glulisine

insulin glulisine (rDNA origin)

(in-su-lin gloo-lye-seen) ,

Apidra

(trade name) Pregnancy Category: C

Indications

Action

Pharmacokinetics

Time/action profile (hypoglycemic effect)

ROUTE	ONSET	PEAK	DURATION
Subcut	within 15 min	1–2 hr	3–4 hr

Contraindications/Precautions

Adverse Reactions/Side Effects

Endocrinologic

• hypoglycemia (life-threatening)

Local

• lipodystrophy
• pruritis
• erythema
• swelling

Miscellaneous

• allergic reactions including anaphylaxis (life-threatening)

Interactions

Drug-Drug interaction

Beta blockers, clonidine, and reserpine may mask some of the signs and symptoms of hypoglycemia.Corticosteroids, thyroid supplements, estrogens, isoniazid, niacin,phenothiazines,, and rifampin may ↑ insulin requirements.Alcohol, ACE inhibitors, MAO inhibitors, octreotide, oral hypoglycemic agents, and salicylates, may ↓ insulin requirements.Concurrent use with pioglitazone or rosiglitazone may ↑ risk of fluid retention and worsening HFGlucosamine may worsen blood glucose control.Fenugreek, chromium, and coenzyme Q-10 may produce additive hypoglycemic effects.

Route/Dosage

Availability

Nursing implications

Nursing assessment

• Assess patient for signs and symptoms of hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait) and hyperglycemia (confusion; drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing; polyuria; loss of appetite; nausea; vomiting; unusual thirst; stomach pain; rapid heart rate) periodically throughout therapy.
• Monitor body weight periodically. Changes in weight may necessitate changes in insulin dose.
• Assess patient for signs of allergic reactions (rash, shortness of breath, wheezing, rapid pulse, sweating, low BP) during therapy.
• Lab Test Considerations: Monitor blood glucose every 6 hr during therapy, more frequently in ketoacidosis and times of stress. A1C may be monitored every 3–6 mo to determine effectiveness of therapy.
Overdose is manifested by symptoms of hypoglycemia. Mild hypoglycemia may be treated by ingestion of oral glucose. Severe hypoglycemia is a life-threatening emergency; treatment consists of IV glucose, glucagon, or epinephrine. Early signs of hypoglycemia may be less pronounced by long duration of diabetes, diabetic nerve disease, and use of beta blockers; may result in loss of consciousness prior to patient's awareness of hypoglycemia.

Potential Nursing Diagnoses

Noncompliance (Patient/Family Teaching)

Implementation

• high alert: Medication errors involving insulins have resulted in serious patient harm and death. Clarify all ambiguous orders, and do not accept orders using the abbreviation “u” for units, which can be misread as a zero, or the numeral 4 and has resulted in tenfold overdoses. Insulins are available in different types and strengths. Check type, dose, and expiration date with another licensed nurse. Do not interchange insulins without consulting health care professional.
• Due to the short duration of action, insulin glulisine must be used with a longer acting insulin or insulin infusion pump therapy.
  • Use only U-100 insulin syringes to draw up dose.
  • When mixing insulins, draw insulin glulisine into syringe first to avoid contamination of insulin glulisine vial. May be mixed only with NPH insulin. Administer immediately after mixing. Solution should be clear and colorless with no particulate matter.
  • Store unopened vials of insulin glulisine in refrigerator. Keep open vials refrigerated or as cool as possible. Use within 28 days. Do not use vials past expiration date.
• Subcutaneous: When used as meal time insulin, administer 15 min before or within 20 min after starting a meal. Administer into abdominal wall, thigh, or upper arm subcutaneously. Rotate sites with each injection.
  • For administration via infusion pump, as a subcut infusion into abdominal wall. Solution is stable for 48 hr and at temperatures not higher than 98.6°F. Discard infusion sets (reservoirs, tubing, catheters) after no more than 48 hr. Infusion sites that are erythematous, pruritic or thickened should be reported to health care professional and a new site selected; continued infusion may increase skin reaction and alter absorption of insulin glulisine.

• Intravenous Administration

• Intravenous: May be administered IV with close monitoring of blood glucose and potassium levels to avoid hypoglycemia and hypokalemia.
• Intermittent Infusion: Dilute to a concentration of 1 unit/mL with 0.9% NaCl, using Polyvinyl Chloride (PVC) Viaflex infusion bags and PolyVinyl Chloride (PVC) tubing (Clearlink System Continu-Flo solution set) with a dedicated infusion line. The use of other bags and tubing has not been studied.
  • When administered via pump, change insulin glulisine in pump every 48 hr.
• Syringe Incompatibility: When used via infusion pump or IV, do not dilute or mix with any other insulin.
• Y-Site Incompatibility: Dextrose solutions.
  • Ringer's solutions.

Patient/Family Teaching

• Instruct patient on proper technique for administration. Include type of insulin, equipment (syringe, cartridge pens, external pumps, alcohol swabs), storage, and place to discard syringes. Discuss the importance of not changing brands of insulin or syringes, selection and rotation of injection sites, and compliance with therapeutic regimen. Caution patient not to make any changes in type of insulin or dose without consulting health care professional. Advise patient to read the Patient Information prior to use and each time prescription is refilled.
• Demonstrate technique for mixing insulins by drawing up insulin glulisine first and rolling intermediate-acting insulin vial between palms to mix, rather than shaking (may cause inaccurate dose).
• Explain to patient that this medication controls hyperglycemia but does not cure diabetes. Therapy is long term.
• Instruct patient in proper testing of serum glucose and ketones. These tests should be closely monitored during periods of stress or illness and health care professional notified of significant changes.
• Advise patient not to share insulin glulisine with another person, even if they also have diabetes; may cause harm.
• Emphasize the importance of compliance with nutritional guidelines and regular exercise as directed by health care professional.
• Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other Rx, OTC, herbal products, or alcohol.
• Advise patient to notify health care professional of medication regimen prior to treatment or surgery.
• Advise patient to notify health care professional if nausea, vomiting, or fever develops, if unable to eat regular diet, or if blood sugar levels are not controlled.
• Instruct patient on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur.
• Advise patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding or planning to breastfeed.
• Patients with diabetes mellitus should carry a source of sugar (candy, glucose gel) and identification describing their disease and treatment regimen at all times.
• Emphasize the importance of regular follow-up, especially during first few weeks of therapy.

Evaluation/Desired Outcomes

• Control of blood glucose levels in diabetic patients without the appearance of hypoglycemic or hyperglycemic episodes.