Diabetes 2 Flashcards
If DM2 pt doesn’t respond to non-insulin therapy in 3-6 months, what do you do?
add another drug or insulin, can use PO and insulin together
If DM2 pt is very symptomatic, what can you do?
start with insulin, skip PO
What is recommended for DM2 pt w/ dec renal function?
glipizide, glimepiride, insulin, TZDs, not glyburide or metformin
What is recommended for DM2 pt w/ dec hepatic function?
insulin, miglitol, sitagliptin, not TZDs, metformin, or glyburide
What is recommended for obese DM2 pts?
metformin, acarbose, not sulfonylureas, TZDs
what is recommended in DM2 pt when hypoglycemia is a concern?
metformin, not insuling, sulfonylureas
When to use short term insulin in DM2 pt?
acute illness, surgery, stress, er, preg, breast-feeding, severe metabolic decompensation aka diabetic ketoacidosis, hyperosmolar nonketotic coma, lactic acidosis, severe hypertriglyceridemia
when to use long term insulin in DM2 pt
if target is not reached after optimal dose of combo therapy, consider change to multi-dose insulin therapy, when initiating, insulin secretagogues should be stopped and insulin sensitizers should con’t
Short acting insulin drugs
Insulin aspart (Novolog), insulin lispro (Humalog), regular insulin (humulin R, novolin R), insulin glulisine (Apidera), insulin inhalation (Afrezza)
Intermediate acting insulin
NPH (Humulin N)
Long acting insulin
Insulin detemir (Levemir), insulin glargine (Lantus)
Clinical uses of insulin
DM1, DM2, hyperkalemia, short term hospitalized pts that are insulin naive
What is the onset, peak of action and duration of short acting insulin? Dosing schedule?
.5-1 hr, 2-4 hrs, and 5-8 hrs, take 30 mins before eating
What is the onset, peak of action and duration of intermediate acting insulin, Dosing schedule?
1-3 hrs, 5-8 hrs, up to 18 hrs, taken at bedtime or twice a day
What is the onset, peak of action and duration of fast acting insulin, Dosing schedule?
90 mins, no peak, 24 hr duration, usually taken once or twice a day
Factors that alter insulin action
route of admin (IV fastest), site of injection (stomach fastest), heat can increase rate of absorption and action, low doses are absorbed more rapidly, pt errors, irregular diet/exss, renal function, stress, drugs
at what conditions is insulin stable?
stable at room temp for 28 days once the vial is open, prefilled syringes are stable 28 days when refrigerated, otherwise 10-28 days
What are advantages of short acting insulin?
decreases post prandial hyperglycemia because of shorter duration, flexibility of schedule (can be given right after meals
What are disadvantages of short acting insulin?
risk of hypoglycemia if planned meal not consumed, needs combined with long acting for optimal BG control, $$
What are advantages of long acting insulin
closely mimics normal physiologic basal pancreatic insulin release, provides 24 hr coverage with a constant absorption and no pronounced peak, good for pts suffering from nocturnal hypoglycemia
What are disadvantages of long acting insulin?
longer hypoglycemia episode in event of too much dose or dec caloric intake, $$$$$
What is insulin glargine (Toujeo)
insulin that is available as 300 units/ml, confusing because there is also insulin glargine (Lantus) which is 100 units
what is a good starting point for insulin dosing?
.1-.2 units/kg/day, or about 10 units daily, always start low and be pt specific
What is once daily injection of long acting insulin good for?
DM2 pts or short term for newly diagnosed DM1 pts
What is considered to be the most efficacious dosing of insulin?
once daily injection of long acting and TID short acting, it mirrors pancreatic funciton
How often can doses by titrated?
every 2-3 days, IF pt understands dosing
What do you do for fasting glucose hyperglycemia in pt on insulin therapy?
eat bedtime snack? need to increase insulin at HS or move to HS dosing
What do you do for pre lunch hyperglycemia in pt on insulin therapy?
add/inc short acting morning dose
What do you do for bedtime hyperglycemia in pt on insulin therapy?
add/inc short acting pre-dinner dose
What do you do for fasting glucose hypoglycemia in pt on insulin therapy?
dec evening dose, check timing of AM test and HS dose
What do you do for pre-lunch hypoglycemia in pt on insulin therapy?
dec/omit short acting am dose
What do you do for bedtime hypoglycemia in pt on insulin therapy?
add HS snack (piece of toast), dec pre-dinner dose of short acting
What is the difference in DM1/DM2 with increased insulin dose?
2 units dec BG by ~50 in DM1, 4 units dec BG by 50 in DM2
What time of insulin is usually used for pumps?
humulin R, 100units or 500 units
What should self care management include?
BG monitoring, wt monitoring, foot care, hygiene, healthy lifestyle?diet or physical activity, identify targets for control, stop smoking
Complications of diabetes?
CV disease, HTN, ACS, hyperlipidemia, nephropathy, retinopathy, neuropathy, poor wound healing
Diabetic ketoacidosis
absolute insulin deficiency results in severe hyperglycemia, ketone body production and systemic acidosis as cell starvation flips metabolism from aerobic to anaerobic
Who does DKA present in?
young, female, Type 1
What is the onset and symptoms of DKA?
what are the causes of DKA?
infection, non-compliance, new onset DM, MI, stroke, meds
Mild DKA?
pH 7.25-7.3, HCO3 15-18, mental status alert
Moderate DKA?
pH 7-7.24, HCO3 10-15, mental status alert/drowsy
Severe DKA
pH
How to treat DKA?
correct hypovolemia, hyperglycemia, acidosis, electrolyte abnormalities, initiate fluids, give IV insulin, correct hypokalemia first, correct metabolic acidosis
When to switch IV fluids in DKA?
switch to dextrose containing fluids when BG is 200-300
