vSim J Carlos Clinical Packet Latest Update 2025

DESCRIBE DISEASE PROCESS AFFECTING PATIENT (Include Pathophysiology of Disease Process) Overview ▪ Endocrine disorder that results from a combination of resistance to insulin action and impaired insulin secretion, which produces hyperglycemia and related complications to many systems of the body, including microvascular (retinal and renal), macrovascular (coronary and peripheral vascular), and neuropathic manifestations ▪ One of the leading causes of morbidity and mortality in the United States and a contributing factor to blindness, kidney disease, and lower limb amputations ▪ Requires long-term medical treatment to manage and limit complications ▪ Also known as T2DM ▪ Previously called adult-onset diabetes and non-insulin-dependent diabetes Pathophysiology ▪ A combination of peripheral insulin resistance and inadequate insulin secretion by pancreatic beta cells leads to a progressive loss of beta-cell function and mass. ▪ Insulin resistance elevates levels of free fatty acids in plasma, leading to decreased glucose transport into muscle cells, elevated hepatic glucose production, and increased breakdown of fat. ▪ Abnormal glucose tolerance occurs, and postprandial blood glucose levels increase; hepatic gluconeogenesis suppression fails, and fasting hyperglycemia develops. ▪ Cellular damage occurs in the capillary endothelial cells of the retina, the mesangial cells in the renal glomerulus, and the neurons and Schwann cells in peripheral nerves because of the inability of cells to regulate the uptake of glucose. ▪ Insulin resistance combined with the presence of lipid and thrombotic abnormalities and atherosclerotic risk factors determines cardiovascular risk; increased cardiovascular risk begins before hyperglycemia, possibly because of insulin resistance. Causes ▪ Environmental pollutants (long-term exposure to traffic-related pollution) ▪ Poor in utero environment, resulting in low birth weight ▪ Genetics (involvement of multiple genes in pancreatic beta cell failure and insulin resistance) ▪ Genetic defects (maturity-onset diabetes of youth, which has been reclassified as a variety of defects in beta cell function); autosomal dominant trait with six mutations identified (HNF-4-alpha, glucokinase gene, HNF-1-alpha, IPF-1, HNF-1-beta, NeuroD1) ▪ Genotype susceptibility (increased risk of diabetes with excess weight that varies among ethnic populations) ▪ Medical conditions that antagonize the actions of insulin (such as Cushing syndrome, acromegaly, and pheochromocytoma) ▪ Medications (such as glucocorticoids and antipsychotics) DIAGNOSTICS TESTS (Reason for Test and Results) Laboratory ▪ A fasting blood glucose level of 126 mg/dL (7.0 mmol/L) or higher (two abnormal test results from the same sample or in two separate test samples in the absence of hyperglycemia) is diagnostic for DM; a level of 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetic. ▪ An oral glucose tolerance test value greater than or equal to 200 mg/dL (11.1 mmol/L) during a 75-g oral glucose tolerance test (two abnormal test results from the same sample or in two separate test samples required in the absence of hyperglycemia) is diagnostic for DM; a blood glucose level of 140 to 199 mg/dL (7.8 to 11.1 mmol/L) 2 hours after ingestion of 75 g of glucose is considered prediabetic. ▪ A random blood glucose level greater than 200 mg/dL (11.1 mmol/L) in the presence of symptomatic hyperglycemia is diagnostic for DM. ▪ A hemoglobin A1c (Hb A1c) level greater than 6.5% (two abnormal test results from the same sample or in two separate test samples required in the absence of hyperglycemia) is diagnostic of DM; an Hb A1c level between 5.7% and 6.4% is considered prediabetic. ▪ Urine albumin level reveals microalbuminuria (30 to 300 mg/dL [20 to 200 mcg/minute]). ▪ Antibodies to insulin, islet cells, and glutamic acid decarboxylase are absent in T2DM. PATIENT INFORMATION Mr. Carlos is a 52-year-old Hispanic male with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia who presented in the emergency department last night complaining of pain in a wound on his right great toe. ANTICIPATED PHYSICAL FINDINGS ▪ Complications of hyperglycemia (such as retinopathy, neuropathy, and poor wound healing) ▪ Hypertension ▪ Acanthosis nigricans ▪ Muscle atrophy ▪ Kussmaul respirations with diabetic ketoacidosis ▪ Hemorrhages or exudates on funduscopic examination ▪ Weak dorsalis pedis and posterior tibialis pulses, indicating poor lower-extremity blood flow ▪ Decreased sensation with foot ulceration ▪ Blurred vision ANTICIPATED NURSING INTERVENTIONS ▪ Frequently assess vital signs and level of consciousness. ▪ Monitor for signs and symptoms of dehydration; check skin turgor and mucous membranes for moisture. ▪ Assess oxygenation status, and anticipate the need for intervention. Assess oxygen saturation level using pulse oximetry. ▪ Consult with a specialized diabetes or glucose management team, if available. ▪ Assess for signs and symptoms of fluid and electrolyte imbalances. ▪ Obtain specimens for laboratory tests, such as a blood sample for electrolyte levels, as ordered. ▪ Auscultate heart sounds, noting arrhythmias, and assess for an underlying cardiac condition. Institute continuous cardiac monitoring, as indicated. ▪ Obtain blood glucose levels, as ordered; anticipate the need for changes in the prescribed medication if the patient's blood glucose level is outside of the prescribed range. ▪ Administer prescribed medications. o If administering insulin subcutaneously, rotate injection sites. o Ensure that the patient has ready access to meals when administering rapid-acting insulin to prevent possible hypoglycemia. ▪ Organize patient care and activities to provide uninterrupted rest. Assist with energy-conservation measures, as appropriate. ▪ Apply antiembolism stockings or sequential compression stockings to prevent VTE while the patient is hospitalized. ▪ Provide a prescribed diet to meet nutritional needs and maintain blood glucose levels. Enlist the aid of a dietitian to assist with meal planning and food selection. ▪ Provide skin care, as indicated. Inspect the patient's feet daily and encourage the use of footwear to prevent injury. ▪ Encourage the patient and family to verbalize feelings and concerns. Provide emotional support, help reduce stress and anxiety, and assist with positive coping strategies. ▪ Encourage the patient to participate in care measures to foster feelings of control and self-confidence. ▪ Identify modifiable risk factors; help the patient develop a plan for lifestyle changes. ▪ Assess peripheral extremities for color, pulses, temperature, and sensation; compare findings bilaterally, and report any changes. VSIM ISBAR ACTIVITY Student Worksheet INTRODUCTION Milagros Ballesteros, LPN, Emergency Department Your name, position (RN), unit you are working on SITUATION Mr. Carlos is a 52-year-old Hispanic male with a history of type 2 diabetes mellitus, hypertension, and hyperlipidemia who presented in the emergency department last night complaining of pain in a wound on his right great toe. He states he dropped a large rock on his toe several weeks ago and sustained an open wound. Admitted for surgical debridement of what showed to be a diabetic ulcer and to Patient’s name, age, specific reason for visit BACKGROUND Diabetic foot ulcer surgical debridement. Admitted on 09/24/21. Vital signs and SpO2 every 4 hours Titrate oxygen to maintain SpO2 above 92% Check dressing to right great toe every shift Assess pedal pulses and examine legs Diet: carbohydrate-consistent diet Activity: Up with assistance Check blood glucose level every 2 hours Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT Assessment: This morning at 0730 Mr. Carlos’ blood sugar was 225 and he received 4 units of insulin aspart, a sliding scale insulin, along with his regular medications before the surgery. It is all in the MAR. He also received his antibiotic treatment this morning as prescribed. The surgery was performed under local anesthesia. He was given one tablet of oxycodone 5 mg/ acetaminophen 325 mg for his pain after surgery. He now reports his pain to be 3 out of 10. He has a dressing on the toe and a right forearm IV that is saline locked. The dressing on his toe is dry and intact. He seems to be doing well, and his wife has just been here to see him. Vitals- Heart rate: 82. Pulse: Present. Blood pressure: 122/73 Current pertinent assessment data using head-to-toe approach, pertinent diagnostics, vital signs. RECOMMENDATION Any orders or recommendations you may have for this patient Check blood sugar and medicate according to orders. Assess wound and vitals. Monitor for post op complications. Advise MD of any complications. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Lisinopril CLASSIFICATION: ACE Inhibitor/Diuretic Combos ACE Inhibitor/HCTZ Combos PROTOTYPE: Enalapril CONTRAINDICATIONS: Do not take Lisinopril if hypersensitive to angiotensin converting enzyme inhibitors, thiazides or sulfonamides. Angiotensin-converting enzyme inhibitors induced rapid edema (angioedema), hereditary or idiopathic. Kidney failure or kidney stenosis. Do not co-administer with aliskiren in patients with diabetes mellitus or with kidney impairment (GFR greater than 60 ml/min/1.73 m2) ADVERSE EFFECTS: Lisinopril may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away: cough, dizziness, headache excessive tiredness, nausea, diarrhea, weakness, sneezing, runny nose, decrease in sexual ability, rash, Some side effects can be serious. If you experience any of these symptoms, call your doctor immediately: swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs, hoarseness, difficulty breathing or swallowing, fever, sore throat, chills, and other signs of infection, yellowing of the skin or eyes, lightheadedness, fainting, chest pain BLACK BOX WARNINGS: Fetal/neonatal morbidity/mortality may occur when drugs that act directly on the renin-angiotensin system are used in pregnancy; D/C drug ASAP once pregnancy detected SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route: PO Dosage: TAB: 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, 40 mg PURPOSE FOR TAKING THIS MEDICATION Lisinopril is an ACE inhibitor that is used to treat high blood pressure (hypertension) in adults and children who are at least 6 years old. Lisinopril is also used to treat congestive heart failure in adults, or to improve survival after a heart attack. PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Follow all directions on your prescription label and read all medication guides or instruction sheets. Your doctor may occasionally change your dose. Use the medicine exactly as directed. ▪ Drink plenty of water each day while you are taking this medicine. ▪ Lisinopril can be taken with or without food. ▪ Measure liquid medicine carefully. Use the dosing syringe provided, or use a medicine dose-measuring device (not a kitchen spoon). ▪ Your blood pressure will need to be checked often. Your kidney function and electrolytes may also need to be checked. PATIENT EDUCATION WORKSHEET PATIENT EDUCATION WORKSHEET ▪ Call your doctor if you are sick with vomiting or diarrhea, or if you are sweating more than usual. You can easily become dehydrated while taking lisinopril. This can lead to very low blood pressure, a serious electrolyte imbalance, or kidney failure. ▪ If you need surgery, tell the surgeon ahead of time that you are using lisinopril. ▪ If you have high blood pressure, keep using this medicine even if you feel well. High blood pressure often has no symptoms. You may need to use blood pressure medicine for the rest of your life. ▪ Store at room temperature away from moisture and heat. Do not freeze the oral liquid. ▪ If you miss a dose, take as soon as you can, but skip the missed dose if it almost time for your next dose. ▪ Do not take two doses at one time. ▪ Drinking alcohol can further lower your blood pressure and may increase certain side effects of lisinopril. ▪ Avoid becoming overheated or dehydrated during exercise, in hot weather, or by not drinking enough fluids. Lisinopril can decrease sweating, and you may be more prone to heat stroke. ▪ Do not use potassium supplements or salt substitutes, unless your doctor has told you to. ▪ Avoid getting up too fast from a sitting or lying position, or you may feel dizzy. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Lovastatin CLASSIFICATION: HMG CoA reductase inhibitors PROTOTYPE: Lipophilic Statins CONTRAINDICATIONS: Hypersensitivity to drug/class/components, pregnancy (non-high-risk pts), myopathy, unexplained elevated LFTs, active hepatic disease, caution if alcohol abuse, caution in pts 65 year old and older, caution in female pts of reproductive potential, caution if renal impairment, caution if hepatic disease history, caution if diabetes mellitus, caution if hypothyroidism. ADVERSE EFFECTS: Serious Reactions: myopathy, immune-mediated necrotizing myopathy, rhabdomyolysis, acute renal failure, hepatotoxicity, pancreatitis hypersensitivity reaction, anaphylaxis, angioedema, lupus erythematosus, polymyalgia rheumatica, dermatomyositis, vasculitis, thrombocytopenia, leukopenia, hemolytic anemia, photosensitivity, toxic epidermal necrolysis, erythema multiforme, Stevens-Johnson syndrome, interstitial lung disease. BLACK BOX WARNINGS: Possible adverse effects on cognitive performance including memory loss, amnesia, and confusion. SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route: PO Dosage: Extended-release Tabs: 20 mg, 40 mg, 60 mg PURPOSE FOR TAKING THIS MEDICATION Lovastatin is used together with diet to lower blood levels of "bad" cholesterol (low-density lipoprotein, or LDL), to increase levels of "good" cholesterol (high-density lipoprotein, or HDL), and to lower triglycerides (a type of fat in the blood). Lovastatin is used to lower the risk of stroke, heart attack, and other heart complications in adults with diabetes, coronary heart disease, or other risk factors. PATIENT EDUCATION WHILE TAKING THIS MEDICATION PATIENT EDUCATION WORKSHEET ▪ Follow all directions on your prescription label and read all medication guides or instruction sheets. Your doctor may occasionally change your dose. Use the medicine exactly as directed. ▪ Swallow the tablet whole and do not crush, chew, or break it. ▪ It may take up to 4 weeks before your cholesterol levels improve, and you may need frequent blood tests. Even if you have no symptoms, tests can help your doctor determine if this medicine is effective. ▪ You may need to stop using lovastatin for a short time if you have surgery or a medical emergency. Do not stop taking this medicine unless your doctor tells you to. ▪ Lovastatin is only part of a complete treatment program that may also include diet, exercise, and weight control. Follow your doctor's instructions very closely. ▪ Store at room temperature away from moisture, heat, and light. ▪ You should not take lovastatin if you have active liver disease, or if you are pregnant or breastfeeding. ▪ Tell your doctor about all your current medicines and any you start or stop using. Many drugs can interact, and some drugs should not be used together. ▪ Do not take two doses at one time. ▪ Avoid eating foods high in fat or cholesterol, or lovastatin will not be as effective. ▪ Avoid drinking alcohol. It can raise triglyceride levels and may increase your risk of liver damage. ▪ Grapefruit may interact with lovastatin and lead to unwanted side effects. Avoid the use of grapefruit products. ▪ Stop taking this medicine and tell your doctor at once if you become pregnant. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Metformin CLASSIFICATION: Biguanides PROTOTYPE: Metformin CONTRAINDICATIONS: Hypersensitivity to drug/class/components, eGFR <30, metabolic acidosis, diabetic ketoacidosis, lactic acidosis, hypoxemia, dehydration, sepsis, surgery, hepatic disease, caution if eGFR 30-60, caution in patients 65-year-old and older, caution in premenopausal anovulatory patients, caution if CHF, caution if alcohol abuse, caution if hypoglycemia risk ADVERSE EFFECTS: Serious Reactions: lactic acidosis, megaloblastic anemia, hepatotoxicity Common Reactions: diarrhea, nausea, vomiting, flatulence, asthenia, indigestion, abdominal discomfort, anorexia, headache, metallic taste, rash, ovulation induction BLACK BOX WARNINGS: Lactic Acidosis: Post-marketing cases of hypothermia, hypotension, resistant bradyarrhythmia’s, and death; onset may be subtle w/ nonspecific surgery including malaise, myalgias, resp. distress, somnolence, abdominal pain; lab findings incl. lactate >5 mmol/L, anion gap acidosis (w/o evidence of ketonuria or ketonemia), incr. lactate/pyruvate ratio, metformin level >5 mcg/mL; risk factors may incl. renal impairment, concomitant meds, pts 65 year old and older, radiocontrast study, any surgery, hypoxemia, excessive acute or chronic alcohol intake, or hepatic insufficiency; D/C metformin immediately if lactic acidosis suspected, hospitalize patient and institute general supportive care, prompt HD recommended. SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route:PO Dosage: Tablets: 500 mg, 850 mg, 1000 mg; ER TAB: 500 mg, 750 mg, 1000 mg; SOL: 500 mg per 5 mL Diabetes Mellitus, type 2 [immediate-release form] Dose: 850-1000 mg PO bid; Start: 850 mg PO every day or 500 mg PO bid, incr. by 500 mg/day every week or 850 mg/day q2wk as tolerated; Max: 2550 mg/day; Info: give w/ meals; hold treatment for surgery if restricting food/fluid; D/C for iodinated contrast study if eGFR 30-60, hepatic disease hx, alcoholism hx, heart failure hx, or receiving contrast intra-arterially; restart after 48h if stable renal function [extended-release form] Dose: mg ER PO every night; Start: 500 mg ER PO every night, incr. by 500 mg/day every week as tolerated; Max: 2000 mg/day ER; Alt: 1000 mg ER PO bid; Info: may add 500 mg regular form if inadequate response; give w/ meals; do not cut/crush/chew ER tab; hold treatment for surgery if restricting food/fluid; D/C for iodinated contrast study if eGFR 30-60, hepatic disease history, alcoholism history, heart failure history, or receiving contrast intra- arterially; restart after 48h if stable renal function. PURPOSE FOR TAKING THIS MEDICATION Metformin is used together with diet and exercise to improve blood sugar control in adults with type 2 diabetes mellitus. Metformin is sometimes used together with insulin or other medications, but metformin is not for treating type 1 diabetes. PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Follow all directions on your prescription label and read all medication guides or instruction sheets. Your doctor may occasionally change your dose. Use the medicine exactly as directed. ▪ Take metformin with a meal unless your doctor tells you otherwise. Some forms of metformin are taken only once daily with the evening meal. Follow your doctor's instructions. ▪ Do not crush, chew, or break an extended-release tablet. Swallow it whole. ▪ Measure liquid medicine carefully. Use the dosing syringe provided or use a medicine dose- measuring device (not a kitchen spoon). ▪ Shake the oral suspension (liquid) before you measure a dose. Use the dosing syringe provided or use a medicine dose-measuring device (not a kitchen spoon). ▪ Some tablets are made with a shell that is not absorbed or melted in the body. Part of this shell may appear in your stool. This is normal and will not make the medicine less effective. ▪ You may have low blood sugar (hypoglycemia) and feel very hungry, dizzy, irritable, confused, anxious, or shaky. To quickly treat hypoglycemia, eat or drink a fast-acting source of sugar (fruit juice, hard candy, crackers, raisins, or non-diet soda). ▪ Your doctor may prescribe a glucagon injection kit in case you have severe hypoglycemia. Be sure your family or close friends know how to give you this injection in an emergency. ▪ Blood sugar levels can be affected by stress, illness, surgery, exercise, alcohol use, or skipping meals. Ask your doctor before changing your dose or medication schedule. ▪ Metformin is only part of a complete treatment program that may also include diet, exercise, weight control, blood sugar testing, and special medical care. Follow your doctor's instructions very closely. ▪ Store at room temperature away from moisture, heat, and light. ▪ Your doctor may have you take extra vitamin B12 while you are taking metformin. Take only the amount of vitamin B12 that your doctor has prescribed. PATIENT EDUCATION WORKSHEET ▪ Take the medicine as soon as you can, but skip the missed dose if it is almost time for your next dose. Do not take two doses at one time. ▪ Avoid drinking alcohol. It lowers blood sugar and may increase your risk of lactic acidosis. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Glyburide CLASSIFICATION: Antidiabetic-Sulfonylureas PROTOTYPE: Glyburide CONTRAINDICATIONS: Contraindicated in patients hypersensitive to drug and in those with type 1 diabetes or diabetic ketoacidosis with or without coma. Use cautiously in patients with hepatic or renal impairment (eGFR less than 60 mL/minute); in debilitated, malnourished, or elderly patients; and in patients allergic to sulfonamides. Patients with G6PD deficiency may be at increased risk for sulfonylurea-induced hemolytic anemia. Use cautiously and consider therapy modification. ADVERSE EFFECTS: GI: nausea, epigastric fullness, heartburn. Hematologic: leukopenia, hemolytic anemia, agranulocytosis, thrombocytopenia, aplastic anemia. Hepatic: cholestatic jaundice, hepatitis. Metabolic: hypoglycemia, hyponatremia. Musculoskeletal: arthralgia, myalgia. Skin: rash, pruritus, other allergic reactions. Other: angioedema. BLACK BOX WARNINGS: Can cause lactic acidosis, Don't use this drug if you already have lactic acidosis. SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route: PO Dosage: Adjunct to diet to lower glucose level in patients with type 2 diabetes Nonmicronized form Adults: Initially, 2.5 to 5 mg PO once daily with breakfast or first main meal. Adjust to maintenance dose at no more than 2.5-mg increments at weekly intervals. Usual daily maintenance dose is 1.25 to 20 mg, in single dose or divided doses. Maximum daily dose is 20 mg PO. Micronized form Adults: Initially, 1.5 to 3 mg PO daily with breakfast or first main meal. Adjust to maintenance dose at no more than 1.5-mg increments at weekly intervals. Usual daily maintenance dose is 0.75 to 12 mg. Dosages exceeding 6 mg daily may have better response with b.i.d. dosing. Maximum dose is 12 mg PO daily. Adjust-a-dose: For elderly patients, patients who are more sensitive to antidiabetics, and for those with renal, hepatic, adrenal, or pituitary insufficiency, start with 1.25 mg (nonmicronized) or 0.75 mg (micronized) daily. To replace insulin therapy Adults: If insulin dose is less than 40 units/day, patient may be switched directly to glyburide when insulin is stopped. If insulin dose is less than 20 units/day, initial dose is 2.5 to 5 mg (1.5 to 3 mg micronized) PO daily. If insulin dose is 20 to 40 units/day, initial dose is 5 mg (3 mg micronized) PO daily. If insulin dose is 40 or more units/day, initially, 5 mg (3 mg micronized) PO once daily in addition to 50% of insulin dose. Gradually taper off insulin as the glyburide dose is increased. PURPOSE FOR TAKING THIS MEDICATION Adjunct to diet to lower glucose level in patients with type 2 diabetes and to replace insulin therapy PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Teach patient about diabetes and the importance of following therapeutic regimen, adhering to specific diet, losing weight, getting exercise, following personal hygiene programs, and avoiding infection. Explain how and when to monitor glucose level, and teach recognition of and intervention for low and high glucose levels. ▪ Tell patient not to change drug dosage without prescriber’s consent and to report abnormal blood or urine glucose test results. ▪ Teach patient to carry candy or other simple sugars for mild low glucose level. Patient experiencing severe episode may need hospital treatment. ▪ Advise patient not to take supplements or other drugs, including OTC drugs, without first checking with prescriber. ▪ Advise patient to always wear or carry medical identification. ▪ Alert: Instruct patient to report episodes of low glucose to prescriber immediately; a severely low glucose level is sometimes fatal in patients receiving as little as 2.5 to 5 mg daily. ▪ Advise patient to avoid alcohol, which may lower glucose level. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Detemir CLASSIFICATION: Long-Acting Insulin PROTOTYPE: Detemir CONTRAINDICATIONS: Hypersensitivity to drug/class/components, IM or IV administration, continuous SC infusion pump, hypoglycemia, caution if infection, illness, or stress, caution if hypokalemia, caution if renal impairment, caution if hepatic impairment, caution if visual impairment (pen form), caution if localized cutaneous amyloidosis ADVERSE EFFECTS: Serious Reactions: hypoglycemia, hypokalemia, hypersensitivity reaction, anaphylaxis, Common Reactions: hypoglycemia, injection site reaction, URI, headache, pharyngitis, gastroenteritis, influenza, abdominal pain, back pain, bronchitis, pyrexia, cough, viral infection, nausea, rhinitis, rash, pruritus, vomiting, weight gain, edema, peripheral, hypersensitivity reaction, injection site lipodystrophy BLACK BOX WARNINGS: Detemir PATIENT EDUCATION WORKSHEET SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route: Sub Q Dosage: INJ (FlexTouch U-100 pen): 100 units per mL; INJ (U-100 vial): 100 units per mL Diabetes Mellitus, type 1 [individualize dose SC qd-bid] Start: approx. 33-50% of total daily insulin requirement; Info: give w/ rapid-acting or short-acting insulin; usual total daily insulin requirement 0.5-1 units/kg/day (basal + prandial); for once-daily regimen, give w/ evening meal or at bedtime; onset 1h, no true peak, duration 8-24h (long-acting basal insulin) Diabetes Mellitus, type 2 [individualize dose SC qd-bid] Start: 10 units/day SC divided qd-bid; Alt: start 0.1-0.2 units/kg/day SC divided qd-bid; Info: for once-daily regimen, give w/ evening meal or at bedtime; onset 1h, no true peak, duration 8-24h (long-acting basal insulin) PURPOSE FOR TAKING THIS MEDICATION Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood. Insulin detemir is a long- acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours. Insulin detemir is used to improve blood sugar control in people with diabetes mellitus. This medicine is for use in adults and children at least 2 years old. PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ You should not use insulin detemir if you are allergic to it. Do not use during an episode of hypoglycemia (low blood sugar) or diabetic ketoacidosis (call your doctor for treatment). ▪ Tell your doctor if you have ever had: o low levels of potassium in your blood (hypokalemia); or o liver or kidney disease. ▪ Tell your doctor if you also take pioglitazone or rosiglitazone (sometimes contained in combinations with glimepiride or metformin). Taking certain oral diabetes medicines while you are using insulin may increase your risk of serious heart problems. ▪ Tell your doctor if you are pregnant or breastfeeding. ▪ Follow all directions on your prescription label and read all medication guides or instruction sheets. Use the medicine exactly as directed. ▪ Insulin detemir is injected under the skin. A healthcare provider may teach you how to properly use the medication by yourself. ▪ Read and carefully follow any Instructions for Use provided with your medicine. Ask your doctor or pharmacist if you don't understand all instructions. ▪ Prepare an injection only when you are ready to give it. Do not use if the medicine looks cloudy, has changed colors, or has particles in it. Call your pharmacist for new medicine. ▪ Your healthcare provider will show you where on your body to inject insulin detemir. Use a different place each time you give an injection. Do not inject into the same place two times in a row. ▪ Do not inject this medicine into skin that is damaged, tender, bruised, pitted, thickened, scaly, or has a scar or hard lump. ▪ If you use this medicine once daily, use the injection at your evening meal or at bedtime. If you use the medicine twice daily, use your evening dose at least 12 hours after your morning dose. ▪ Your doctor may want you to also use a short-acting insulin. Always inject your insulins separately. Insulin detemir must not be given with an insulin pump or mixed with other insulins. Do not inject into a vein or a muscle. ▪ If you use an injection pen, use only the injection pen that comes with insulin detemir. Attach a new needle before each use. Do not transfer the insulin from the pen into a syringe. ▪ Never share an injection pen or syringe with another person, even if the needle has been changed. Sharing these devices can allow infections or disease to pass from one person to another. ▪ Use a needle and syringe only once and then place them in a puncture-proof "sharps" container. Follow state or local laws about how to dispose of this container. Keep it out of the reach of children and pets.