DSME Taking Medication Powerpoint

1. TAKING MEDICATION
Stacy McDaniel, RN/Diabetic Educator

2. 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

3. SKILLS
Participants who are taking injected medications will:
• Demonstrate proper preparation and self-administration of injection
• Demonstrate proper disposal of used needles

4. 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.

5. ORAL DIABETES
MEDICATIONS
Insulin Sensitizers

6. 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.

7. METFORMIN CONTINUED
Precautions:
• 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.

8. 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.

9. PIOGLITAZONE AND
ROSIGLITAZONE CONT.
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.

10. DPP-IV INHIBITORS
(STIAGLIPTIN, ALOGLIPTIN,
LINAGLIPTIN, SAXAGLIPTIN
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.

11. DPP-IV INHIBITORS
(STIAGLIPTIN, ALOGLIPTIN,
LINAGLIPTIN, SAXAGLIPTIN 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.

12. INSULIN
SECRETAGOGUES(GLYBURIDE,
GLIPIZIDE, GLIMEPIRIDE)
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.

13. INSULIN
SECRETAGOGUES(GLYBURIDE ,
GLIPIZIDE, GLIMEPIRIDE CONT. )
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)

14. 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

15. 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.

16. ALPHA-GLUCOSIDASE
INHIBITORS (MIGLITOL AND
ACARBOSE CONT.)
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.

17. 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.

18. SODIUM-GLUCOSE CO-
TRANSPORTER INHIBITORS
(CANAGLIFLOZIN, DAPAGLIFLOZIN,
EMPAGLIFLOZIN
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.

19. COMBINATION ORAL
DIABETES MEDICATIONS
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

20. COMBINATION ORAL
DIABETES MEDICATIONS
CONT.
Jentadueto: linagliptin and metformin
Kazano: alogliptin and metformin
Kombiglyze XR: saxagliptin and metformin ER
Metaglip: glipizide and metformin
Oseni: alogliptin and pioglitazone
Prandimet: repaglinide and metformin
Xigduo XR: dapagliflozin and metformin ER

21. INSULIN
When 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.

22. 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.

23. TYPES OF INSULIN AND
HOW THEY WORK
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.

24. INSULIN AND ITS ACTION
Classification Generic
Name
Brand Name Onset Peak Duration Color
Rapid Acting Aspart
Glulisine
Lispro
Inhaled Insulin
Novolog
Apidra
Humalog
Afrezza
5-15 min
12-15 min
1-2 hrs
1 hr
4-6 hrs
3 hrs
Clear
N/A
Short Acting Regular,
human
Humulin R
Novolin R
Relion/Nov R
30-60 min 2-4 hrs 6-10 hrs Clear
Intermediate-
Acting
Isophane,
human (NPH)
Humulin N
Novolin N
Relion/ Nov N
1-2 hrs 4-8 hrs 10-18 hrs Cloudy
Long-Acting Detemir
Glargine
Levemir
Lantus
1-2 hrs No peak Up to 24
Hrs
Clear

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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

32. 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.

33. 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.

34. 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.

35. 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.

36. 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.

37. 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.

38. 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.

39. 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

40. 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.

41. 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.

42. 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.

43. 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.

44. 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

45. INJECTING DIABETES
MEDICATION

46. INJECTING DIABETES
MEDICATION
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.

47. INJECTING DIABETES
MEDICATION
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.

48. INJECTING DIABETES
MEDICATION
Needles 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.

49. INJECTING DIABETES
MEDICATION
Preparing 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.

50. INJECTING DIABETES
MEDICATION
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.

51. INJECTING DIABETES
MEDICATION
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.

52. INJECTING DIABETES
MEDICATION
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.

53. INJECTING DIABETES
MEDICATION
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.

54. INJECTING DIABETES
MEDICATION
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.

55. INJECTING DIABETES
MEDICATION
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.

56. INJECTING DIABETES
MEDICATION
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.

57. COMPLEMENTARY AND
ALTERNATIVE
MEDICATIONS
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.

58. COMMON SUPPLEMENTS
USED TO LOWER BLOOD
GLUCOSE
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 distress
Skin Rashes
None Known No studies have been done in
humans to show
effectiveness of lowering
glucose

59. Name Possible S/E Possible Drug
Interactions
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

60. Name Possible S/E Possible Drug
Interactions
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 supplement
No long term studies done