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PDAT2 > 14/15 - DM Injectables > Flashcards

14/15 - DM Injectables Flashcards

1
Q

LipoAtrophy

A

thought to be due to insulin antibodies

or allergic-type reactions w/ destruction of FAT @ site of injection

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2
Q

Levemir Vial / 300-Unit Flexpen

Dosed / Onset / Duration

MoA

A

Long-Acting Insulin Detemir

Dose QD or BID

BID benefits patients with elevated PRE-Dinner BG

Onset = 1 hour, relatively FLAT peak

monomers are 98-99% albumin bound, delays the distribution into target tissues.

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3
Q

Initiating RX:

Mixed Insulin Regimen

A

Premixed Insulins like 70% NPH (LA) + 30% Regular (SA)

  1. ​Estimate total insulin needed per day:
    1. 0.4 - 0.5 units/kg/day (same as MDI)
  2. Before breakfast:
    1. 2/3 of total daily dose before breakfast
  3. ​Before Dinner
    1. 1/3 of total daily dose before dinner
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4
Q

How are Insulin products CHARACTERIZED by?

A

All insulin products contain only ACTIVE insulin peptide

Onset

Duration of Action

Strength

Source

Analog

insulin that had AA within molecule modified for physiochemical / PK advantages

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5
Q

Weight Gain from Insulin

In comparison to Metformin & SulfonylUreas

A

Insulin > Sulfonylurea > metformin (no weight gain)

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6
Q

When to consider Dual Therapy for T2DM?

A

A1C > 9%

Lifestyle management + Metformin + ADDITIONAL AGENT

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7
Q

Diabetes KetoAcidosis

DKA

Criteria / Physical Findings

A

Typically seen in T1DM, rare in T2DM

  • Glucose > 250mg/d
  • Presence of serum ketones, serum pH < 7.3
  • Anion gap >10, plasma bicarb <18 meq/I
  • S/S of:
    • polyuria / polydipsia / N&V / Coma
    • dehydration, hypotention + tachycardia
    • fruity breath from ketones
    • MORE Respirations
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8
Q

Insulin Sensitivity Factor

ISF

(correction Factor)

A

“1800 Rule” for RAPID-Acting Insulin

“1500 Rule”** for **short-acting insulin

  • Determines how much
    • Glucose is lowered by 1 unit of insulin
  • Based on ALL THE UNITS of insulin that person takes in 1 day
  • Ex. Used 54 units / day
    • 1800 / 54 units = 33.33
      • BG will be lowered by ~33mg/dL
        • ​for every 1 unit of humalog
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9
Q

Insulin Release Kinetics

A

2 Phase Kinetics - difficult to replicate when dosing insulin

Acute 1st Phase - lasts a few minutes (0-10), high peak

Sustained Second Phase - SECRETION, persists for the duration of the high-glucose stimulus (10-80+)

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10
Q

When to consider Injectable Therapy?

A

A1C > 10%

BG > 300mg/dl

or patient is markedly symptomatic

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11
Q

Fast-Acting Analog

Aspart (Fiasp) / Novo Nordisk

Dosed / Onset / Duration

A

Newly approved formulation of Novolog

+ niacinamide -> increase speed of initial absorption

+ L-arginine to boost stability

Dosed at the BEGINNING OF A MEAL or within

20 MIN AFTER STARTING A MEAL

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12
Q

Advantages & Disadvantages

of MDI Insulin Regimen

A

Basal = LA (Lantus or Levemir)

Bolus = RA (LAG - Humalog/Novolog)

  • Adv:
    • _​_Offers FLEXIBILITY in meal size & timing
    • ​​best MIMICS endogeneous insulin production
  • ​Disadv:
    • ​Required multiple injections
    • have to test BG often
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13
Q

Insulin Therapy for

T1DM vs T2DM

A

T1DM

  • almost NO insulin secretion*
  • will be dependent on insulin for the rest of their lives*

T2DM** - **lower A1C >2%

most effective in lowering hyperglycemia,

Initiate AFTER optimized ORAL therapy or failure to achieve target goals

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14
Q

Types of Premixed Insulins

A

•Humalog Mix 50/50

•Humalog Mix 75/25

•NovoLog Mix 70/30

•Humulin 70/30

•Novolin 70/30

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15
Q

Types of Short-Acting (Regular) Insulins

+ Concentrated Regular Insulin

A

Considered Bolus / R = Regular

Humulin R

Humulin R U-500

Novoin R

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16
Q

Sliding Scale Insulin

SSI

A

Reactive, not PROACTIVE

NOT RECOMMENDED TYPICALLY, only seen in Hospital care

  • Does not provide physiologic insulin needs:
  • “Chasing” of BG
  • supplementation / correction scale
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17
Q

Types of Long-Acting Insulins

A

Glargine (Lantus)

Detemir (Levemir)

  • can not be mixed*
  • considered Basal*
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18
Q

Resolving GDM

gestational diabetes

A

Insulin -> reduction in fetal moridities

similar efficacy among VARIOUS insulin regimens

TARGET A1C = 6-6.5%

A1C target is *LOWER* due to INCREASED RBC turnover

FPG <95 mg/dl

1hr PPG < 140mg/dl or 2hr PPG < 120mg/dl

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19
Q

HHS

Hyperglycemic Hyperosmolar State

A

Similar to DKA except patients are

NOT acidotic

Fluid Deficit is GREAT

common in T2DM, mortality rate is 50%

Treatment is the SAME as DKA

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20
Q

Insulin to Carbohydrate Ratio

ICR

A

“Rule of 500”

T1DM on average = 1unit:10g

T2DM on average = 1unit:15g

  • Divide 500 by the TDD of Insulin
    • Ex. TDD = 54 units
      • 500 / 54units = ~10g
        • therefore - 1 unit of insulin per 10g of carbs
  • Each person has their OWN ICR
    • used to figure out meal BOLUS
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21
Q

Premixed Insulin Regimen Effects

of PM=EVENING- Short-Acting (Bolus) insulin

major action time & effect reflected?

A

Major action is between Supper & Bedtime

Effect is reflected in the Bedtime BG levels

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22
Q

Types of Ultra Long-Acting Insulin

A

Glargine

( Toujeo U-300 )

Degludec

(Tresiba U-100 / U-200)

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23
Q

Sick Day Management

A

MUST FOR T1DM

  • Continue insulin therapy 50-100% of basic insulin dose
    • even when NOT eating
    • or presence of N/V
  • ​Test BG & Ketone MORE frequently
    • Q3-4
    • may need to supplement insulin
  • ​FLUID REPLACEMENT
    • very important
    • jello / chicken broth / soup
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24
Q

Treatment of DKA

A

FLUID REPLACEMENT

Insulin supplement

Potassium Replacement

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25
Q

DM for Special Populations

Older Adults (Elderly)

A
  • Need to consider risks
    • hypoglycemia
    • comorbiditiesm, microvascular disease + CVD
    • dexterity / self-care
    • Nutrition
    • Social support / mental status / life expectency
    • FALLS RISK
  • Decline in renal function needs to be considered
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26
Q

3 Primary Physiological Actions

of Insulin

A

INCREASE glucose disposal

  • Decrease* hepatic glucose production
  • Supresses* ketogenesis
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27
Q

Intermediate-Acting Insulin / NPH

Humulin N / Novolin N

Dosed / Onset / Duration

A

DOSED BID

Onset = 1-3 hours

LONG Duration = 12-16 hours

Prominent Peak = 8 HOURS (4-10 hours)

–> risk of hypoglycemia @ time of PEAK

Weight GAIN

Major factor in limiting insulin adjustments

28
Q

Basal Insulin / (Ultra) Long-Acting Insulin

Glargine / Detemir / Degludec

Dosed / Onset / Duration

A

Onset & Duration VARIES

between each formulation

MIMICS normal pancreatic basal insulin secretion

Peakless, predictable effects

Reduced risk of nocturnal hypoglycemia

29
Q

Switching Insulin Products

NPH –> Basal

(Intermediate Acting, -N) –> (Long Acting, Lantus/levemir)

Basal –> NPH

A

don’t need to know these specifics

QD NPH -> QD Basal (LA)

same dose 1 to 1

BID NPH -> QD Basal (LA)

initiate w/ 80% of TDD

30
Q

LipoHYPERtrophy

A

Injection site complication

caused by Many injections into SAME SITE

thick / rubbery scar

avoid by ROTATING INJECTION SITES

use larger injection zone >1cm frome ach

do not reuse needles

31
Q

Initiating RX:

Basal + Bolus Regimen

(MDI = multiple dose insulin, Regimen)

A

LA (Lantus or Levemir) + RA (LAG - Humalog/Novolog)

  1. Start insulin based on WEIGHT
    1. 0.4 - 0.5 units/kg/day
  2. ​BOLUS (LAG)​
    1. ​20% of starting dose (calculated above) @ each meal
      1. 20% x Dose TID-AC
  3. ​​Basal (NPH - glargine/detemir/degludec)
    1. 40% of starting dose @ bedtime
      1. ​40% x Dose QHS
32
Q

Premixed Insulin Regimen Effects

of AM-_Intermediate-Acting (Basal)_ insulin

major action time & effect reflected?

A

Major action is between BREAKFAST & Supper

Effect is reflected in the Pre-SUPPER BG levels

33
Q

Dosage Adjustment for

Basal + Bolus MDI Regiment

A

Basal = LA (Lantus or Levemir)

Morning glucose reading, PRE meal

Bolus = RA (LAG - Humalog/Novolog)

POSTPRANDIAL

34
Q

What differs between Insulin Preparations

A

There is NO DIFFERENCE IN EFFICACY between newer & older formulations

its the PHARMACOKINETIC PROFILES that are different

HIGHER DOSE for T2DM vs T1DM

Adjusted based on BG results

MAX DOSE = Based on effectively lowering BG

35
Q

Premixed Insulin Regimen Effects

of AM-Short-Acting (Bolus) insulin

major action time & effect reflected?

A

Major action is between BREAKFAST & LUNCH

Effect is reflected in the Pre-Lunch BG Levels

36
Q

Lantus, SolaSTAR Pen

Dosed / Onset / Duration

MoA

A

Long-Acting Insulin Glargine

Administered ONCE A DAY & should be SAME TIME EACH DAY

no pronounced peak, 1 hour Onset

Injection of acidic solution (pH 4.0) –> precipitation of Glargine in subQ tissue (pH 7.4) –> slow dissolution of glargine from hexamers

37
Q

GDM

Gestational DM

A

Any Degree of GLUCOSE INTOLERANCE

with onset or first recognition during pregnancy

4-5% of ALL pregnancies

Increased Risk of Macrosomia (birth weight)

& Birth Complications (spinal bifida, birth defect)

Neonatal hypoglycemia

Maternal Hypertention

38
Q

Types of Rapid-Acting Insulins

A

Considered BOLUS

L L A G

Lispro (Humalog U-100 / U-200)

Lispro (Admelog)

Aspart (Novolog)

Glulisine (Apidra)

Inhaled AFREZZA

39
Q

Concept of Basal + Bolus Insulin

LA (Lantus or Levemir) + RA (LAG - Humalog/Novolog)

A
  • Basal Insulin = Long Acting
    • Supresses glucose production between meals & overnight
    • nearly consistant levels
    • covers 40-50% of daily needs
  • BOLUS INSULIN = Rapid acting
    • ​for mealtime/prandial
    • limits hyperglycemia AFTER meals
    • immediate rise / peak @ 1 hour
    • ~10-20% of total daily insulin req @ each meal
      *
40
Q

Toujeo (U-300)

Dosed / Onset / Duration

MoA

A

ULTRA Long-Acting Insulin Glargine

Dose = QD @ same time each day

LATE Onset: 6 hours

Duration = 36 Hours

Same maker as LANTUS & smaller volume

41
Q

Disadvantages of Insulin

A

HYPOGLYCEMIA / WEIGHT GAIN

Pt / provider RELUCTANCE

Training requirements / Injectable

(pulmonary toxicitiy_

42
Q

ICR vs ISF

(Insulin to Carb ratio) vs (Insulin Sensitivity Factor

A

ICR

Bolus insulin,

Determines how many grams of carbs are convered by 1 unit of insulin

Units : Carbs

ISF

Used in correction or supplementation

of insulin doses when glucose levels are too high/low BEFORE meals

___ mg/dl for every 1 unit of insulin

43
Q

Premixed Insulin Regimen Effects

of PM=Evening -Intermediate-Acting (Bolus) insulin

major action time & effect reflected?

A

Effect is reflected in the NEXT MORNING BG Reading

44
Q

Tresiba (U-100/U-200)

Dosed / Onset / Duration

MoA

A

ULTRA Long-Acting Insulin Degludec

Duration ~42 hours

Onset = 90 minutes

no peak, lower risk of hypogllycemia

Allows for flexibility in dosing, especially with a MISS

slow release from subQ depot

45
Q

Rapid - Acting Insulin

Lispro / Aspart / Glulisine

Dosed / Onset / Duration

A

Compared to Regular/Short-Acting,

ACTION is faster / PEAK is HIGHER / dissapears faster

Convenient, take immediately prior to means

Onset = 15 Minutes

Duration = 3-5 Hours

46
Q

Resolution & Prevention

of DKA

A
  • Resolution:
    • Patient is clinically stable
    • BG < 200mg/dl
    • Serum bicarbonate > 18 meq/l
    • Venus pH >7.3
  • ​Prevention:
    • ​educate patient about precipitating factors
    • sick day management
47
Q

Options after Initiating Basal Insulin

A1C not Contolled

3

A

Combination Injectable Therapy

  • Add 1 Rapid-Acting Insulin before largest meal
    • 4 units or 0.1 units/kg
      • ​ (or 10% basal dose)
  • Add GLP-1 RA
    • possibly not tolerated for A1C target
  • Change to premixed insulin BID (b4 breakfast + supper
    • 2/3 AM –> 1/3PM
48
Q

Advantages of Pre-MIXED Insulin

A

Increase Glucose Disposal

  • Decrease hepatic glucose production*
  • Supressess Ketogenesis*

Mixing with other formulation in the same syringe prior to injection

is NOT RECOMMENDED

49
Q

Dawn Effect

A

AE of Insulin

Elevated FBG due to

early morning CORTISOL & EPInephrine Release

50
Q

Toujeo (U-300)

Other stuff

A

ULTRA Long-Acting Insulin Glargine

INITIATION in T1DM, glucose lowering effect may take up to 5 days & first few doses may NOT be sufficient to cover needs

After switch, temporary RISE in FPG in first WEEKS of therapy

Titrate no more frequently than q3-4 days, to minimize hypoglycemia risk

51
Q

DM for Special Populations

Children & Adolescents

A
  • METFORMIN is the ONLY FDA approved ORAL agent
    • 10-16 years of age
    • ​unfortunately, monotherapy is POOR in many adolescents
    • ​​​​Sulfonylureas are also commonly used
      • INSULIN continues to be the standard of care
    • when glycemic goals cant be reached with
      • metformin/sulfonylureas
52
Q

S/Sx of hypoglycemia

A

Shaking / Sweating / weakness fatigue

Fast Heartbeat / Anxious / Dizziness / Irritable

Impaired VISION / HEADACHE / HUNGER

53
Q

Somogyi Phenomenon

A

AE of INSULIN

Nocturnal hypoglycemia followed by REBOUND HYPERglycemia

54
Q

Treating GDM

Gestational Diabetes

A

Lifestyle modification is ESSENTIAL

restrict calories / carbs / small meals many times thru day

INSULIN is preffered medication, does not cross placenta

metformin + glyburide may be used but –> crosses placenta

55
Q

Advantages of Insulin

A

NEARLY Universal Response

Theoretically Unlimited Efficacy

  • Decrease microvascular risk*
  • (UKPDS)*
56
Q

Basaglar KwikPen

A

First approved “FOLLOW-ON” insulin

LONG-acting Glargine

biologically similar to LANTUS, same protein sequence & effects

57
Q

Humulin R U-500

Used for who? / Testing / onset+duration

A

CONCENTRATED human insulin, for those who require >200 units of insulin /day

need proper training / special syringe

BID/TID 30 min prior to meal

onset = ~15 min

peak = 4-8 hours

duration = ~21 hours

58
Q

Regular (Short-Acting) Insulin

Humulin-R / Novolin-R

Dosed / Onset / Duration

A
  • inconvenient administration*: 20-40 minutes PRIOR to meals
  • Slow Onset =* 30-60 min

LONG duration = 5-8 hours

peak is @ 2-4 hours

multiple-injection regimen, potential for late PP-hypoglycemia

  • caution with PP-exercise*,
  • SLOW to correct hyperglycemia*
59
Q

Hypoglycemia

Glucose Level / 2 categories of Symptoms

A

Glucose < 70mg/dl

2-3x HIGHER RISK when needed to intensively regimen dose

Adrenergic ( epi secretion )

sweating / tremor / tacyCardia / anxiety / hunger

Neuroglycemic ( CNS dysfunction )

dizziness / headache / blunted mental activity / loss of fine motor skill / confusion / abnormal behaviro / convulsion / loss of conciousness

60
Q

Insulin Storage & Disposal

A

Avoid Heat / Light / Freezing

Store UNOPENED products in FRIDGE

Pen can be kept at room temperature, keep storage in fridge

check exp date & appearance

61
Q

Types of Fast-Acting Insulin

A

ASPART

(Fiasp)

Novo Nordisk

new formulation of Novolog

62
Q

Afrezza

Rapid-Acting Insulin

A

Human Insulin INHALATION powder

Oral inhalation @ beginning of each meal

  • many NEGATIVES:*
  • need to Assess Lung Function + Spirometry (FEV1)*
  • Contraindicated in pts w/ Chronic Lung Disease*
63
Q

Types of Intermediate-Acting Insulin / NPH

A

(NPH = isophane Insulin, neural protamine Hagedorn) N = NPH

Only one that can be MIXED,

also considered BASAL

Humulin N

Novolin N

64
Q

Initiation of Injectable Therapy

A

Initiate BASAL INSULIN

start: 10 U/day or 0.1-0.2U/kg/day
* adjust 10-15% or 2-4 units QD/BID to reach FBG target*

usually with Metformin +/- *noninsulin agent*

65
Q

Adverse Effects

of Insulin

A

hypoglycemia / weight GAIN

LipoAtrophy & LipoHYPERtrophy

Somogyi Phenomenon

Dawn Effect

PDAT2 (22 decks)

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