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PHS 933 > Block 1 Lecture 2 -- Diabetes II > Flashcards

Block 1 Lecture 2 -- Diabetes II Flashcards

1
Q

Normal post-prandial [glucose]

A

120-140 mg/dL

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2
Q

normal fasting [glucose]

A

70-100 mg/dL

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3
Q

Describe the structure of insulin.

A

51 AA with alpha and beta chain

    • 2 disulfides link chains
    • 1 addl disulfide on alpha chain
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4
Q

Normal fasting [insulin]

A

50 pM

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5
Q

Normal bolus insulin [concentration] at mealtime

A

500 pM

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6
Q

How is insulin secretion stimulated?

A

primarily by glucose

    • also GLP-1, GIP
    • cholinergic vagal stimulation
    • medications
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7
Q

Describe endogenous insulin clearance.

A

60% hepatic; 40% renal

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8
Q

Describe exogenous insulin clearance

A

40% hepatic; 60% renal

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9
Q

What is the t1/2 of insulin?

A

5 minutes

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10
Q

Describe [insulin receptor] on non-responsive cells

A

40/cell

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11
Q

Describe [insulin receptor] on responsive cells.

A

300,000/cell

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12
Q

Describe structure of insulin receptor.

A

2 covalently-linked heterodimers

    • extracellular alpha subunit recognition site
    • beta membrane-spanning TK unit
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13
Q

What are the GLUT isoforms?

A

1-4

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14
Q

Location and fx of GLUT-1:

A

1) brain

2) transport across BBB

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15
Q

Location and fx of Glut-2:

A

1) beta cells, liver

2) regulation of insulin release and glucose homeostasis

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16
Q

Location and fx of Glut-3:

A

1) brain

2) uptake into neurons

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17
Q

Location and fx of GLUT-4:

A

1) skeletal muscle, adipose

2) insulin-mediated glucose uptake

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18
Q

What is the inhaled insulin on the market, and when was it approved?

A

1) Afrezza

2) June ‘14

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19
Q

What is the equivalent mg/mL concentration of 100 units/mL insulin?

A

3.6 mg/mL

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20
Q

What are the rapid acting insulin analogs?

A

1) Aspart (Novolog)
2) Glulisine (Apidra)
3) Lispro (Humalog)

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21
Q

What are the short-acting insulins?

A

Regular (Humulin/Novolin R)

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22
Q

What insulin forms come U-500?

A

Humulin R (lilly)

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23
Q

What are the intermediate-acting analogs?

A

1) NPH (neutral protamine Hagedorn)

- - also NPA/NPL in mixtures

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24
Q

What insulin products are identical to human insulin?

A

1) Regular (Humulin/Novolin R)

2) NPH

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25
Q

What are the long-acting insulin analogs?

A

1) Detemir (Levemir)

2) Glargine (Lantus)

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26
Q

What is the usual dosage of insulin glargine?

A

once-daily (24h coverage)

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27
Q

What is the usual dosage of insulin detemir?

A

often BID

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28
Q

What insulins are mixed?

A

1) intermediate + rapid/short
- - NPH + rapid
- - NPA/NPL + rapid
- - short can be used in place of rapid
2) NPH + regular

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29
Q

What modifications are made in insulin aspart?

A

Pro replaced with Asp in beta-chain

– reduced aggregation

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30
Q

What modifications are made in insulin glulisine?

A

Glu and Lys replace AA’s in beta-chain

– reduced aggregation

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31
Q

What modifications are made in insulin lispro?

A

identical except 2 residues reversed to match IGF-1

    • no aggregation
    • dissociates into monomers following inj.
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32
Q

Describe onset and duration of rapid-acting analogs.

A

1) inject ≤ 15 mins before meal

2) duration ≤ 4-5 hrs

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33
Q

Which insulin class has the lowest variability of absorption?

A

rapid-acting

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34
Q

Which insulin class is approved for CSII pumps?

A

rapid-acting

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35
Q

Describe onset of Short-acting/regular insulins.

A

30 minutes

    • injected 30 mins prior to meal
    • 25% variability in F
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36
Q

Describe the peak and duration of short-acting/regular insulins.

A

Peak @ 2-3 hours
Duration = 5-8 hours
– bigger dose = longer

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37
Q

How are short-acting/regular insulins supplied?

A

U-100 or U-500 in clear solution

38
Q

How are intermediate-acting insulin analogs supplied?

A

cloudy susp of human insulin + Zn + Protamine in a neutral buffer

39
Q

What is Protamine?

A

positively-charged polypeptide that is degraded by proteolytic enzymes SubQ to delay absorption

40
Q

Describe the onset of intermediate-acting insulin analogs.

A

2-5 hr onset

– 50% variability in F

41
Q

Describe duration of intermediate-acting insulin analogs.

A

4-12 hr duration

– small dose = earlier peak, shorter duration

42
Q

What modifications are made to insulin detemir?

A

Thr removed, myristic acid added

    • increased aggregation
    • binding to albumin in tissue
43
Q

Describe duration of insulin detemir.

A

variable duration

    • ≥ 0.8 u/kg = 23 hrs
    • lower dose = variable, ≤ 12 hours
44
Q

Which insulins cannot be mixed?

A

Long-acting (PD changes)

45
Q

What is the only insulin analog to have modifications in the alpha-chain?

A

insulin glargine (lantus)

46
Q

How is insulin glargine supplied?

A

clear solution of pH 4 for hexamer stabilization

47
Q

Describe modifications to insulin glargine?

A

alpha-Gly sub, 2 beta-Arg subs

48
Q

How does insulin glargine produce long-lasting release?

A

pH of 4 = hexamers in vial

neutral pH = aggregation in SubQ

49
Q

Describe absorption and duration of glargine.

A
    • 24 hr prolonged, peakless duration

- - onset not altered by injection site or exercise

50
Q

What is the issue with insulin glargine?

A

increased binding to IGF-1 receptor

– cell growth, may increase cancer risk

51
Q

Brand name of NPH + regular

A

Humulin/Novolin Mix

52
Q

Brand name of intermediate-acting NPA/NPL + rapid (A/L)

A

Humalog/Novolog Mix

53
Q

What is a usual dosing regimen for patients on intermediate-acting + rapid-acting insulin mix?

A

breakfast: mix
lunch: rapid
dinner: rapid
hs: intermediate

54
Q

What is a usual dosing regimen for patients on NPH + regular mix?

A

breakfast and supper mix

55
Q

What are common pre-mixed formulation ratios?

A

50/50, 75/25, 70/30

– first # = longer acting

56
Q

Why is intermediate-acting mixed with rapid-acting?

A

to avoid post-prandial glucose peak

57
Q

What mix proportions are allowed?

A

any

58
Q

What is the important consideration for mixing intermediate + rapid?

A

NPH + rapid

    • must be mixed ≤ 15 mins prior to inj.
    • unstable
59
Q

What is the most consistent insulin injection site for absorption?

A

abdomen

60
Q

What is the slowest insulin injection site?

A

arm (30% slower)

61
Q

What factors affect insulin onset?

A

1) IM injection more rapid onset

2) increased SubQ blood flow more rapid onset

62
Q

What is the average dose of insulin in T1DM?

A
  1. 7 units/kg/day

- - obese ~ 1-2 units/kg/day

63
Q

What proportion of the total daily dose does long-acting basal make up vs. short- or rapid-acting postprandial?

A

long-acting: 50-75%

short/rapid: 50-25%

64
Q

What are the general insulin regiments?

A

1) basal/bolus
- - long @ breakfast or qhs
- - bolus @ mealtimes
2) split-mixed
- - breakfast + dinner mix
- - if dinner doesn’t control hyperglycemia @ night, pre-dinner regular + NPH qhs

65
Q

What is the usual initial insulin dose in T1DM?

A

0.3-0.5 units/kg/day

66
Q

What is the usual initial insulin dose during DKA or illness?

A

1-1.5 units/kg/day

67
Q

How does initial insulin dose compare to eventual insulin dose and why?

A

1) eventual less than initial

glucose toxicity causes IR

68
Q

What are symptoms of hypoglycemia?

A

SNS symptoms
– sweating, palpitations, tremor, anxiety
PNS symptoms
– nausea, hunger

69
Q

What are symptoms of severe hypoglycemia?

A

neuroglycopenic symptoms

    • confusion, weakness, drowsy, dizzy, blurred vision, loss of consciousness
    • convulsions, coma
70
Q

When do hypoglycemia symptoms start?

A

60-80 mg/dL

71
Q

When do severe hypoglycemia symptoms start?

A

less than 60 mg/dL

72
Q

When do neurons stop signaling?

A

When glucose less than 10 mg/dL

73
Q

What is hypoglycemic unawareness?

A

condition that occurs after prolonged, untreated hypoglycemia

74
Q

How is severe hypoglycemia treated?

A

20-50 mL of 50% glucose IV over 2-3 minutes

– if unconscious and IV not available, 1 mg SQ/IM glucagon, then dextrose po

75
Q

How are DKA and hyperglycemic hyperosmolar state treated?

A

IV insulin
IV fluids
electrolyte replacement
monitoring

76
Q

What insulins are approved for IV use?

A

regular and rapid-acting

77
Q

What insulins are OTC?

A

R and NPH

78
Q

How is hypoglycemia counteracted endogenously?

A 
\+++ glycogenolysis (faster)
-- ACTH: EPI/NE
-- SNS: NE
\+ gluconeogenesis (slower)
-- SNS: glucagon
-- ACTH: cortisol
79
Q

What causes DKA?

A

lack of insulin (usually T1)

– unchecked FA/AA breakdown, KB production

80
Q

Sxs of DKA:

A

1) blood pH less than 7.3
2) osmotic diuresis
- - dehydration worsens DKA

81
Q

What are the KB’s in DKA?

A

acetoacetic acid

beta-HB

82
Q

What causes the hyperglycemic hyperosomolar state?

A

reduced insulin (usually T2)

    • severe hyperglycemia (600 mg/dL)
    • osmotic diuresis
83
Q

What are Sxs of hyperglycemic hyperosmolar state?

A

600 mg/dL glucose
osmotic diuresis
– volume depletion
– hemo-concentration = viscosity, thrombosis

84
Q

[FA] during fasting and post-prandial:

A

fasting: 400 uM

post-prandial: ≤ 400 uM

85
Q

How does insulin aggregate?

A

hexamers, dimers, monomers

86
Q

What is the fx of basal insulin release?

A

inhibition of glucose production by liver

87
Q

insulin effects on adipose:

A

1) glucose transport
2) glucose –> glycerol for ester
3) inhibition of lipolysis

88
Q

insulin effects on muscle:

A

1) glucose transport
2) glycogen + protein synthesis
3) inhibition of protein catabolism

89
Q

insulin effects on liver:

A

1) G6K activation - glucose uptake
2) glycogen synthase
3) inhibits glycogenolysis and gluconeogenesis

90
Q

Common causes of hypoglycemia?

A

1) large dose
2) mismatch b/w peak and food intake
3) pre-disposition (adrenal/pituitary insufficiency)
4) increased insulin-dependent uptake (exercise)

PHS 933 (14 decks)

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