Diabetes Flashcards

1
Q

what is the A1c?

A

% of hemoglobin molecule glycosylated with glucose

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2
Q

how often is the A1c ordered?

A

ordered at least 2x/year (if pt very well controlled)

-more commonly every 3 months

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3
Q

what info does the A1c provide?

A

“long term” marker of glycemic control

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4
Q

what do you use to help to explain A1c (%) to patients?

A

eAG - estimated average glucose

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5
Q

rule of A1c?

A

A1c of 7% = eAG of 150

-every 1% increase of A1c add 30 to the 150

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6
Q

what is normal blood sugar if fasting?

A

120

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7
Q

what is normal blood sugar post-prandial?

A

140

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8
Q

the higher the A1c means what?

A

the more contribution of fasting glucose

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9
Q

the lower the A1c means what?

A

the more contribution of postprandial glucose

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10
Q

what factors falsely decrease A1c?

A

any condition that shortens the life cycle of the RBC

  • blood loss w/in 3 months - e.g., donated blood, had trauma
  • hemolytic anemia
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11
Q

what factors falsely increase A1c?

A
  • iron deficiency anemia (that’s not treated)

- blood transfusion w/in 3 months

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12
Q

what is the ADA recommendation for glycemic targets in adults for A1c?

A

< 7%

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13
Q

what is the ADA recommendation for glycemic targets in adults for pre-prandial/fasting plasma glucose (FPG)?

A

80-130 mg/dL

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14
Q

what is the ADA recommendation for glycemic targets in adults for 1-2 hr. post-prandial glucose (PPG)?

A

< 180 mg/dL

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15
Q

what are the ADA recommendations for glycemic targets in adults older than 65 that are healthy?
(A1c, fasting/pre-prandial glucose, bedtime glucose)

A

A1c- < 7.5% (7-7.5%)

FPG- 90-130 mg/dL

Bedtime glucose- 90-150

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16
Q

what are the ADA recommendations for glycemic targets in adults older than 65 that have complex/intermediate health?
(A1c, fasting/pre-prandial glucose, bedtime glucose)

A

A1c- < 8% (7.5-8%)

FPG- 90-150

Bedtime glucose- 100-180

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17
Q

what are the ADA recommendations for glycemic targets in adults older than 65 that have very complex/poor health?
(A1c, fasting/pre-prandial glucose, bedtime glucose)

A

A1c- < 8.5% (8-9%)

FPG- 100-180

Bedtime glucose- 110-200

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18
Q

what are the ADA recommendations for glycemic targets in children & adolescents < 18?
(A1c, pre-prandial/fasting plasma glucose, bedtime glucose)

A

A1c- <7.5%

FPG- 90-130 mg/dL

Bedtime- 90-150 mg/dL

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19
Q

why are glycemic goals relaxed for children and adolescents <18?

A

glycemic goals are relaxed for children and adolescent to prevent cognitive impairment/worsening of brain development

-hypoglycemia can interfere with brain development and cognitive development

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20
Q

what is the ADA recommendation for glycemic targets in pregnancy?
(A1c, FPG, 1hr post-prandial glucose, 2hr post-prandial glucose)

A

A1c- ≤ 6-6.5%

FPG- ≤ 95 mg/dL

1hr post-prandial glucose- ≤140 mg/dL

2hr post-prandial glucose- ≤120mg/dL

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21
Q

what may gestational diabetes present with more?

A

postprandial hyperglycemia due to carbohydrate intolerance

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22
Q

what is postprandial monitoring associated with when pregnant?

A

less preeclampsia

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23
Q

who does hyperglycemia effect when pregnant?

A

mom and baby

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24
Q

what is the FIRST LINE txt for someone with diabetes?

A

Metformin

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25
Q

why would a pt with diabetes not be on metformin?

A

if C/I due to can’t stand GI effects or they have bad kidney function

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26
Q

what is the regimen for someone that didn’t achieve goals in 3 months with just metformin?

A

dual therapy (metformin PLUS another medication)

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27
Q

what is the regimen for someone that didn’t achieve goals in another 3 months with dual therapy?

A

triple therapy (metformin PLUS 2 more medications)

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28
Q

what is the regimen for someone that didn’t achieve goals in another 3 months with triple therapy?

A

combination injectable therapy

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29
Q

pharmacotherapy selection considerations (2 types of factors)

A

patient factors and medication factors

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30
Q

pharmacotherapy selection considerations (patient factors)

A
  • preference (e.g., do they want pill, injection, etc)
  • co-morbid conditions
  • insurance coverage
  • duration of diabetes
  • current weight
  • hypoglycemia risk
  • age
  • aptitude for self-care
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31
Q

why is the duration of diabetes a factor when selecting pharmacotherapy?

A

medications that are reliant on beta cell function for use may not be applicable for someone that has had diabetes for years

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32
Q

pharmacotherapy selection (medication factors)

A
  • safety (side effects)
  • efficacy (A1c lowering effects/durability)
  • targeted blood glucose effects
  • ease of use/administration
  • cost/generic availability
  • dosage form availability
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33
Q

what do diabetics have an increased risk of in terms of infection?

A

have increased risk of developing infection and hard time clearing the infection

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34
Q

what is the number one cause of death in diabetic patients?

A

CVD: heart attacks and strokes

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35
Q

what is the blood pressure goal for someone with diabetes with comorbid HTN?

A

≤ 140/90

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36
Q

what are the recommendations for CVD risk management?

A
  • BP ≤ 140/90 with co-morbid HTN
  • low-dose aspirin therapy for those with increased CV risk
  • statin therapy for those with ASCVD and those >40 years with increased CV risk (smokers, older, obese)
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37
Q

when do you screen for diabetic nephropathy?

A

yearly

ACEi or ARB for those with urinary albumin excretion

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38
Q

how often do you screen for retinopathy?

A

year or every 2 years

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39
Q

how often do you screen for neuropathy?

A

yearly

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40
Q

what 2 types of insulin does pancreas secrete?

A

basal and bolus

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41
Q

what is basal insulin?

A

constant, low level release of insulin

-role is to maintain glucose homeostasis in the fasting state

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42
Q

what is bolus insulin?

A

meal stimulated insulin

-role is to cover meal stimulated bursts of glucose

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43
Q

what is A1c lowering ability?

A

approx. 1.5-3.5%

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44
Q

who needs insulin?

A
  • type 1 diabetes
  • gestational diabetes
  • hyperglycemic crisis (DKA)
  • type 2 diabetes
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45
Q

type 2 diabetes criteria that requires insulin?

A
  • A1c ≥ 9%
  • Glucose ≥ 300 mg/dL
  • Marked hyperglycemia (classic six’s)
  • A1c above goal despite 3, non-insulin anti diabetic agents
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46
Q

what insulin can be used as a second line agent, after metformin?

A

basal insulin

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47
Q

what percent of beta cell function has been lost at time of diagnosis?

A

about 50% and decreases as the disease progresses

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48
Q

what route do you take afrezza insulin?

A

inhalation (pulmonary administration)

-good for people that don’t like injections

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49
Q

what type of insulin is afrezza?

A

dry powder of human (recombinant DNA) insulin

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50
Q

what is the onset, peak, and duration of afrezza?

A

onset- 12-15 min

peak- 30 min

duration- 3 hrs

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51
Q

what are the ads for afrezza?

remember it is inhaled

A
  • cough
  • throat/mouth irritation
  • hypoglycemia
  • acute bronchospasm (pts w/restricted airway diseases)
  • hypersensitivity rxns
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52
Q

what routine test is required when someone takes afrezza?

A

routine pulmonary fxn tests (PFTs) @ baseline, 6 months and annually

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53
Q

agrezza insulin is C/I in who?

A
  • if pt has COPD and/or asthma

- causes increased bronchoconstriction in asthma

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54
Q

what patients can you NOT use afrezza in?

A

smokers due to it having less efficacy in them

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55
Q

what dosages is inhaled insulin available in?

A

4 unit- blue

8 unit- green

12 unit- yellow

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56
Q

why do you need multiple cartridges for doses > 12 units of inhaled insulin?

A

b/c inhaled insulin only comes in 4, 8, and 12 units

-if pt needs 17 units then need more cartridges

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57
Q

what is the dosage for a insulin naive patient taking inhaled insulin?

A

inhale 4 units with each meal

titrate every 7 days by 4 units per meal until PPG within goal range

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58
Q

what is the conversion for injected mealtime insulin dose of up to 4 units to afrezza dose?

A

4 units (1 blue)

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59
Q

what is the conversion for injected mealtime insulin dose of 5-8 units to afrezza dose?

A

8 units (1 green)

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60
Q

what is the conversion for injected mealtime insulin dose of 9-12 units to afrezza dose?

A

12 units (1 yellow)

61
Q

what is the conversion for injected mealtime insulin dose of 13-16 units to afrezza dose?

A

16 units (2 green)

62
Q

what is the conversion for injected mealtime insulin dose of 17-20 units to afrezza dose?

A

20 units (1 yellow, 1 green)

63
Q

what is the conversion for injected mealtime insulin dose of 22-24 units to afrezza dose?

A

24 units (2 yellow)

64
Q

what is the onset (hrs) and duration (hrs) of insulin glargine U-300 (Toujeo)?

A

Onset- 6 hrs

Duration- 36 hrs

65
Q

what is the onset (hrs) and duration (hrs) of insulin degludec U-100/U-200 (Tresiba)?

A

Onset- 0.5-1.5 hrs

Duration- 42 hrs

66
Q

what is the onset (hrs) and duration (hrs) of insulin glargine U-100 (Basaglar)?

A

Onset- 1-2 hrs

Duration- 10-24 hrs

67
Q

what are the ultra long-acting insulin analogs?

A

insulin glargine U-300 (Toujeo) and insulin degludec U-100/U-200 (Tresiba)

68
Q

what are some differences between insulin glargine U-300 and insulin glargine U-100?

A
  • U-300 provides the same number of units as U-100 at a third of the volume
  • U-300 is released more slowly from the SQ tissue to prolong its duration of action (~36 hrs)
  • U-300 has more predictable absorption -> less inter patient variability

**less severe and nocturnal hypoglycemia with U-300

69
Q

do insulin glargine U-300 and U-100 have comparable efficacy?

A

yes & also similar risk of weight gain

70
Q

difference in hypoglycemia with U-300 and U-100?

A

U-300 has less severe and nocturnal hypoglycemia than U-100

71
Q

what is the dosing of insulin glargine U-300 for an insulin-naive person that has type 1 diabetes?

A
  1. 2 to 0.4 units/kg for total daily insulin dose
    - recommended starting dose of U-300 glargine is 30-50% of the total daily dose & bolus insulin should satisfy the remainder
72
Q

what is the dosing of insulin glargine U-300 for an insulin-naive person that has type 2 diabetes?

A

0.2 units/kg for initial dose

73
Q

what is the dosing of insulin glargine U-300 for pt whose prior txt of insulin was once daily basal insulin in:

T1DM?
T2DM?

A

T1DM- 1:1 conversion given once daily

T2DM- 1:1 conversion given once daily

74
Q

what is the dosing of glargine U-300 for a patient who’s prior txt of insulin was twice daily NPH in:

T1DM?
T2DM?

A

T1DM- 80% of total NPH dose

T2DM- 80% of total NPH dose

75
Q

what are some differences b/w insulin degludec and insulin glargine U-100?

A
  • comparable efficacy to insulin glargine U-100
  • -degludec has less nocturnal hypoglycemia
  • degludec has flexible dosing (8-40 hrs)

**(Good for non-compliant pts or pts with weird schedules)

76
Q

what is the starting dose of insulin degludec for:

  • insulin naive?
  • pt converting from another basal insulin?
A

insulin naive- 10 units daily

pt converting from another basal insulin- 1:1 conversion given once daily

77
Q

what time of day do you administer insulin degludec?

A

any time of the day with 8 hours b/w doses

78
Q

when is stead state achieved for insulin degludec?

A

steady state is achieved after 2-3 days

79
Q

what is the recommended dose increase for insulin degludec?

A

no more frequent than every 3-4 days

80
Q

who needs ultra long acting insulin?

A
  • anyone that requires basal insulin
  • pts at high risk of hypoglycemia
  • pts experiencing hypoglycemia on NPH
  • pts on 2x daily insulin glargine U-100 and deter
  • pts who need flexible dosing schedules
  • pts requiring high doses (> 80 units/day)
  • pts who are not getting 24 hrs of coverage
  • obese/insulin resistant pts
81
Q

what type of insulin is insulin glargine U-100 (Basaglar)?

A

follow-on biologic

82
Q

is insulin glargine U-100 (Basaglar) bioequivalent to insulin glargine U-100 (Lantus)?

A

NO!

-but it does have similar pk, safety, efficacy, comparable A1c lowering ability, and potential for weight gain

83
Q

who is insulin lispro U-200 (Humalog kwikpen U-200) good for?

A

patients who require large mealtime doses

BUT most likely created because they wanted to keep their market share because its bioequivalent to U-100 Lispro

84
Q

what are some differences b/w insulin lispro U-200 and insulin lispro U-100?

A

U-200 contains more insulin per pen

U-200 delivers half the volume vs U-100
-consider for those with high mealtime doses

85
Q

do insulin lispro U-200 and insulin U-100 deliver the same dose?

A

YES!

1:1 conversion

86
Q

what is the onset, peak, duration of Humulin R U-500?

A

Onset- 30 min

Peak- 1-3 hrs

Duration- 8-24 hrs

87
Q

when should you consider prescribing Humulin R U-500?

A

patients on >200 units of insulin per day

becomes their only insulin if switch them to U-500 insulin

88
Q

what type of insulin is Humulin R U-500?

A

regular insulin, but behaves like NPH

  • not a basal insulin
  • dosed 2-3x/day
89
Q

what is the concentration of Humulin R U-500?

A

high concentration delivered in a smaller volume

SUPER CONCENTRATED

90
Q

what forms is Humulin R U-500 available as?

A

vials (20ml) and pens

91
Q

what is the conversion of insulin U-100 to U-500 insulin if its A1c >8%?

A

start 100% of the U-100 TDD (3x daily)

92
Q

what is the conversion of insulin U-100 to U-500 insulin if its A1c < 8% or mean glucose <183 mg/dL for past 7 days?

A

start 80% of the U-100 TDD

93
Q

what is the conversion of insulin U-100 to U-500 insulin you want to prescribe BID?

A

If BID, give 60% with breakfast & 40% with dinner

94
Q

what is the conversion of insulin U-100 to U-500 insulin you want to prescribe TID?

A

If TID, give 40% with breakfast & 30% with lunch & 30% with dinner

95
Q

what are some barriers to initiating insulin therapy?

A
  • feelings of failure
  • expensive
  • compliance
  • injection phobia
  • concern for weight gain & hypoglycemia
  • clinician thinks it’s last resort
  • limited training on use
96
Q

what are advantages of early use of insulin?

A
  • reduce glucose toxicity
  • facilitates beta-cell “rest”; preserving fun
  • prevent or minimize diabetes related complications
  • may protect against endothelial damage
  • overcome patient and clinician
97
Q

what are disadvantages of early use of insulin?

A
  • Most studies that show benefit use Multiple daily Injections or Extensive therapy
  • complex instructions
  • expensive
  • more healthcare utilization
98
Q

when should treatment intensify in a patient?

A

treatment intensification should occur every 3 months if not meeting goals

99
Q

how do you overcome education as a patient barrier to insulin?

A
  • discuss role of insulin at time of dx
  • review progressive nature of the disease (have beta cell decline)
  • ask about concerns (dispel misconceptions/myths)
100
Q

how do you overcome injection phobia as a patient barrier to insulin?

A
  • prescribe thinnest, shortest needles
  • injection tolls (i.e. auto shield, injectese)
  • try pens (vs. syringe)
101
Q

how do you overcome hypoglycemia risk as a patient barrier to insulin?

A

-use rapid acting and long acting basal analogues

102
Q

what type of insulin coverage does type 1 diabetes require?

A

both basal and bolus (b/c beta cells are destroyed and exogenous insulin is needed for survival)

103
Q

what is the typical starting dose if pt is metabolically stable and type 1 dm?

A
  • 0.5 units/kg/day
  • 1/2 to 2/3rds = basal requirement
  • 1/3 to 1/2 = bolus requirement (divided among meals)
104
Q

what types of regimen are preferred when initiating insulin for T1DM? (physiologic or non-physiologic regimens?)

A

physiologic regimens

105
Q

Explain the initiation of basal insulin in Type 2 diabetes

A

Start:
- 10 units/day OR 0.1-0.2 units/kg/day

Adjust:
- 10-15% OR 2-4 units 1-2 x/wk to reach FPG goal

For Hypo:
- determine and address cause; if no clear cause, decrease dose by 4 units or 10-20%

106
Q

Explain how to add 1 Rapid acting insulin injection before the largest meal in T2

A

Start:
- 4 units, 0.1 unit/kg OR 10% of basal dose

Adjust:
- 10-15% or 1-2 units 1-2x/week until target reached

107
Q

Explain how to change to premixed insulin twice daily (before breakfast and dinner) in T2

A

Start:
- Divide current basal dose into 2/3 am, 1/3 pm OR 1/2 am, 1/2 pm

Adjust:
- 10-15% or 1/2 units 1-2 times per week until target reached

108
Q

what do you adjust if there is FPG dysfunction?

A

adjust basal insulin

109
Q

what do you adjust if there is pre or post-prandial dysfunction?

A

adjust bolus insulin

110
Q

what do you if pt has hyperglycemia all day?

A

“fix the fasting first”

-then target post-prandial glucose

111
Q

what is Humulin R?

A

short acting (regular) insulin

112
Q

what is Humulin R U-500?

A

regular insulin but behaves like NPH

113
Q

what is Novolin R?

A

short acting (regular) insulin

114
Q

what is Lispro (Humalog) insulin?

A

rapid acting insulin

115
Q

what is aspart (Novolog) insulin?

A

rapid acting insulin

116
Q

what is glulisine (apidra) insulin?

A

rapid acting insulin

117
Q

what is Humulin N (NPH) insulin?

A

intermediate acting insulin

118
Q

what is Novolin N (NPH) insulin?

A

intermediate acting insulin

119
Q

what is Glargine 100-U (Lantus) insulin?

A

long acting insulin

120
Q

what is Glargine 300-U (Toujeo) insulin?

A

ultra-long acting insulin

121
Q

what is glargine U-100 (Basaglar) insulin?

A

follow on biologic

very equivalent to Lantus

122
Q

what is Detemir (Levemir) insulin?

A

long acting insulin

123
Q

what is Degludec (Tresiba) insulin?

A

ultra long acting insulin

124
Q

if have dysfunctional glucose post-breakfast or before lunch, what insulin do you adjust?

A

pre-breakfast rapid or short acting insulin

125
Q

if have dysfunctional glucose post-lunch or pre-dinner, what insulin do you adjust?

A

pre-lunch rapid or short acting insulin

126
Q

if have dysfunctional glucose post-dinner or at bedtime, what insulin do you adjust?

A

pre-dinner rapid or short acting insulin

127
Q

if have dysfunctional glucose in the early morning, what insulin do you adjust?

A

basal insulin or PM dose of NPH

128
Q

insulin adjustments for NPH -> detemir?

A

1:1 conversion given once daily

129
Q

insulin adjustments for NPH -> glargine U-100, U-300, insulin degludec?

A

Once daily NPH: 1:1 conversion given once daily

Twice daily NPH: 80% of TDD given once daily

130
Q

insulin adjustments for insulin glargine -> insulin detemir or insulin detemir -> insulin glargine?

A

1:1 conversion

131
Q

insulin adjustments for insulin glargine U-100 OR insulin detemir -> insulin glargine U-300 OR insulin degludec U-100/200?

A

1:1 conversion given once daily

132
Q

insulin adjustments for insulin glargine U-100 OR detemir -> NPH?

A

1: 1 conversion
- give NPH 2x/day
- can consider 20% dose reduction to be conservative

133
Q

insulin adjustments for rapid -> short acting or short acting -> rapid?

A

1:1 conversion; watch for meal timing

134
Q

in the bolus category, what has the highest risk of hypoglycemia?

A

short-acting

135
Q

in the basal category, what has the highest risk of hypoglycemia?

A

NPH

136
Q

signs and symptoms of hypoglycemia?

A
  • shaking
  • hunger
  • rapid heart beat
  • sweating
  • impaired vision
  • anxious
  • irritable
  • weakness
  • dizziness

(sympathetic activation)

137
Q

what serum glucose constitutes hypoglycemia?

A

< 70 mg/dL

138
Q

what serum glucose constitutes severe hypoglycemia?

A

< 50 mg/dL

139
Q

when patient is hypoglycemic (glucose < 70) what is the txt?

A

ingestion of quick acting glucose; not complex carbs!

apply 15:15 rule

  • check glucose
  • consume 15g of carb (4oz or 1/2 cup of fruit juice, 1 tbsp sugar, 3-4 glucose tabs)
  • recheck glucose 15 min later
  • repeat until glucose normalizes
140
Q

what does severe hypoglycemia require?

A

severe hypoglycemia requires assistance from another person
-can’t be treat with oral carbs d/t state of unconsciousness

USE GLUCAGON KIT! -> emergency!!!

141
Q

side effects of insulin injection?

A

lipohypertrophy

  • accumulation of subcutaneous fat deposits
  • can reduce the absorption of insulin
  • may or may not be painful, but are hard bu
  • due to repeated injections at same site OR reuse of needles (or length/thickness of needle)
142
Q

how to reduce lipohyperatrophy from occurring?

A

rotate injection sites and use new needles with each injection!

143
Q

what abbreviation should you avoid when prescribing insulin?

A

“U”

e.g.,:
Lantus inject 10 U SC daily -> INCORRECT

Lantus inject 10 units SC daily -> CORRECT

144
Q

when prescribing insulin, how must you prescribe it?

A

requires separate prescriptions for the vial and syringes (or pen and needles)

145
Q

what should you consider when prescribing insulin needles?

A

consider volume capacity (syringe), needle length and needle (gauge)

  • length: expressed in inches or mm
  • thickness: the higher the gauge, the thinner the needle
146
Q

1mL (cc) syringe holds?

  • each line represents?
  • given to what patients?
A

1mL syringe holds up to 100 units of insulin
-each line represents 2 units

-given if patient on 50-100 units of insulin

147
Q
  1. 5mL (cc) syringe holds?
    - each line represents?
    - give to what patients?
A
  1. 5mL syringe holds up to 50 units of insulin
    - each line represents 2 units

-given if patient on 50 units or less of insulin

148
Q

3/10mL (cc) syringe holds?

  • each line represents?
  • give to what patients?
A

3/10 mL holds up to 30 units of insulin
-each line represents 1 unit

-given if patient on < 30 units of insulin (unless expecting to titrate rapidly)

149
Q

if patient is uses .5mL or 1mL syringe, what should you make the dose?

A

make the dose an even number b/c the increments are by 2 on these syringes