Dsme taking medication powerpoint

TAKING MEDICATION

Stacy McDaniel, RN/Diabetic Educator

LEARNING OBJECTIVES

The Participant will:• Name the prescribed diabetes medications and state its proper

dose and frequency• State the purpose of the medication• Explain relevant side effects to watch for• Describe actions to minimize side effects and what to do if side

effects occur• Demonstrate awareness of relevant precautions about his or her

medication• Describe proper storage and transport of medication

SKILLS

Participants who are taking injected medications will:• Demonstrate proper preparation and self-

administration of injection• Demonstrate proper disposal of used needles

Why is medication necessary?

In type 1 diabetes, insulin is always needed to replace what the pancreas no longer produces. Type 2 diabetes is a progressive condition. It starts with insulin resistance. This means that the body is unable to respond properly to its own insulin. Physical activity and healthy eating, combined with weight loss, can help reverse insulin resistance, but only to a point. There comes a time when medicine is needed to help your body cells be more sensitive – and less resistant – to insulin. The next thing that happens in type 2 diabetes is a decline in production of insulin. This decline continues for as long as you live. When your pancreas cannot make enough insulin, medicine is needed to help you control your blood glucose level. In the earliest stages of type 2 diabetes, pills can often help you make more insulin. If your body doesn’t respond to pills, insulin can be taken.

ORAL DIABETES MEDICATIONS

Insulin Sensitizers

METFORMIN

Metformin is the generic name for Glucophage, Glucophage XR, Riomet, Glumetza and Fortamet.

Metformin works in two ways. It reduces the amount of glucose your liver produces and also helps your body cells (fat and muscle) use insulin better. Metformin used alone, does not cause hypoglycemia (low blood glucose).

Typically, your provider will start you at a low dose and increase it gradually until the desired effect is seen. If taking the extended release (XR), do not crush the pill. It should be taken with the first bite of a meal.

METFORMIN CONTINUEDPrecautions: • Get a blood test to check kidneys before starting

metformin. People over 80 should have a 24 hour urine test in addition to the blood test.

• Stop metformin temporarily if seriously ill (heart attack, surgery, worsening heart failure).

• Should not be taken the day of an x-ray using injected dye containing iodine. Wait 2 days to restart metformin.

Side Effects:• Slight weight loss (up to about 10 lb) may occur• Improvement in lipids (triglycerides, cholesterol, LDL

and HDL)• Gastrointestinal effects: metallic taste, abdominal

bloating, nausea, diarrhea, cramping and feeling full. Usually go away after a week or two.

PIOGLITAZONE AND ROSIGLITAZONE

Pioglitazone is the generic name for Actos. Rosiglitazone is the generic name for Avandia. Together, these medications belong to a class of drugs referred to as TZDs (thiazolidinediones).

How it works:Work by helping your body cells use insulin better. It does not cause you to make more insulin. If used by itself, neither medications cause hypoglycemia.

Precautions: You should have a blood test to check your liver before starting therapy. Your provider should repeat liver function tests periodically while taking this medication. Should not be taken by pregnant or breastfeeding women or by children.

PIO GL ITAZO N E AND RO SIGLITAZ O NE CO NT.

Side effects:• Small changes in lipids may occur with either

medication.• Weight gain, probably due to fluid retention (edema).

Edema tends to be worse in those taking insulin along with either medication. If you notice an increase of weight of over 7 lb, notify your provider.

• Any swelling in the feet or lower legs, shortness of breath, trouble breathing at night, or unexplained cough should be reported promptly to your provider.

• Muscle aches, abdominal pain, or flank pain should be reported to your provider.

DPP-IV INHIBITORS ( S T I A G L I P T I N, A L O G L I P T I N, L I N A G L I P T I N, S A X A G L I P T I N

Sitagliptin is generic for Januvia. Alogliptin is generic for Nesina. Linagliptin is generic for Tradjenta. Saxagliptin is generic for Onglyza.

How it works:Work by blocking the action of an enzyme so that it cannot destroy GLP-1 (hormone produced by your intestine). It stimulates the pancreas to produce insulin after a meal. It also helps lower the amount of glucose released by the liver after a meal. These actions work to blunt the rise in blood glucose after eating. Usually do not cause hypoglycemia when used alone. Studies show that these medications are weight neutral.

DPP-IV INHIBITORS (ST IA GLIP T IN, A LOG LIPT IN,

L IN AGLIP T IN, S AXA GLIP T IN CONT.

Side effects:• Gastrointestinal effects like diarrhea or abdominal

pain, headache, and runny nose are rare but may occur. In short, these medicines have very few side effects, so any unusual problems that occur after starting them should be reported to your healthcare provider.

INSULIN SECRETAGOGUES ( G LY B U R I D E ,

G L I P I Z I D E , G L I M E P I R I D E )Glyburide is generic for Micronase and Glynase. Glipizide is generic for Glucotrol and Glucotrol XL. Glimepiride is generic for Amaryl.

How it works:Work by increasing the amount of insulin your pancreas releases. In some people, they work at first then stop working later on. If your pancreas can no longer produce enough insulin, these medications will be ineffective. There is a risk of hypoglycemia because of increase insulin. Glyburide is also used in the treatment of gestational diabetes. It is classified as Category B in pregnancy by the FDA.

INSULIN SECRETAGOGUES ( G LY B U R I D E ,

G L I P I Z I D E , G L I M E P I R I D E C O N T. )

Precautions:Your provider should have lab results that prove you have good kidney and liver function to safely take these medications. The main precaution to watch for is hypoglycemia. Do not split or crush a Glucotrol XL pill. This will increase the risk of hypoglycemia. Hypersensitivity rash after sun exposure is possible. Use sunscreen to limit skin problems with sun exposure.

Side effects:• Hypoglycemia• Weight gain, probably related to increased insulin

(which promotes the storage of fat)

REPAGLINIDE AND NATEGLINIDE

Repaglinide is generic for Prandin. Nateglinide is generic for Starlix.

How it works:Works by increasing the amount of insulin released from your pancreas. If your pancreas no longer produces enough insulin, these medicines will not be effective. Has a lower risk for hypoglycemia than with similar medicines that affect insulin release.

Precautions:Should not be taken by pregnant or breastfeeding women or by children.They should be used with caution in those with liver disease.Side effects: • Hypoglycemia is possible

ALPHA-GLUCOSIDASE INHIBITORS (MIGLITOL AND

ACARBOSE)Miglitol is generic for Glyset. Acarbose is generic for Precose.

How it works:Works by limiting the absorption of carbohydrate in your intestine during digestion. This blunts the rise of blood glucose after meals. Because they do not cause an increase in insulin, it does not cause hypoglycemia. But if taken in combination with medicines like insulin secretagogues, yu may be at risk for hypoglycemia. If hypoglycemia occurs while taking these medicines, treatment should be with glucose tabs or glucose gel. Because of how these medicines work, hypoglycemia treatment with other types of carbohydrates (like table sugar, juice, or soda) will not be effective.

ALPHA-GLUCOSIDASE INHIBITORS ( M I G L I T O L A N D A C A R B O S E C O N T. )

Side effects:• Gastrointestinal effects like flatulence, diarrhea, and

abdominal pain are the main side effects of miglitol and acarbose. They are generally worse when the medicine is first started and when the dosage is increased. Side effects usually subside after several weeks of taking the medicines. Being active after a meal will help limit the buildup of gas.

SODIUM-GLUCOSE CO-TRANSPORTER

INHIBITORS (CANAGLIFLOZIN,

DAPAGLIFLOZIN, EMPAGLIFLOZIN

Canagliflozin is generic for Invokana. Dapagliflozin is generic for Farxiga. Empagliflozin is generic for Jardiance.

How it works:Works by blocking the reabsorption of glucose in the kidney. The increases the excretion of glucose in the urine and decreases blood glucose levels. These medicines can cause hypoglycemia, but the risk of hypoglycemia is increased if taken with sulfonylureas or insulin.

S O D I U M - G LU C O S E C O - T R A N S P O R T E R I N H I B I T O R S ( C A N A G L I F L O Z I N , D A P A G L I F L O Z I N ,

E M P A G L I F L O Z I N

Precautions: Dehydration may occur in people who have low blood pressure, take blood pressure medications, have kidney problems, or a 65 years old. Women and men may experience yeast infections and urinary tract infections. Those prone to these infections are more susceptible. Increase in LDL cholesterol have been observed.

Side effects:• Include an increased risk of infections, particularly of the

urinary tract, genitals and upper respiratory tract. More likely to occur in those prone to such infections.

COM BIN ATION O RAL DIABETES MEDICATION S

There are a number of combination diabetes medicines today. Combinations may simplify your diabetes therapy. If you take one of these medicines, you should be aware of how each part works, as well as possible side effects.• Actoplus met: pioglitazone and metformin• Actoplus met XR: pioglitazone and metformin ER• Avandaryl: rosiglitazone and glimepiride• Avandamet: rosiglitazone and metformin• Duetact: pioglitazone and glimepiride• Glucovance: glyburide and metformin• Invokamet: canagliflozin and metformin• Janumet: sitagliptin and metformin• Janumet XR: sitagliptin and metformin ER

COMB INAT ION ORAL DIAB ET ES MEDICAT IO NS CO NT.

Jentadueto: linagliptin and metforminKazano: alogliptin and metforminKombiglyze XR: saxagliptin and metformin ERMetaglip: glipizide and metforminOseni: alogliptin and pioglitazonePrandimet: repaglinide and metforminXigduo XR: dapagliflozin and metformin ER

INSULINWhen a person has diabetes, there is a problem with insulin production. In type 1 diabetes, insulin production stops completely. Insulin therapy is always needed to maintain life and regulate the blood glucose level. In type 2 diabetes, there is a continual decline in the amount of insulin produced. In most people with type 2 diabetes, the time will come when their pancreas can no longer make enough insulin to meet their needs. At that point, insulin therapy is needed to regulate the blood glucose level.

Insulin is available by injection or by way of an insulin pump. Insulin cannot be taken in pill form, because the digestive juices would destroy it.

More recently, inhaled insulin was approved by the FDA and is on the market.

INSULIN CONT.Human insulin is made in a laboratory using special gene technology. It is not made from the pancreases of humans. Its chemical structure is the same as human insulin. In the past, insulin was made from the pancreases of pigs and cows. This form of insulin is no longer available in the United States. Insulin is obtained at a pharmacy. A prescription is required.

Insulin is measured in unites. In the US, insulin is made in two strengths: U-100 and U-500. U-100 means that there are 100 units of insulin in each milliliter of liquid. U-500 means that there a 500 units of insulin in each milliliter of liquid; this is five times more concentrated than U-100. U-500 is needed for those people who require unusually large doses of insulin.

TYPES O F IN SUL IN AN D HO W THEY WO RK

There are many types of insulin, and they work in different ways after they are injected. When the insulin first starts to lower the glucose level is called the onset of action. When it lowers the glucose the most it is called the peak. The period of time the insulin is lowering the glucose is called the duration of action. Insulin types are classified according to their onset, peak and duration. For safety reasons it is important to know when your dose of insulin is working to lower your blood glucose.

INSULIN AND ITS ACTIONClassification

Generic Name

Brand Name

Onset Peak Duration

Color

Rapid Acting

AspartGlulisineLisproInhaled Insulin

NovologApidraHumalogAfrezza

5-15 min

12-15 min

1-2 hrs

1 hr

4-6 hrs

3 hrs

Clear

N/A

Short Acting

Regular, human

Humulin RNovolin RRelion/Nov R

30-60 min

2-4 hrs 6-10 hrs

Clear

Intermediate-Acting

Isophane, human (NPH)

Humulin NNovolin NRelion/ Nov N

1-2 hrs 4-8 hrs 10-18 hrs

Cloudy

Long-Acting

DetemirGlargine

LevemirLantus

1-2 hrs No peak

Up to 24Hrs

Clear

INSULIN CONT.Side Effects:Because insulin lowers glucose, there is always a possibility the glucose level could drop too low. This is called hypoglycemia. To keep hypoglycemia from occurring, you should balance your food and activity with insulin’s action. You should also monitor glucose to see how you respond to insulin. If you take insulin that peaks, you should eat a meal during the peak time to avoid hypoglycemia. If you take insulin that peaks, it is best not to exercise during the peak time. Physical activity lowers the glucose level. If both insulin and activity are lowering glucose at the same time, hypoglycemia may occur. Time your activity for when the insulin is not peaking.

INSULIN CONT.Storage:• Unopened, unused vials of insulin should be kept

refrigerated and protected from light. Refrigerated, unopened vials of insulin can be used until the printed expiration date.

• If the unopened, unused vial of insulin is kept at room temperature (not to exceed 86°F) it must be discarded after 1 month.

• Opened vial or pen device of insulin that is in use at home or while traveling: store at room temperature not to exceed 86° F.

• Most brands of insulin are good for 1 month at room temperature after opening the vial or pen device. Throw away after 30 days, even if some insulin is left in the vial.

• It is OK to keep the vial or pen device you are using in the refrigerator.

• Never freeze or microwave insulin. This will harm the insulin.

INSULIN CONT.

Rapid Acting Insulin:Rapid acting insulin is intended to control the blood glucose rise that happens after a meal. Once injected, the insulin starts to enter the bloodstream quickly, within 5 to 15 minutes. You should begin to eat within 15 minutes of injecting rapid-acting insulin to prevent hypoglycemia. After you eat, the food is actively raising your glucose level for the next 1 to 2 hours. Rapid-acting insulin is actively moving this glucose into your body cells during this same time. The insulin continues to lower blood glucose somewhat until it wears off, in about 4 to 6 hours.

INSULIN CONT.

Short-Acting Insulin:Regular insulin is the generic name for short acting insulin. If you see a colored tint to the solution, or if a colored ring has formed at the top, do not use. Regular insulin is intended to impact the blood glucose rise that happens after a meal, but there is a lag in its action. For this reason, you should take regular insulin 30 to 45 minutes before eating. This gives the insulin a head start. It takes 30 to 60 minutes for regular insulin to enter the bloodstream. After you eat, the food is actively raising your glucose level for the next 1 to 2 hours. Regular insulin moves this glucose into your body cells the most (peak) in 2 to 4 hours. The insulin continues to lower blood glucose somewhat until it wears off, in about 6 to 10 hours.

INSULIN CONT.Intermediate-Acting Insulin:Insulin isophane is the generic name for intermediate-acting insulin. Commonly referred to as NPH. NPH is a cloudy white color. It is cloudy because a substance has been added to the insulin to slow down its action. If you see any white clumps floating in solution after mixing, or if the bottle has a frosted look to it, do not use. You must gently mix this solution before you prepare your injection. Roll the container between the palms several times. NPH is intended to impact the blood glucose rise that occurs man hours after injection. Once injected, NPH begins to enter the bloodstream in 1 to 2 hours. It has a long, drawn out peak time, 4 to 8 hours after injection. It stays in the system for 10 to 18 hours before it wears off.

INSULIN CONT.Long-Acting Insulin:There are two long-acting insulin products currently on the market. Insulin detemir is the generic for Levemir. Insulin glargine is the generic for Lantus. Both are clear solutions. Long-acting insulin is intended to mimic the constant, steady release of insulin that occurs in people without diabetes. Once injected, it begins to enter the bloodstream in 1 to 2 hours. It has no peak. Instead, a little insulin at a time enters the bloodstream. It works up to 24 hours after injection. Be aware that Lantus may cause a mild burning sensation when injected.

INSULIN CONT.Premixed insulin:Premixed insulin is generally prescribed for people who have problems mixing 2 separate types of insulin into 1 syringe.

Humulin 50/50

Novolin 50/50

= 50% intermediate-acting insulin (NPH)

+ 50% regular (R) insulin

Humalog Mix 50/50

= 50% intermediate-acting insulin (NPL)

+ 30% Humalog (lispro) insulin

Novolog Mix 50/50

= 50% intermediate-acting insulin (NPA)

+ 50% Novolog (aspart) insulin

INSULIN CONT.Inhaled Insulin:Inhaled insulin is the generic name for Afrezza. It is the only orally inhaled insulin currently available. It is rapid-acting, so it must be used at the beginning of a meal. Inhaled insulin is not a substitute for long-acting insulin. Storage and Inhaler Care:Cartridges should be at room temp for 10 minutes prior to use.Cartridges NOT in use should be refrigerated and may be used until the expiration date.Cartridges in use can be stored at room temperature but must be used within 10 days.An open strip of 3 cartridges must be used within 3 days.The inhaler should be kept at room temperature in a clean, dry place.Use 1 inhaler at a time and replace the inhaler every 15 days.

INSULIN CONT.Inhaled Insulin Continued:Precautions – Lung function should be assessed before starting inhaled insulin, 6 months after starting it, and annually, regardless of whether the person develops symptoms (eg, shortness of breath, cough). Inhaled insulin might cause acute bronchospasm in those with asthma or chronic obstructive pulmonary disease (COPD).Side effects:• Similar to injectable insulin, inhaled insulin can cause

hypoglycemia. • Throat pain or irritation and cough may develop from

exposure to drug powder.• A decrease in lung function and cough may develop.

INSULIN PUMP THERAPY

An insulin pump can deliver a steady amount of insulin constantly throughout the day and night. The constant flow is the basal insulin. At mealtime, it can deliver a larger burst of insulin, which is called a bolus of insulin. In this way, it mimics the normal action of the pancreas.An insulin pump consists of:• A reservoir of rapid-acting insulin.• Pump casing, which is about the size of a cell phone. The

casing houses the insulin reservoir. Within the casing is a computer chip that allows programming of the insulin doses.

• Plastic tubing which connects the insulin pump. This tubing is referred to as an infusion set.

• A thin, flexible needle, called a cannula, that is attached to the end of the tubing. The cannula is inserted into the layer of fat beneath the skin. It is taped in place and can stay for up to 3 days, after which it should be replaced.

INSULIN PUMP THERAPY CONT.

Advantages of Insulin Pump Therapy:• Can help users achieve blood glucose levels that are

normal or very near. Fasting high blood glucose, often referred to as the dawn phenomenon, is reduced with insulin therapy.

• Users’ lifestyles can be spontaneous in terms of mealtimes, timing of activity, and the ability to sleep in. This is because the pump can allow insulin dosage adjustment during these times to match the user’s needs.

• Insulin doses given with a pump are very precise. Absorption is predictable.

• With a pump, users can respond very quickly to any changes in their blood glucose level.

• The risk of severe hypoglycemia is about 75% less with pump therapy as comparing with other ways of taking insulin.

INSULIN PUMP THERAPY CONT.Realities of Insulin Pump Therapy:• It takes a lot of initial training to learn how to use the

pump. The person must be willing and motivated to accept the extra responsibility.

• Not all healthcare providers are familiar with pump therapy. Ideally, training should be done by a skilled diabetes care team that is familiar with pump therapy.

• About ½ of people who start using a pump quit within 2 years’ time.

• Using a pump requires ongoing trial-and-error experiments to learn to match insulin to food and activity. Carbohydrate counting allows for more flexibility and freedom in terms of eating schedule and food choices when using a pump.

• Pump users must be willing to monitor and record their blood glucose levels frequently each day.

INSULIN PUMP THERAPY CONT.

Realities of Insulin Pump Therapy Cont.:• Pump therapy is expensive. The pump may cost over

$6000. Supplies can exceed $200 per month. Insurance plans vary in coverage of the pump, supplies and training.

• Infection at the cannula insertion site is possible, although proper skin care and insertion technique lower this risk.

• There is always the possibility that insulin delivery could be interrupted. The pump itself could fail, there could be an error in programming, the insulin in the reservoir could go bad, or there could be a problem with the tubing or cannula. Pump failure could lead to a diabetic crisis (diabetic ketacidosis) within just a few hours in those with type 1 diabetes.

GLP-1 AGONISTS ( E X E N A T I D E , E X E N A T I D E L A R , L I R A G L U T I D E , A L B I G L U T I D E , D U L A G L U T I D E )

Exanatide is generic for Byetta. Extended release exenatide is generic fo Bydureon. Liraglutide is generic for Victoza. Albiglutide is generic for Tanzeum. Dulaglutide is generic for Trulicity. Together, these medications belong to a class of drugs known as GLP-1 agonists. These medications are intended for people with type 2 diabetes who take 1 or more oral diabetes medicines, but whose glucose levels remain above target. These agents are NOT a replacement for insulin. These medications give you a feeling of fullness after eating, which may lead to less eating and weight loss. Also, your sugar levels will not increase as much after meals since these medications slow down the time it takes food to leave the stomach. Weight loss is common. Used alone, the agents usually don not cause hypoglycemia.

GLP-1 AGONISTS ( E X E N A T I D E , E X E N A T I D E L A R , L I R A G L U T I D E , A L B I G L U T I D E , D U L A G L U T I D E C O N T. )

Precautions:Since GLP-1 agonists slow down the emptying of your stomach, the action of certain oral medicines may be affected. This is especially true for pain pills, birth control pills, and antibiotics. Take any oral medicines 1 hour before your injection. Pain pills, however, should be taken 2 hours before or 2 hours after your injection.Side effects:The most common side effect is nausea. It is more likely to occur when first beginning therapy. In most cases nausea decreases over time. To lower the risk and severity of nausea, eat slowly and stop eating when you feel the least bit full. Nausea is less likely with the longer acting GLP-agonists. f

GLP-1 AGONISTS ( E X E N A T I D E , E X E N A T I D E L A R , L I R A G L U T I D E , A L B I G L U T I D E , D U L A G L U T I D E C O N T. )

Storage:• Unopened, unused packages: keep refrigerated and

protected from light. Good until expiration date.• Prior to fist use. Extended release exenatide and

albiglutide may be kept at room temperature, not to exceed 77°F, for up to 4 weeks, while dulaglutide may be kept at room temperature for up to 14 days.

• Opened pen device of exenatide and liraglutide that is in use at home or while traveling: store at room temperature, not to exceed 77°F, for up to 30 days. Throw away after 30 days, even if some medicine remains.

• Remove needle from pen device in between injections. If the needle stays on, medicine may leak out and/or air may leak in.

• Never freeze ANY of the GLP-1 agonists. If frozen, do not use.

AMYLIN ANALOGS ( P R A M L I N T I D E )

Pramlintide is generic for Simlin. It is intended for people with type 1 or type 2 diabetes who take mealtime insulin, but whose blood glucose levels are still not at target level. It does not replace insulin therapy. The usual amount of insulin taken before meals will need to be adjusted. You will need less insulin before meals. It is available in a pen device. It is a clear solution.

How it Works:Normally, the pancreas releases a hormone called amylin with insulin. People with type 1 diabetes make no amylin; people with type 2 make too little amylin and eventually none at all. Pramlintide is the synthetic version of amylin.

AMYLIN ANALOGS ( P R A M L I N T I D E C O N T. )

Pramlintide works in 3 ways:• Through its action on the brain, it gives you a feeling of

fullness after eating. This may cause you to eat less; and weight loss may occur.

• It slows down how quickly food leaves the stomach. This helps to blunt the rise of glucose after meals.

• It limits the amount of glucose that is released by the liver, especially after meals when you do not need any extra glucose.

Precautions:Never mix with insulin in the same syringe. Space the injections with pramlintide and insulin at least 2 inches apart. Use the abdomen or thigh for injection. If you skip a meal or ill and cannot eat, do not take pramlintide. If you are having surgery, do not take until directed. If having lab tests or procedures that require you to fast, don not take until you can eat again.

AMYLIN ANALOGS ( P R A M L I N T I D E C O N T. )

Side effects:Most common is nausea, and it is most likely to occur in the first few weeks of therapy. Usually goes away after a few weeks. Because it lowers glucose, there is always a possibility the glucose level could drop too low. If it does cause hypoglycemia, it will occur within 3 hours of injection. Monitor glucose level to see how you respond to this therapy. Preferably before and after each meal and at bedtime. Storage: • Unopened, unused packages: keep refrigerated and

protected from light. Good until expiration date.• Opened vial or pen device in use: store at room temp,

not to exceed 86°F.• Never Freeze.• Good for 30 days at room temp after opening. Throw

away after 30 days.• Remove needle from pen device in between injections.

INJECTING DIABETES MEDICATION

Where to inject:Insulin, GLP-1 agonists and pramlintide should be injected into the fat layer between the skin and the muscle. This is call a subcutaneous injection. There are many places on the body that can be used for a subcutaneous injection:• Back of the upper arm• Tops and outer part of the thigh• Hips/outer part of the buttock• abdomen



Some exceptions apply to pramlintide and GLP-1 agonist injections:• Pramlintide users should inject this medicine only in the

abdomen or thighs.• GLP-1 agonists users should inject only in the thighs,

upper arms or abdomen.

Never inject into the muscle, as it can cause the medication to be absorbed too quickly. Do not inject into scars. Don’t inject within 2 inches of the belly button. Pinch up the fat between your fingers and insert the needle at a 90° angle. Extremely thin people may need to angle the needle to avoid going into the muscle. Never inject into a vein.


Rotating Injection Sites:Injecting into the same area for too long can cause scar tissue to develop. Medicine injected in scar tissue will not be absorbed and used properly.

Different areas of the body absorb medicine differently. It is not recommended to change randomly from area to area for injection every day.

Try to inject into a slightly different spot within an area for no more than 2 weeks. For example, inject into the arms in slightly different spots each time for up to 2 weeks. Then rotate to the thighs, using slightly different spots for the next 2 weeks. If you use the abdomen, you do not need to rotate to other areas of the body. The abdomen is large enough to simply rotate your injection sites within this area.

INJECTING DIABETES MEDICATIONNeedles for Injection:Standard injection needles come attached to a disposable syringe. Pen needles are separate disposable needles that are screwed onto a pen device. The needles used to inject insulin and other medicines into the subcutaneous space are very fine.

The thickness of a needle is called its gauge. The smaller the gauge number, the thicker the needle. For example, a 31-gauge needle is thinner than a 28-gauge needle. Needles come in a variety of lengths. The standard length is ½ inch. A “short” needle is 5/16 of an inch. A “mini” needle is 3/16 of an inch.Use of short or mini length needles by people who are overweight or obese may affect glucose control. Manufacturer’s don’t recommend reuse of needles or syringes. Using a needle more than once may increase the risk of infection for some people.

INJECTING DIABETES MEDICATIONPreparing and taking and injection using a syringe and vial:• Wash hands.• Make sure the skin where you plan to inject is clean.• Using alcohol, clean the rubber top of the vial.• Draw air into the syringe. The amount of air you draw up is

the same as the dose of medicine you need from the vial. • With the vial upright, stick the needle into the rubber top

of the vial. Inject the air.• Hold the vial and syringe firmly together as a unit, and

turn it upside down.• Slowly draw the medicine into the syringe.• If you see air bubbles, slowly inject back into the vial and

redraw. Tapping sharply on the syringe helps the bubbles rise to the top. Repeat until no bubbles are seen and you dose is correct. Make sure the top of the black rubber stopper is aligned with the measuring line on the syringe for the dose you want.


Preparing and taking an injection using a syringe and vial continued:

• Remove needle from vial.• Gently pinch up a layer of fat. Quickly insert the needle

into the skin. Inject.• After waiting a few seconds, remove the needle. This

allows the medicine to begin to absorb. If you remove the needle too quickly, sometimes a bit of the medicine leaks out. Do not massage the skin after injection.


Mixing 2 kinds of insulin in the syringe:

Some insulin types may be manually mixed together in the same syringe. Others come premixed in a vial or pen device.

There are some insulin types that should never be mixed together. Never mix long-acting insulin detemir or glargine with another type of insulin in the same syringe.

If mixing NPH and regular insulin, always draw up the regular (clear) insulin into the syringe first. This prevents accidentally injecting NPH into the vial of regular insulin, which will slow down the action of the regular insulin.


Steps for mixing clear and cloudy insulin:• Wash your hands.• Clean the skin where you plan to inject.• Using alcohol, clean the rubber to of both vials.• Draw air into the syringe. The amount of air you draw up is

the same as your dose of cloudy insulin. • With the vial upright, stick the needle into the rubber top of

the vial of cloudy insulin. Inject the air into the vial and remove the needle.

• Draw air into the syringe a second time. The amount of air you draw up is the same as your dose of clear insulin.

• With the vial upright, stick the needle into the rubber top of the vial of clear insulin. Inject the air into the vial, but don’t remove the needle.

• Hold the vial and syringe firmly together as a unit, and turn it upside down.


Steps for mixing clear and cloudy insulin continued:• Slowly draw the clear insulin into the syringe.• If you see air bubbles, slowly inject back into the vial and

redraw. Tapping sharply on the syringe helps the bubble rise to the top. Repeat until no bubbles are seen and your dose is correct.

• Remove needle from vial.• Stick the needle into the rubber top of the vial of cloudy

insulin.• Slowly draw the cloudy insulin into the syringe until you

reach your total insulin dose.• Gently pinch up a layer of fat. Quickly insert the needle

into the skin. Inject.• After waiting a few seconds, remove the needle.• Your total dose equals the units of clear insulin plus

the units of the cloudy insulin.


Preparing and Taking an Injection Using a Pen Device:There are many brands of injection pens. Follow the manufacturer’s directions for setting your dose and injecting using a pen device. Disposable needles are purchased separately and may require a prescription. Always remove the needle from the pen device in between injections. If the needle stays on the device, medicine may leak out and/or air may leak in.

Before a pen device may be used, a procedure called an air shot is done. Sometimes this is called priming the pen. To perform an air shot, dial the device as directed to expel any air that may be in the cartridge. Follow the manufacturer’s directions for when to perform an air shot and how far to dial the device.


Can you fix your mixed insulin syringes for the week all at once?

The answer is yes. Single formulation or mixed insulin can be safely prefilled in syringes and used later on. Follow these guidelines:• Prefilled syringes must be kept in the refrigerator.• Use prefilled syringes of insulin within 21 to 30 days. • Store syringes containing a mix of insulin upright or at

an angle, with the needle pointing up. This will help avoid problems with the needle becoming plugged with dried insulin particles.

• Cloudy insulin must be rolled several times between the palms to properly mix the 2 insulin types before injecting. Also, slightly pull back and forth on the plunger to help agitate the insulin before injecting.


Disposal of Used Needles:Used needles are a health hazard. They should be stored in a container that is shatterproof and has a lid that holds firm if the container is dropped. Heavy plastic containers like detergent or bleach jugs are ideal. When the needles are ready for disposal, the top of the container should be tightly closed and the words medical sharps written on the container. Another option is to use a store bought sharps container. Follow your local sanitation department for disposal of either type of container. Some areas allow marked sharps containers to be placed in the regular trash. Sharps container should never be placed in a recycle bin. Never break the needle off the syringe. This practice allows very tiny shards of metal to scatter when the needle is broken. These tiny pieces could penetrate your skin and cause an infection. Place the entire syringe into the sharps container.

COM PL EMENTARY AND ALTER NATIVE MEDICATION S

Complementary and alternative medicine (CAM) is defined as healthcare practices and treatments that are not generally considered part of mainstream Western medicine. Complementary therapies are those that are used along with conventional medicine; alternative therapies are used in place of conventional medicine. Integrative medicine refers to therapy that combines conventional medicine with CAM for which there is proven safety and efficacy.

Always inform your provider of all the OTC products or natural remedies that you take.

COM M ON SUP PL EME NTS USE D T O LOWE R BL OOD G LUC OSE

Name Possible S/E Possible Drug Interactions

Summary

Aloe Gel May cause fluid and electrolyte imbalance

Hypoglycemia possible, if taken with insulin secretagogues

Not enough evidence to support use. Not recommended as oral supplement

Banaba None reported Hypoglycemia possible, if taken with insulin secretagogues

Only very small studies have been done. No long term safety info available

Bilberry Mild GI distressSkin Rashes

None Known No studies have been done in humans to show effectiveness of lowering glucose


Summary

Bitter Melon

GI discomfort and vomiting; Hypoglycemic coma; Anemia; Can cause miscarriage

Hypoglycemia possible, if taking with insulin secretagogues

Safe to be used as a food, may be unsafe in persons with Mediterranean descent. May be unsafe in women of childbearing age.

Caiapo Constipation; GI pain; Gas Accumulation and distention

Hypoglycemia possible, if taken with insulin secretagogues

Reduces fasting and postmeal glucose, lowers weight, and reduces cholesterol; no long term safety info available

Cinnamon None reported Hypoglycemia possible, if taken with insulin secretagogues

Significantly improves fasting glucose and lipids

Fenugreek Diarrhea; gas; uterine contractions; allergic reactions

May increase anticoagulant effect of Warfarin, garlic, boldo, and ginger


Summary

Ginseng Insomnia, H/A, restlessness, increased b/p, increased heart rate, breast pain, mood changes

Decreases effectiveness of Warfarin, diuretics; Increases effect of estrogen, increased effect of analgesics and antidepressants, Hypoglycemia may occur

May lower glucose for type 2 diabetes; safety questionable due to effects of b/p and nervous system

Gymnema May cause hypoglycemia

Hypoglycemia may occur if taking with insulin secretagogues

Limited evidence of effectiveness in humans

Milk Thistle

GI upset, diarrhea, allergic reactions if allergic to ragweed, daisies, marigolds

Beneficial for those with liver disease. May attenuate liver toxicity from acetaminophen, antipsychotic, alcohol

Long term safety and exact doses are unknown

Nopal Diarrhea, nausea, abdominal fullness, increased volume of stool

Improved blood glucose with sulfonylurea

Safe as food. Decreases postmeal glucose. May help lower glucose when cooked or taken as supplementNo long term studies done

Health & Medicine

Dsme taking medication powerpoint