28.2: Insulin and Non-Insulin Injectable Diabetes Drugs
By the end of this section, you should be able to:
- 28.2.1 Identify the characteristics of insulin and non-insulin injectable drugs used to treat diabetes.
- 28.2.2 Explain the indications, actions, adverse reactions, contraindications, and interactions of insulin and non-insulin injectable drugs used to treat diabetes.
- 28.2.3 Describe nursing implications of insulin and non-insulin injectable drugs used to treat diabetes.
- 28.2.4 Explain the client education related to insulin and non-insulin injectable drugs used to treat diabetes.
Insulin
Insulin is released by ß cells from the islets of Langerhans in the pancreas after eating a meal. The carbohydrates from the meal are broken down into glucose. As glucose enters the bloodstream, insulin is secreted and allows the cells in muscles, fat, and the liver to absorb the glucose for energy (American Diabetes Association, n.d.-d). Insulin not only is important for glucose homeostasis, but it also plays a role in lipid metabolism through lipolysis and assists in protein metabolism through downregulation of hepatic and muscle enzymes, and its action within endothelial cells and macrophages has an anti-inflammatory effect on the body.
Insulin has three characteristics: onset, peak, and duration. Onset is the length of time before insulin reaches the bloodstream and begins to lower glucose levels. Peak time is discussed below. Duration is how long insulin continues to lower blood glucose levels.
Peak Time
Peak time is when insulin is at its maximum strength in terms of lowering blood glucose levels. Individuals are at a higher risk of developing hypoglycemia symptoms when insulin is peaking (American Diabetes Association, n.d.-d).
Types of Insulin
There are different types of insulin based on the client’s needs. In this chapter, rapid-acting, short-acting, intermediate-acting, and long-acting insulins, as well as premixed insulins, will be discussed. Insulins are typically clear except for insulin isophane NPH, which is cloudy.
Safety Alert
Insulin-Independent Double Checks
- Double-check to ensure the correct type of insulin is being administered, especially if the client is taking more than one type of insulin. Perform independent double checks on the vial and dose of insulin.
- Only use insulin syringes to administer insulin.
- Double-check client identifiers, type, product, dose, and measured dose of insulin prior to administering the drug to the client to decrease the risk of medication error.
(Source: Institute for Safe Medication Practices, 2019).
Rapid-Acting Insulin
Rapid-acting insulin begins to work approximately 15–30 minutes after injection. It peaks in 1–2 hours after injection, and its duration is 2–4 hours. Insulin aspart (Novolog), insulin glulisine (Apidra), and insulin lispro (Humalog) are rapid-acting insulins (DailyMed, Novolog , 2021; DailyMed Apidra , 2023; DailyMed, Humalog , 2022).
Short-Acting Insulin
Short-acting insulin , also known as regular insulin, begins to work within 30 minutes to 1 hour after injection. It peaks in 2–3 hours after injection, and its duration is 3–6 hours. Human regular insulin (Humulin R and Novolin R) is a short-acting insulin (DailyMed, Humulin R , 2023; DailyMed, Novolin R , 2022).
Intermediate-Acting Insulin
Intermediate-acting insulin begins to work 2–4 hours after injection. It peaks in 4–12 hours, and its duration is 12–18 hours. Insulin isophane NPH (Humulin N and Novolin N) is a type of intermediate-acting insulin (DailyMed, Humulin N , 2023; DailyMed, Novolin N , 2022).
Long-Acting Insulin
Long-acting insulin begins to work 1–2 hours after injection. It has no peak time and acts to lower blood glucose levels up to 24 hours. Insulin degludec (Tresiba), insulin detemir (Levemir), and insulin glargine (Lantus) are long-acting insulins (DailyMed, Tresiba , 2022; DailyMed, Lantus , 2022).
Premixed Insulin
Premixed insulin combines intermediate- and short-acting insulin into a single injection. These injections are usually taken 10 to 30 minutes before breakfast and dinner to provide both basal and mealtime coverage.
Table 28.2 lists common insulin s and their actions.
| Drug | Onset | Peak | Duration | Method |
|---|---|---|---|---|
|
Rapid-acting insulin
Insulin aspart ( Novolog ) Insulin glulisine ( Apidra ) Insulin lispro ( Humalog ) |
15–30 minutes | 1–2 hours | 2–4 hours | Take 15 minutes before a meal or immediately after a meal. Often used with a longer-acting insulin. |
|
Short-acting insulin
Human regular insulin ( Humulin R , Novolin R ) |
30 minutes–1 hour | 2–3 hours | 3–6 hours | Take 30–60 minutes before a meal. May be used with a longer-acting insulin. |
|
Intermediate-acting insulin
Insulin isophane NPH ( Humulin N , Novolin N ) |
2–4 hours | 4–12 hours | 12–18 hours | Covers insulin needs for 12 hours or longer, or overnight. Often used with a rapid- or short-acting insulin. |
|
Long-acting insulin
Insulin degludec ( Tresiba ) Insulin detemir ( Levemir ) Insulin glargine ( Lantus ) |
1–2 hours | Does not peak | Up to 24 hours | Covers insulin needs for approximately an entire day. Often used with a rapid- or short-acting insulin. |
Administration of Insulin
Insulin typically comes as an injectable source because it needs to bypass the first pass of digestion for absorbtion due to its instability in the presence of gastric acid. Insulin is injected into the subcutaneous tissue via an insulin syringe, insulin pen, or insulin pump. Injection sites for insulin are located primarily on the abdomen, back of the upper arm, lower back, buttocks, and upper outer thigh (see Figure 28.4). The rate of absorption depends on the injection site. Insulin injection sites should be rotated to prevent fatty deposits and site irritation (American Diabetes Association, n.d.-d).
Non-Insulin Injectable Drugs
Non-insulin injectable drugs provide an alternative to insulin therapy for clients with diabetes. They act on hormones that are secreted along with insulin by the pancreas to control glucose homeostasis. These drugs were first approved for use in the United States in 2005 (Feingold, 2022; Campbell, 2021).
Amylin Analogs
Amylin is a hormone secreted along with insulin by the pancreas in response to food intake. In 2005, pramlintide (Symlin) was the first FDA-approved amylin analog non-insulin injectable drug. This drug can be used for clients with diabetes who are taking insulin. Pramlintide slows gastric emptying and blocks the release of glucagon from the liver after a meal. This drug is administered before mealtimes. Adverse effects include nausea, loss of appetite, fatigue, headache, and weight loss. It is contraindicated in clients with hypersensitivity to amylin analogs or who have hypoglycemia or gastroparesis (Maikawa et al., 2020; Campbell, 2021).
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists
GLP-1 receptor agonists are a class of non-insulin injectable drugs that impact the gut hormone incretin, which works to increase insulin secretion in response to meals. These drugs help the pancreas release insulin after eating, limit glucagon, and slow down digestion. GLP-1 receptor agonists are approved for type 2 diabetes treatment. They have not yet been approved for type 1 diabetes management. Adverse effects include nausea, vomiting, diarrhea, abdominal discomfort, and loss of appetite. Contraindications include hypersensitivity to GLP-1 receptor agonists, medullary thyroid carcinoma, and multiple endocrine neoplasia (Feingold, 2022).
Clinical Tip
GLP-1 Receptor Agonists
Hypoglycemic reactions are greater when GLP-1 receptor agonists are used with sulfonylureas and insulin. Clients should be monitored closely for signs of hypoglycemia (Feingold, 2022).
Dulaglutide
Dulaglutide (Trulicity) is taken once a week at any time of day, with or without food. It can be used in combination with sulfonylureas, non-sulfonylurea biguanides, thiazolidinediones, and insulin. Adverse effects include nausea, diarrhea, vomiting, abdominal pain, decreased appetite, indigestion, fatigue, and weight loss (Jódar et al., 2022).
Exenatide
Exenatide (Byetta) is taken twice a day, 1–2 hours before a meal. It can be used in combination with sulfonylureas, non-sulfonylureas biguanides, thiazolidinediones, and insulin. Adverse effects include nausea, vomiting, decreased appetite, and weight loss (Wysham et al., 2020).
Exenatide extended release (Bydureon) is taken once every 7 days. It can be used in combination with sulfonylureas, non-sulfonylureas biguanides, and thiazolidinediones. It should not be administered with exenatide (Byetta) or used in combination with insulin. Adverse effects include nausea, vomiting, decreased appetite, and weight loss (Wysham et al., 2020).
Liraglutide
Liraglutide (Victoza) is taken once a day at any time of the day regardless of mealtimes. It can be used in combination with sulfonylureas, non-sulfonylureas biguanides, and thiazolidinediones. Adverse effects include headache, nausea, diarrhea, decreased appetite, and weight loss (He et al., 2019).
Tirzepatide
Tirzepatide (Mounjaro) is taken once a week at any time of day, with or without meals. Adverse effects include nausea, diarrhea, decreased appetite, vomiting, constipation, dyspepsia, and abdominal pain (DailyMed, Mounjaro , 2023).
Semaglutide
Semaglutide (Ozempic) is taken once a week at any time of the day regardless of mealtimes. It can be used in combination with sulfonylureas, non-sulfonylureas biguanides, thiazolidinediones, and insulin. Adverse effects include nausea, diarrhea, abdominal pain, decreased appetite, weight loss, and constipation (Smits & Van Raalte, 2021).
Table 28.4 lists common non-insulin injectable drugs and typical routes and dosing for adult clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Pramlintide (Symlin) |
Type 1 diabetes:
15 mcg subcutaneously before major meals. Increase in 15 mcg increments to a maximum pre-meal dose of 30–60 mcg.
Type 2 diabetes: 60 mcg subcutaneously before major meals, then increase to 120 mcg before meals as tolerated. Wait at least 3 days between dose titrations to minimize nausea. |
| Dulaglutide (Trulicity) |
0.75 mg subcutaneously once weekly. Increase dosage by 1.5 mg increments after at least 4 weeks.
Maximum dose: 4.5 mg subcutaneously once weekly. |
| Exenatide (Byetta, Bydureon) | 5 mcg subcutaneously within 60 minutes prior to morning and evening meals at least 6 hours apart. Increase to 10 mcg twice daily after 1 month based on clinical response. |
| Liraglutide ( Victoza ) |
0.6 mg subcutaneously daily for one week, then increase to 1.2 mg daily.
Maximum dose: 1.8 mg daily. |
| Tirzepatide (Mounjaro) | Initial dose: 2.5 mg injected subcutaneously once weekly. After 4 weeks, increase the dosage to 5 mg injected subcutaneously once weekly. If additional glycemic control is needed, increase the dosage in 2.5 mg increments after at least 4 weeks on the current dose. Maximum dose: 15 mg injected subcutaneously once weekly. |
| Semaglutide (Ozempic) |
0.25 mg subcutaneously once weekly; after 4 weeks increase to 0.5 mg once weekly.
Maximum dose: 2 mg once weekly. Wait 5 days between dose titrations. |
Adverse Effects and Contraindications
Adverse effects of amylin analogs include hypoglycemic symptoms (shakiness, dizziness, sweating, confusion, and, in severe cases, loss of consciousness), gastrointestinal symptoms (nausea, vomiting, diarrhea, abdominal pain, and loss of appetite), and injection site reactions.
Contraindications include hypersensitivity to the drug or any of its components and in clients with medullary thyroid cancer and multiple endocrine neoplasia (as these drugs can exacerbate these conditions). Caution should be used in clients with gastroparesis as amylin analogs may further slow down gastric emptying, in clients with severe renal impairment as the drugs are excreted in the urine and can further impair renal function, and in clients with hepatic insufficiency due to the drugs being metabolized by the liver and thus can impede liver functioning.
Table 28.5 is a drug prototype table for non-insulin injectable drugs featuring dulaglutide. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Glucagon-like peptide (GLP-1) receptor agonist Mechanism of Action Increases insulin secretion when glucose levels are elevated, decreases glucagon secretion, and delays gastric emptying in an effort to lower postprandial glucose levels |
Drug Dosage
0.75 mg subcutaneously once weekly. Increase dosage by 1.5 mg increments after at least 4 weeks. Maximum dose: 4.5 mg subcutaneously once weekly. |
|
Indications
As an adjunct to diet and exercise to improve glycemic control in individuals older than 10 years of age To reduce the risk of major cardiovascular events in adults with type 2 diabetes who have established cardiovascular disease or multiple cardiovascular risk factors Therapeutic Effects Lowers postprandial glucose levels |
Drug Interactions
Delays gastric emptying and has the potential to reduce the rate of absorption of concomitantly administered oral drugs Food Interactions No significant interactions |
|
Adverse Effects
Nausea Vomiting Diarrhea Abdominal pain Decreased appetite |
Contraindications
Medullary thyroid carcinoma Multiple endocrine neoplasia Hypersensitivity Caution: Thyroid C cell tumors Pancreatitis Hypoglycemia Aute kidney injury Severe gastrointestinal disease Diabetic retinopathy Acute gallbladder disease |
Nursing Implications
The nurse should do the following for clients who are taking insulin and non-insulin injectable diabetes drugs:
- Assess the client’s knowledge about diabetes, signs and symptoms, and treatment and clarify any gaps in knowledge.
- Assess and monitor the client for adverse effects, drug and food interactions, and contraindications.
- Refer client to social services for obstacles in obtaining prescribed drugs, test strips, or a glucometer.
- Provide client teaching regarding the drug, how to administer an injection, and when to call the health care provider. See below for client teaching.
Client Teaching Guidelines
The client using an insulin or non-insulin injectable diabetes drug should:
- Report symptoms of hypoglycemia such as headache, nervousness, sweating, clammy skin, tremor, and tachycardia.
- Report symptoms of hyperglycemia such as increased thirst, increased urine output, hot/dry skin, and sweet, fruity breath odor.
- Keep 15 grams of carbohydrates on hand in case of a hypoglycemic reaction. Orange juice, graham crackers, and hard candy are appropriate carbohydrate choices during hypoglycemia.
- Show family members and their support system how to administer glucagon during a hypoglycemic reaction if the client cannot eat or drink or is unconscious.
- Store insulin in a refrigerator at approximately 36–46°F.
- Store non-insulin injectables per manufacturer’s packaging.
- Ask the health care provider prior to taking any OTC drugs or herbal supplements with insulin and non-insulin injectables because they may increase the risk of hypoglycemia or hyperglycemia.
- Keep a blood glucose journal for tracking blood glucose levels.
- Rotate insulin injection sites to prevent fatty deposits and injection site reactions.
- Eat an appropriate diet as prescribed and as scheduled with their insulin routine.
- Use safety with injectable syringes and needles and dispose of them properly.
FDA Black Box Warning
GLP-1 Receptor Agonists
GLP-1 receptor agonists should not be taken if a client has a history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2.