Diabetes Flashcards
What is an insulin pump?
Small microcomputer which delivers insulin continuously 24 hours a day (may be programmed to deliver increments as small as 0.025 units/hour (pediatrics and insulin sensitive individuals)
Insulin pumps use what type of insulin?
One type - rapid acting
What are some benefits to using an insulin pump? (8)
- Insulin delivery that’s customizable, flexible and adjustable
- Insulin delivery that’s more precise than pen or syringe doses
- Fewer injections
- More flexibility with daily routines
- Feeling healthier, better blood glucose control
- Improved control during exercise
- Patient is in control, not the diabetes
- Opportunity for sensor integration
Why is using an insulin pump more effective? (3)
- Can be programmed to more closely mimic the insulin secretion of a functioning pancreas than injections
- More predictable insulin absorption
- More accurate bolus doses
What are some of the downsides of using an insulin pump? (3)
- Can be challenging and more work for the patient, especially initially
- Expensive
- Various Complications
- Empty reservoir, kinked line, set problems, low batteries
- Higher risk of DKA
- Body image – always “attached”
Who is a good candidate for using an insulin pump? (5)
- Motivated and willing to check blood sugars
- Wants to improve glucose control
- Desire to live a more physiological lifestyle
- Have family support
- Realistic Expectations
What are some good indications for using an insulin pump? (9)
- A1C
- Frequent hypoglycemia
- Dawn Phenomenon
- Exercise
- Pediatrics
- Pregnancy
- Gastroparesis
- Lifestyle
- Shift work
What are some of the available pumps in Canada? (4)
- Tandem t:slim X2
- Medtronic 630G, 780G
- YpsoPump
- Omnipod DASH
What is a pump infusion set? (3)
- Delivers the insulin from the reservoir in the pump into the body
- Consists of tubing, an adhesive mount, quick disconnect and a plastic or metal cannula that is inserted into the skin
- Changed every 2, 3, or 7 days
What are the best infusion sites for a pump? (4)
- Abdomen
- Hips and Buttocks
- Outer thigh
- Back of the arms
What is a 90 degree infusion set? (5)
- Soft, flexible Teflon cannula inserted under the skin at a 90 ̊ angle
- Cannula lengths can be 6mm or 9mm
- Various tubing lengths available from 18” to 43”
- Must be changed every 3 days
- Extended wear set available for 7 day wear
What is a 30 degree infusion set? (4)
- Soft, flexible Teflon cannula inserted under the skin at a 30 ̊ to 45 ̊ angle
- Cannula lengths can be 13mm or 17mm
- Various tubing lengths available from 18” to 43”
- Must be changed every 3 days
What is a steel needle infusion set? (3)
- Enhanced security: designed with a kink-free steel needle.
- Combined with an extra disconnection site 10 cm away from the infusion site, this provides extra security against clogging and dislodging.
- Particularly suited for infants and children, pregnant women or people allergic to Teflon®.
Difference between basal and bolus rates in an insulin pump?
- Basal rate is constantly running – tiny micro-doses delivered as background insulin
- Different profiles can be programmed to coincide with different physiologic needs
- Newest insulin pump automatically adjusts basal rates based on sensor glucose readings - Bolus amounts are temporary surges in dose, given in response to food intake and as correction
What is basal insulin? (4)
- Rapid-acting insulin delivered around the clock in small pulses preprogrammed to meet metabolic needs when not eating
- Takes the place of long-acting insulin
- Typically start on the pump with one basal rate
- Rate(s) may vary throughout the day and can be increased or decreased according to needs
When set correctly, basal insulin will: (2)
- Keep glucose stable between meals and through the night
- Allow you to sleep late, eat late, even skip meals
There are 2 reasons a bolus of insulin is given. What are they?
- For food or drink that contains carbohydrate at meals or snacks
- To bring down a glucose level that is above your target range (correction dose)
What to know about bolus doses in insulin pumps?
Insulin pumps also track insulin that is still working from previous bolus doses (called Active Insulin or Insulin on Board) and takes this into account when calculation correction doses if blood glucose (BG) is above target
Four personal settings are required for bolus dose insulin pump calculation. What are they?
- Carbohydrate ratio
- Sensitivity
- BG target
- Active insulin time
Continuous glucose monitoring (CGM) measures glucose levels in the ____________ _____ in the body
interstitial fluid
A higher Time in Range results in a(n) _________ of Glycemic Variability (GV)
reduction
What to know about glycemic variability? (4) (mostly why is it bad?)
- Increasing GV is correlated with more frequent episodes of hypoglycemia
- GV has been associated with increased is risk of diabetic retinopathy and nephropathy
- Emerging evidence of the relationship between GV and increased risk of severe hypoglycemia and cardiovascular outcomes
- Patients experiencing severe hypoglycemia have an increased risk of cardiovascular outcomes and death, therefore reducing hypoglycemia is important
What to know about insulin pump coverage in Sask?
- The Saskatchewan Aids to Independent Living (SAIL) program fully covers insulin pumps for eligible individuals; however supply coverage will vary
- Coverage is available for one pump every 5 years
- The selected pump and 3 months of pump supplies are provided at no charge
When is A1C of 7.1-8.5 the target? (3)
- Recurrent severe hypoglycemia and/or hypoglycemia unawareness
- Limited life expectancy
- Frail elderly and/or with dementia
When is A1C of 7.1-8.0 the target?
Functionally dependent
When is A1C of ≤7.0 the target?
Most adults with Type 1 or Type 2 diabetes
When is A1C of ≤6.5 the target?
Adults with T2DM to reduce the risk of chronic kidney disease and retinopathy if at low risk of hypoglycemia
When is A1C of ≤6.0 the target?
Selected adults with T2DM with potential for remission to normoglycemia
What are the 3 currently available biosimilar insulins?
- Insulin glargine (Lantus; Basaglar, Semglee)
- Insulin lispro (Humalog U-100; Admelog)
- Not Humalog U-200 - Insulin aspart (NovoRapid; Trurapi, Kirsty)
What are 2 classes of drugs with MACE benefits?
- Injectable GL1 agonists (dulaglutide, liraglutide, semaglutide)
- Not oral semaglutide - SGLT2i (canagliflozin, empagliflozin)
- Dapagliflozin non-inferior to placebo
Which diabetes drug class has renal benefits?
- SGLT2is (all 3)
- SubQ semaglutide (FLOW trial)
Which diabetes drug class has heart failure benefits?
SGLT2is - only dapagliflozin and empagliflozin
What was the PICO of the FLOW trial?
Population: patients with T2DM and CKD
Intervention: subcut semaglutide 1mg once weekly compared to placebo
Primary Outcome: Major kidney disease events
Results: Risk of primary outcome was 24% lower in semaglutide group
Newer diabetes drugs in T1DM. Yay or nay? (That being SGLT2i and GLP1)
- DEPICT studies: Dapagliflozin
- Improved glycemic control and induced weight loss in T1DM
- Increased risk of DKA - ADJUNCT 1,2: Liraglutide (26 and 52 weeks)
- Improved glycemic control, body weight & reduced total insulin dose
- Higher rates of hypo and hyperglycemia with ketosis - EASE-2,3: Empagliflozin (26 and 52 weeks)
- Improved glycemic control and weight without ↑ hypo & reduced total insulin dose
- At 2.5mg no increase in DKA; was an ↑ with 10mg and 25mgJAMA review
What is the MOA of tirzepatide? (3)
- It is a GIP receptor and GLP-1 receptor agonist
- It selectively binds to and activates both GIP and GLP-1 receptors, the targets for endogenous GIP and GLP-1
- It enhances first- and second-phase insulin secretion, and reduces glucagon levels, both in a glucose-dependent manner
Who is indicated for tirzepatide use? (3)
- T2DM adults (not in those <18yo and not in pregnancy/breastfeeding)
- If a patient wishes to become pregnant, tirzepatide should be discontinued at least 1 month before a planned pregnancy due to the long half-life of tirzepatide
- Plasma concentrations in people with renal and hepatic impairment do not differ from healthy people (therefore no dose adjustments necessary – although only limited clinical experience so it will depend on prescriber specialty/experience/comfort level)
How is tirzepatide administered? (4)
- A SC injection given once a week
- Initiate at 2.5mg dose once weekly x 4 weeks (this dose not intended for glucose control)
- Then increase dose to 5mg once weekly – assess for efficacy
- If additional glycemic control is needed increase the dosage in 2.5 mg increments after at least 4 weeks on the current dose up to a max dose of 15mg once weekly
What if a dose of tirzepatide is missed? (2)
- Administer as soon as possible within 4 days (96hrs) of missed dose
- If more than 4 days have passed, the missed dose should be skipped and the next dose should be administered on the regularly scheduled day
What sites are appropriate for tirzepatide injection?
- Stomach
- Thigh
- Back of upper arm
What are some ADEs of tirzepatide? (4)
- Nausea: most common. In placebo-controlled trials:
- Others: diarrhea, vomiting, heartburn, constipation
- Generally described as mild to moderate but may be severe in some
- Typically occur during dose escalation and decrease over time
What are some practical tips to help manage nausea with tirzepatide use? (8)
- Tell patients what to expect
- Appreciate the feeling of fullness: stop eating when full
- Eat smaller portions and eat slowly
- Titrate slowly; Stay on low dose until nausea improves
- Avoid fatty, spicy, and high-fibre foods
- Consider using on an empty stomach – don’t administer close to a large meal
- Consider end of day dosing
- Stay hydrated and drink cold water when nauseous
What to know about hypogylcemia use and tirzepatide? (3)
- Tirzepatide stimulates insulin secretion in a glucose-dependent manner
- Hypoglycemia is more frequent when tirzepatide is used in combination with a sulfonylurea or basal insulin than when used with non-secretagogues
- When initiating tirzepatide, consider reducing the dose of concomitantly administered insulin secretagogues (e.g. sulfonylureas) or insulin to reduce the risk of hypoglycemia.
What are the CIs of tirzepatide?
- CI in those with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
Who should be cautioned to use tirzepatide? (2)
- Retinopathy - caution in those with existing diabetic retinopathy
- Cholelithiasis - gallbladder
Tirzeaptide covered or not?
Not on SK formulary or NIHB
What is insulin icodec designed to do?
Designed to achieve a long half-life by changes to the human insulin molecule
Insulin icodec creates 3 amino acid substitutions which does what? (3)
- Molecular stability
- Reduced enzymatic degradation
- Slow receptor-mediated clearance
What to know about the first injection MOA of insulin icodec? (4)
- The formulation (700 U/mL) ensures the injection volume is similar to once-daily insulin
- After injection, hexamers slowly dissociate into monomers and bind to albumin
- Although a week’s worth of insulin is administered, almost all icodec is albumin-bound to form an inactive depot
- Slowly, a small fraction of icodec reaches the insulin receptors at target tissues to stimulate glucose lowering
What to know about the second/third injection MOA of insulin icodec? (3)
- With the second injection, more icodec is added to the inactive icodec albumin-bound depot
- Slow clearance of icodec via the insulin receptor further contributes to the build-up of albumin-bound icodec
- Over time, the glucose-lowering effect slowly increases as more icodec interact with insulin receptors
Once insulin icodec is at steady state, what is the steady state MOA? (3)
- After 3–4 injections, steady state* is achieved, giving the full effect of the icodec dose
- The icodec-albumin-bound depot is sufficiently large enough to provide slow and continuous release of active
icodec to achieve effective glucose lowering throughout the week - At steady state, any variations in dosing time and amount lead to minimal changes in immediate glucose-lowering effects due to the slow release of icodec
For an insulin naive person, what is the starting dose of insulin icodec?
70 units once weekly
For someone currently using basal insulin, what is the dosing of insulin icodec? (2)
- Current daily dose x 7 = new weekly insulin dose
- If current daily dose = 10 units
- New weekly dose = 70 units - OR loading dose (1st dose only) – current daily dose x 7 x1.5
- If current daily dose = 10 units
- 1st dose – 105 ~ 110 units (round to nearest 10 units)
- Subsequent doses = 70 units weekly
When switching daily to a weekly insulin it is common to give a higher initial dose. What to know about this when it comes to insulin icodec? (4)
- Shortens time to reach efficacious insulin level
- Only one higher starting dose then back to 7x daily basal dose (rounded to nearest 10) for subsequent week
- Further dose increases and reductions may be required
- For a patient taking 20 units of daily basal insulin:
- Week 1 dose is 20U x 10.5 = 210 units
- Week 2 dose is 20U x 7 = 140 units
- Week 3 adjust based on fasting glucose levels
Weekly dosing adjustment of insulin icodec is based on what?
The average of the three pre-breakfast CBG values, measured 2 days prior to and on the day of titration or CGM fasting reading average
How many U of insulin icodec is adjusted when titrating to target dose?
20U + or -
What are some side effects of insulin icodec? (4)
Same concerns as with all insulins
1. Hypoglycemia
2. Injection site reactions
3. Lipohypertrophy (rotate injection sites)
4. Weight gain
Insulin icodec covered or not?
Not on SK formulary or NIHB formulary
What is cool about the InsuJet?
The first needleless insulin administration device
What are 2 ways to calculate starting doses for insulin?
- Of the total daily dose (TDD) of insulin:
- 40-50% should be basal insulin
- 50-60% should be prandial insulin - Calculating a baseline dose can be based on either:
- Body weight
- Current TDD (sum of basal and bolus)
- if already using insulin and we want to change their regimen
How to calculate starting dose of insulin by weight? (3)
- TDD of insulin for adults with T1DM range from 0.3 to 1 unit per kg
- TDD of insulin for adult with T2DM range from 0.3 to 0.5 units per kg (on initiation)
- Most often, we initiate at 0.5mg/kg/day
How to calculate starting dose of insulin by TDD?
For patient currently using insulin, and we want to change their insulin regimen (change the types of insulin used and/or the number of daily injections)
- Start by calculating their total daily dose
- Reduce the dose by ~10% to determine the new starting dose
What to know about basal-bolus insulin regimen adjustments? (4)
- Adjustments to insulin doses will be guided by blood glucose readings
- Only change one dose at a time
- Treat the lows first!
- Treat the first problem of the day
