NCLEX - Diabetes Mellitus Treatments

Here are key facts for NCLEX from the Diabetes Mellitus - Pathophysiology tutorial, as well as points of interest at the end of this document that are not directly addressed in this tutorial but should help you prepare for the boards. See the tutorial notes for further details and relevant links.

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1. Administration routes: Insulin is often administered into subcutaneous tissues via injections or continuously via an insulin pump; an inhaled version with rapid action can be used before meals. 2. Types and timing: Rapid, regular (or "short"), intermediate, and long-acting versions of insulin that are given in different patient scenarios. 3. Hypoglycemia risk: Insulin has potential hypoglycemic effects; the risk is higher when human insulin is used. 4. Renal dosing: Give lower doses of insulin when a patient's estimated GFR is low. 5. Type 1 considerations: Insulin is a required treatment and must be taken regularly throughout the day, with special considerations given to infection and surgery. 1. First-line therapy: Metformin is first-line therapy in patients with Type 2 diabetes. 2. Safety advantage: It does not cause hypoglycemia. 3. Administration: This drug is administrated orally. 4. Contraindication: Metformin doesn't seem to affect the development of chronic kidney disease, but is contraindicated in patients with low estimated GFR (eGFR < 30 mL/min/1.73m²). 5. Common side effects: Side effects include gastrointestinal issues (nausea, vomiting), and there is potential for vitamin B12 deficiency. 1. Preoperative care: SGLT-2 inhibitors should be discontinued prior to surgery to avoid diabetic ketoacidosis. 2. Administration: Oral administration. 3. Side effect monitoring: Weight loss, bone fractures, urogenital infections, volume depletion and hypotension, increases in LDL levels, and increased risk of Fournier's gangrene and necrosis of the lower limb leading to foot and leg amputation. 4. Patient education: These drugs decrease blood glucose levels by increasing glucose output in the urine. They do this by inhibiting the sodium-glucose co-transports and blocking glucose reabsorption in the nephron. 1. Hypoglycemia risk: Because sulfonylureas increase insulin release, they can cause hypoglycemia. 2. Administration: Oral administration. 3. Side effect monitoring: These drugs can cause weight gain (like insulin does), and, despite being the second most prescribed drug for diabetes treatment, these drugs are associated with increased risk of cardiovascular event and mortality.

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1. Patient barriers: In the US, especially, the price of insulin is an impediment to proper diabetes management. 2. Side effect management: Weight gain is a common side effect of insulin use. 3. Type 2 instruction: These patients may not need insulin if their glucose levels are controlled by other medications and/or changes in diet and exercise. However, when glucose targets are not met by these measures, patients will need insulin. 1. Cardiovascular benefits: Metformin seems to have beneficial effects on cardiovascular outcomes, though more conclusive studies are needed. 2. Cost consideration: It is relatively low in cost. 3. Mechanism for patient education: Metformin is a highly effective drug that reduces hepatic gluconeogenesis as a means of reducing blood glucose levels. 1. Administration teaching: Administration can be subcutaneous injection or orally. 2. Side effect monitoring: They are associated with weight loss and gastrointestinal side effects. These drugs are associated with increased risk of acute pancreatitis. 3. Patient education: Highly effective drugs that increase insulin secretion by stimulating receptors for Glucagon-Like-Peptide-1, which is an incretin that facilitates pancreatic release of insulin. They also aid with appetite control and inhibition of glucagon secretion. 4. Cost consideration: These drugs are expensive. 1. Safety profile: No hypoglycemic effects. 2. Administration: Indicate that administration is orally, and cost is high. 3. Side effect monitoring: Associated with Pancreatitis. 4. Heart failure considerations: Saxagliptin is associated with an increased risk of heart failure. 1. Contraindications: They are associated with increased risk of heart failure, and can cause fluid retention; thus, do not give to patients with renal impairment. 2. Administration: Oral administration. 3. Side effect monitoring: These drugs are associated with weight gain, bone fractures, bladder cancer, increased LDL, and, as mentioned fluid retention.

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1. Assessment: Daily blood glucose monitoring, recognition of hypoglycemia/hyperglycemia signs and symptoms, and foot examination. 2. Nursing Diagnosis: Risk for unstable blood glucose, risk for infection, impaired skin integrity, and knowledge deficit. 3. Implementation: Proper insulin injection technique, rotation of injection sites, and teaching self-monitoring of blood glucose. 1. Sick day management: Guidelines for medication adjustments, increased monitoring, and when to seek medical help. 2. Hypoglycemia management: Rule of 15-15 (15g carbohydrate, wait 15 minutes, recheck). 3. Lifestyle modifications: Dietary management, exercise recommendations, and smoking cessation. 1. Insulin timing: Rapid-acting with meals, intermediate/long-acting as scheduled regardless of meals. 2. Insulin storage: Refrigeration requirements for unopened insulin, room temperature stability for opened vials/pens. 3. Drug interactions: Important interactions with beta-blockers, diuretics, and steroids. 1. Signs of DKA: Kussmaul respirations, fruity breath odor, altered mental status, dehydration. 2. Long-term monitoring: A1C targets, screening for microvascular and macrovascular complications. 3. Foot care: Daily inspection, proper footwear, prompt treatment of minor injuries. 1. Geriatric patients: Increased risk of hypoglycemia, cognitive assessment for self-management ability. 2. Pregnancy: Insulin as primary agent, stricter glucose targets, increased monitoring frequency. 3. Surgery/procedures: NPO status management, temporary insulin adjustments, IV insulin protocols.