lab tests Sodium-glucose co- • Blocks reabsorption • Hypotension, • Patient education: transporter 2 (SGLT2) of glucose by the especially with older • • Be aware of and inhibitors kidney, increases people, those with • Moderate or severe report s/s UTI • glucose excretion impaired renal renal impairment • Keep appointments (Invokana) function, and those • Active bladder cancer for regular kidney • (Farxiga) receiving function lab tests • empaglifozin • Urinary tract • Encourage self- (Jardiance) infection (UTI) monitoring of BP if • Vaginal candidiasis at risk for hypotension

This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National 3 Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-050216C Oral Medication Action Possible Side-effects Contraindications Nursing Responsibilities (TZDs) • Decreases insulin • Weight gain and • May cause or worsen Patient education: • (Avandia) resistance and edema (FDA • Monitor weight • (Actos) improves uptake in • Abnormal liver Black Box warning) regularly muscle and fat cells function tests • Active • Be aware of and • Decreases glucose • Actos may increase report s/s heart production in the risk of bladder failure liver cancer (FDA Black • Keep appointments • Pioglitazone increases Box warning) for regular kidney HDL levels and lowers function lab tests

Injectable Medication Action Possible Side-effects Contraindications Nursing Responsibilities mimetics • Used with insulin • Hypoglycemia; • Pregnancy Patient education: • (Symlin) • Slows food digestion • Nausea • History of frequent • Monitor blood glucose • Reduces glucose • Headache hypoglycemia 3 hours after production from liver • Irritation at injection • Confirmed diagnosis injection • May suppress hunger site of gastroparesis • Know that nausea/ • Weight loss vomiting may occur • Severe hypoglycemic when first starting risk 3 hours after this medicine injection (FDA Black Box warning)

This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National 4 Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-050216C Injectable Medication Action Possible Side-effects Contraindications Nursing Responsibilities GLP-1 Agonist ( • Stimulates release of • Nausea or vomiting • Kidney disease Patient education: mimetics) insulin • Headache • • Know that nausea is • (Byetta) • Reduces glucose • Dizziness • Pregnancy usually worse during • exenatide extended production from liver • Hypoglycemia, • Stomach or digestive first few weeks of release (Bydureon) - • Slows food digestion especially if used problems treatment and gets once weekly dosing • Used with metformin with sulfonylureas • Victoza and better over time • (Victoza) and sulfonylureas • Weight loss Bydureon have • Keep appointments • (Trulicity) • May suppress hunger increased risk of for regular kidney - once weekly dosing thyroid C-cell tumor function lab tests • (Tanzeum) (FDA Black Box • Explain extended - once weekly dosing warning) release may form small lumps at injection site which absorb as the medicine is released Insulin Type Onset* Peak* Duration Action Side Effects Nursing * Responsibilities Rapid-Acting <15 lispro 3-6 • Bolus insulin Primary side effect of Patient Education for • lispro (Humalog) minutes (Humalog) hours • Used with meals all insulin all insulin: • aspart (NovoLog) =30-60 • Often used with • Hypoglycemia, • Know type of insulin • glulisine min basal rate particularly during being used, (Apirda) aspart • Less chance of peak effect times including onset, (NovoLog) hypoglycemia after peak and duration of =1-3 hrs meals due to action glulisine shorter duration • Teach/observe (Apirda) injection technique, =1-2 hrs site rotation • Emphasize Short-Acting 30 2-3 hours 4-10 • Coverage for meals importance of SMBG • Regular minutes hours eaten within 30-60 • Teach proper storage o Novolin R minutes of insulin o Humulin R • Have sick-day plan • Teach to inspect

This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National 5 Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-050216C Injectable Medication Action Possible Side-effects Contraindications Nursing Responsibilities • Teach to inspect Intermediate-Acting 2-4 4-8 hours 10-18 • Coverage for later- injection sites for • NPH hours hours half the day or lipodystrophy (loss o Novolin N overnight of fatty tissue at o Humulin N • Often used with sites) short-acting insulin

Long-Acting • Basal insulin • 3-4 Steady 20-24 • Used for 24-hour (Lantus) hours delivery hours coverage (no peak)

• 3-4 3-14 hours 6-24 (Levemir) hours hours

• 30-90 Steady Up to 42 (Tresiba) minutes delivery hours available in (no peak) U100 and U200 • U300 insulin 2-4 6-8 hours < 24 • Basal insulin (more glargine hours hours concentrated than (Toujeo) Lantus) • Taken once a day

Pre-Mixed 5-15 Varies 10-16 • Convenient • Humulin 70/30 minutes hours combination but no • Novolin 70/30 flexibility with • Humalog 50/50; individual insulin 75/25 doses • NovoLog 70/30 Taken 2-3 times a day prior to meals

This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National 6 Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-050216C Injectable Medication Action Possible Side-effects Contraindications Nursing Responsibilities • Insulin 5-15 Varies 10-16 • Helps lower A1c degludec/insulin minutes hours • Decreases aspart 70/30 hypoglycemia (Ryzodeg) episodes • Taken once or twice daily depending on need of meal time insulin

This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National 7 Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-050216C Inhaled Insulin Onset* Peak* Duration Action Side Effects Nursing * Responsibilities Afrezza 15 1 hour 3 hours • Bolus-rapid acting • Hypoglycemia • Emphasize (regular human minutes insulin used before • Cough importance of insulin) meals • Throat irritation keeping regularly • Risk of acute scheduled exams to bronchospasm assess for chronic in patients with lung diseases such as chronic lung asthma or COPD disease • Teach how to use inhaler correctly

*Onset, Peak and Duration may vary with individuals. Patient self-monitoring blood glucose logs will help determine individual responses. References:

AHRQ (2015); ADA: Oral Medications (2015); ADA: Insulin Basics (2015); ADA Standards of Medical Care in Diabetes -2016, (2016); Mayo Clinic: Type 2 Diabetes (2014); NDIC: Amylin Mimetic (NIDDK) (2013); NDIC: Incretin Mimetic (NIDDK) (2013); Papadakis & McPhee (2013); U.S. FDA (2013)

This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National 8 Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-050216C