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Diabetes 3 Flashcards

1
Q

What is insulin?

A

hormone secreted from pancreatic B-cells to help regulate blood glucose
in the body, proinsulin is cleaved to release insulin + C-peptide

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2
Q

True or false: commercial versions of insulin contain insulin and C-peptide

A

false
only contain insulin

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3
Q

What is the history of insulin?

A

originally derived from the pancreases of cows and pigs
-pork insulin still available, uncommonly used
1982/83: Humulin; first human insulin using rDNA
-human insulin produced via rDNA has identical aa sequence
to human insulin
-with rDNA concerns of purity, hypersensitivity, and
lipodystrophy are much less common

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4
Q

What is the structure of insulin?

A

51 amino acids in 2 chains (A and B) linked by 2 disulfide bonds

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5
Q

Differentiate between basal and bolus insulin.

A

basal: B cells secrete small amounts of insulin throughout day
bolus: at mealtime, insulin is rapidly released in response to
food

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6
Q

What are the two classes of bolus (prandial or mealtime) insulins?

A

rapid-acting insulin analogues
short-acting insulins

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7
Q

What are the rapid acting insulin analogues?

A

aspart (NovoRapid; biosimilars: Trurapi, Kirsty)
glulisine (Apidra)
lispro (Humalog U-100 & U-200 and biosimilar: Admelog U-100)
faster-acting insulin aspart (Fiasp)

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8
Q

What are the short-acting insulins?

A

insulin regular (Humulin R, Novolin Toronto)
insulin regular U-500 (Entuzity)

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9
Q

When are short acting insulins administered?

A

30-45 min prior to meals to cover mealtime glucose excursions

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10
Q

What is the appearance of short acting insulins?

A

clear solutions

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11
Q

What is a special use of short acting insulins?

A

can be used IV to treat DKA

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12
Q

What is the onset, peak, and duration of action of short acting insulins?

A

onset: ~30mins
peak: ~2-3hr
duration of action: ~6hr

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13
Q

How does the PK of insulin regular U-500 (Entuzity) differ from the rest of the short acting insulins?

A

entirely different PK profiles
-onset: 15 mins
-peak: 4-8h
-duration: 17-24h

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14
Q

What do the modifications of RAIAs allow for?

A

more rapid absorption vs short acting insulins and more closely mimic endogenous insulin release

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15
Q

When are RAIAs administered?

A

with or just prior to meals (0-15min) to cover mealtime excursions

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16
Q

What is the appearance of RAIAs?

A

clear solutions

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17
Q

What are the advantages of RAIAs?

A

more rapid absorption:
-fast onset
-quicker peak
-shorter duration of action
convenience:
-0-15min before a meal or within 15min of eating
-Fiasp: up to 2 min before or 20 min after a meal
-although better before a meal
better PPG control
decreased hypoglycemia

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18
Q

What are the disadvantages of RAIA?

A

more $ and similar effectiveness

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19
Q

True or false: Fiasp shows better PPG in T2 studies

A

false
shows better PPG in T1 studies; not T2

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20
Q

What is special about Humalog (lispro) KwikPen 200U/ml?

A

more concentrated formulation for those who require higher doses
the dose counter window on each of the KwikPen (100U/ml and 200U/ml) indicate the number of units of insulin to be injected. As a result the same number of units of insulin would be chosen for both devices. The Kwikpen automatically delivers the correct volume of insulin so conversion of dose between devices is not needed

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21
Q

Describe Entuzity.

A

very concentrated form of insulin (500U/ml)
for those who require >200U/d
given 2-3x/d
short-acting: administer 30min before a meal
can dial up in 5U increments
no dose conversion required when using this KwikPen
extreme caution required to avoid inadvertent overdose

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22
Q

What is the onset, peak, and duration of action of RAIA?

A

onset: 4-20min
peak: 0.5-2h
duration of action: 3-5h

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23
Q

What are the classes of basal insulins?

A

intermediate-acting
long-acting

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24
Q

What are the intermediate-acting insulins?

A

insulin neutral protamine Hagedorn
-Humulin N, Novolin NPH

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25
What are the long-acting insulins?
detemir U-100 (Levemir) glargine U-100 (Lantus; biosimilars: Basaglar, Semglee) glargine U-300 (Toujeo) degludec U-100, U-200 (Tresiba)
26
How frequently are intermediate acting insulins administered?
once or twice daily to provide a background amount of insulin
27
What is the appearance of intermediate acting insulins?
cloudy (they are a suspension) -must hand-roll and invert (10x) before use to re-suspend
28
What is the onset, peak, and duration of action of intermediate acting insulins?
onset: 1-3h peak: 5-8h duration of action: ~18h
29
What do the modifications to long acting insulin allow for?
modifications result in an extended and more flat absorption
30
What happens to insulin glargine once injected?
*has an isoelectric point from pH 5.4-6.8, making it more soluble at acidic pH; buffered to a pH of 4.0 for distribution* once injected, it forms micro precipitates which slowly dissolve
31
What gives insulin detemir its prolonged duration of action?
its hexamer stability
32
What are the advantages of LAIAs compared to intermediate acting insulins?
peakless more consistent/less variable BG less hypoglycemia (mainly nocturnal)
33
What are the disadvantages of LAIAs compared to intermediate acting insulins?
cost more $ and they all have similar efficacy
34
What is the onset and duration of action of LAIAs?
onset: 90 mins duration of action: -glargine U-100: 24H -detemir: 16-24h -U-300 glargine: >30h -degludec: 42h
35
True or false: use of intermediate acting insulin is declining
true due to the LAIAs
36
How frequently is insulin NPH dosed?
usually BID
37
What is the duration of action of detemir based on?
dose dependent: -0.2U/kg ~12hrs -0.4U/kg ~20hrs *administered OD or BID*
38
How frequently is insulin glargine U-100 dosed?
usually OD but some use BID
39
How is Toujeo dosed?
SoloSTAR: 1.5ml disposable pen, can dose between 1-80U per injection DoubeSTAR: 3ml disposable pen, can dose between 2-160U per injection
40
How is insulin degludec dosed?
prefilled pens: 100U/ml & 200U/ml dosed OD at any time of day, if miss dose inject when realize the omission *ensure at least 8hrs between injections*
41
What are the forms of insulin delivery?
syringes and vials insulin pens insulin pumps
42
Describe syringes and vials as a form of insulin delivery.
the traditional method of insulin delivery, some still prefer: -least expensive -used to it -prefer less injections and want to combine insulins syringes available in differing volumes (3/10, 1/2, 1cc) and differing lengths (BD 6mm and 8mm) and differing thickness (30 and 31 gauge)
43
What volume of syringe is needed for the following: <30 units of insulin 31-50 units of insulin 51-100 units of insulin
<30U: 3/10 cc/ml 31-50U: 1/2 cc/ml 51-100U: 1 cc/ml
44
Describe insulin pens as a form of insulin delivery.
largely supplanted vials/syringes because: -portable/convenient/easier to use -advantageous id dexterity/visually impaired -allows for precision dosing a new needle tip must be attached each time, they are available in different lengths -BD 4, 5, 8mm -31 and 32 gauge
45
Describe insulin pumps as a form of insulin delivery.
small computerized device that delivers insulin continuously 24hrs a day worn on outside of body, and delivers insulin via a tube, which is attached to a cannula placed under the skin -changed every 3d only uses RAIA and delivers it continuously, as well as increased amounts when a bolus dose is required
46
When should insulin pumps be considered?
poorly controlled with optimized injections significant glucose variability frequent severe hypoglycemia pregnacny
47
How do insulin pumps and CGM work in tandem?
a closed loop system-the pump and CGM automatically communicate to one another via a computer program to create somewhat of an artificial pancreas
48
What are the adverse effects of insulin?
hypoglycemia -most common AE and more frequent in those trying to achieve tight control weight gain -insulin is anabolic -varies (2-7kg); depends on amount taken and often a result of over correcting localized fat hypertrophy (minimize by rotating sites) blurry vision -not really an AE, can occur when initiate for a few weeks allergic reactions: rare
49
What are the factors affecting insulin absorption?
site of injection -abdomen>arm>thigh>buttock (not as much of an issue for R/LAIA) exercise of injected area -strenuous exercise of a limb within 1hr will speed absorption massage -vigorous massage will speed absorption temperature -heat can increase absorption rate lipohypertrophy -delays absorption dose -larger doses delay absorption and prolong action renal function -renal failure decreases insulin clearance depth of injection -IV>IM>SQ
50
What are some good practices for injection technique of insulin?
wash your hands alcohol swabs to clean cartridge/vial rotate injections systematically within the same anatomical region avoid moles, scars, etc use quick, smooth movement
51
What are the preferred injection sites of insulin?
abdomen thigh buttock under arm
52
How do we systematically rotate injection site within the same anatomical region?
split selected injection area into four large sections select one section and split it into four smaller sections rotate clockwise through these four small sections for a week in the following week select the next large section (clockwise) and divide into four smaller sections
53
What are the steps for injecting insulin via syringes?
1. pull air in syringe (to roughly 5U) 2. push air into the bottle 3. pull in and push out a little insulin to remove air bubbles 4. pull your exact dose of insulin into the syringe
54
What are the recommendations regarding syringes and vials for injecting insulin?
6mm syringe: -recommended -with or without skin lift -preferentially a 90 angle (45 angle if lean) 8mm syringe: -do a skin lift and inject at 90 angle -if lean at 45 angle 12mm syringe: not recommended *hold needle in place for 10 seconds, when needle is removed skin should look normal*
55
What are the steps in using an insulin pen?
1. wash hands, remove pen cap 2. wipe pen tip with alcohol swab, attach needle (new needle) 3. prime (2U) with needle pointing up, watch for stream 4. dial up amount of insulin 5. inject at 90 angle with no skin lift for most, count to 10 6. remove needle, dose window should say 0
56
Where should unopened insulin be kept? What if in-use?
unopened: fridge closed: room temperature
57
How long is in-use good for?
depending on the insulin, recommended to discard after 28 days up to 56 days (degludec)
58
What is a sign of unstable insulin?
cloudy or with particles (NPH is suspension so its cloudy) *avoid freezing, extreme heat, direct sunlight*
59
Which insulins can be mixed?
R + NPH: may be pre-mixed and stored together RAIA + NPH: may mix together with immediate administer LAIA: cannot mix with any other insulins
60
What are the average daily insulin requirements for T1DM?
initial dose: 0.5-0.6 U honeymoon: 0.1-0.4 U ketosis or acute illness: 0.5-1.0 U
61
What are the average daily insulin requirements for T2DM?
initial dose: 0.1U/kg (or more commonly 10U of basal insulin hs) with insulin resistance: up to 2.5U/kg (or greater)
62
What is the usual split of insulin for T1DM or those who are on MDI with T2DM?
bolus: 50-60% (<60%) basal: 40-60% (>40%)
63
True or false: the insulin regimen and dose is usually the same for life for Type 1 diabetics
false changes over time, rarely ever the same
64
What are insulin changes in Type 1 diabetics based on?
age goals general health glucose levels physical activity
65
What is the carbohydrate to insulin ratio?
ratio used to estimate how many grams of CHO each unit of meal-time insulin will cover typical ratio is 15:1 but may be higher or lower
66
How is C:I ratio calculated?
initial C:I ratio can be estimated by 500 or 550 by the total daily dose of insulin
67
What is the use of the correction factor?
for someone who is counting carbs, utilizing a correction factor can help bring down BG detected before meals
68
What is the correction factor?
expected amount that 1 unit of insulin will normally decrease BG by -typically 1U of insulin will decrease BG by 2-3mmol over the next 2-4hrs
69
How do we estimate CF? What about how many units must be given to correct a high reading?
100/TDD current glucose-target glucose/CF
70
What are general rules when interpreting BG/adjusting doses?
fix the lows first -generally adjust by 1-2 units at a time only adjust 1 dose at a time, begin with correcting the 1st problem BG of the day *make dose adjustments every few days based on glucose trends*
71
How do we evaluate morning hyperglycemia?
try to determine the cause before adjusting therapy do this by checking blood glucose levels while one is sleeping x several nights -3am CBG or via CGM -glucose <4mmol suggest Somogyi effect -glucose >4mmol suggests the dawn phenomenon
72
What are tell tale signs of nocturnal hypoglycemia?
nightmares restless sleep sweating (wet pillow/sheets) headache in am hunger
73
What is the Somogyi Effect?
unrecognized nocturnal hypoglycemia that patient sleeps through; as a result the body increases production of counter-regulatory hormones & see rebound hyperglycemia
74
What are possible ways to rectify the Somogyi Effect?
fix the excess/ill-timed insulin -decrease dose of insulin -shift predinner basal (NPH) to hs -consider a LAIA if on NPH consider a bedtime snack, evaluate meals/alcohol/exercise the key is to prevent overnight lows
75
What is the Dawn Phenomenon?
fasting hyperglycemia that is the result of growth hormones, cortisol, glucagon being released in early am before waking (usually between 3-8am)
76
What are possible ways to rectify Dawn Phenomenon?
avoid eating CHO after dinner/eat earlier be active after dinner adjust basal insulin/dose time consider an insulin pump

PHAR152 (21 decks)

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