Diabetes Insulins Flashcards
Type 1
-an absolute deficiency of insulin secretion
-insulin dependent (~10–20%)
-Most common in youth, can be diagnosed at any age
immune
-Not overweight
-Low endogenous insulin, Low C-peptide, A proinsulin that is made at the same time as insulin, Good indicator of insulin production, Positive autoantibodies, Insulin antibodies, Glutamic acid decarboxylase (GAD), Islet cell antibodies
-Diabetic kitatosis (DKA): high ketone levels
-Produced when no insulin in production
-Body must break down fats instead of carbohydrates as a source of energy
-Ketones are the by-product of that process
Type 2
- a combination of resistance to insulin action and inadequate compensatory insulin secretory response
- Patients do not make enough insulin to keep blood glucose levels within target range
- insulin resistance (~80–90%)
- Most common in adults, on the rise in youth
- Sedentary lifestyle, diet, refined foods, and rising rates of obesity
- Obesity could be associated with either type
- nonimmune
- Overweight (BMI: > 80 percentile)
- High endogenous insulin levels
- Body must work hard to keep glucose levels within target range
- High C-peptide, Indicator of insulin production, Negative autoantibodies
- Low ketone levels
Diabetes
- hyperglycemia
- Poor glycemic control can lead to the development of long-term complications: retinopathy, neuropathy, nephropathy, and cardiovascular disease
Other Diabetes
- Gestational (2–5% of all pregnancies)
- Ends after delivery but 40–50% are at risk for type 2 diabetes
- Secondary and other forms
- Maturity-onset diabetes of youth (MODY)
- Cystic fibrosis–related diabetes (CFRD)
Diabetes Kids
- Type 1:
- Increasing incidence/prevalence
- Shift towards younger age of onset
- More intensive in younger ages: more resistant and require higher doses
- Increasing frequency of DKA diagnosis
- Type 2:
- Increasing occurrence due to obesity
- Programs started to encourage increasing physical activity and changing diet
- More likely to have a genetic component
Diagnosing Diabetes
- Hemoglobin A1C >6.5%
- Fasting glucose >126 mg/dl
- 2-hour glucose >200 mg/dl
- Random glucose >200 mg/dl
- Symptoms: increase in thirst, hunger, urination, weight loss, and fatigue
Hemaglobin A1C
- A glycoprotein formed when glucose binds to hemoglobin A in the blood
- Typically measured 3 or 4 times a year
- A1C goals are age-specific
- Hemoglobin A1C >6.5%
Diabetes Goals
- To maintain normal growth and development
- To avoid symptomatic hyperglycemia and hypoglycemia
- To intervene early for high blood glucose and rising glycohemoglobins
- To provide realistic expectations
- To prevent parent/child burnout and isolation
- To prevent deterioration of glycemic control during adolescence
- To identify and treat behavioral/adjustment dilemmas
- To provide positive medical experiences
Differential Dx: Type 1
- Type 1: Immune
- Not overweight
- Low-endogenous insulin
- Low C-peptide
- Positive autoantibodies
- High ketone levels (DKA 30–40%)
Differential Dx: Type 2
- Type 2: Nonimmune
- Overweight (85%)
- High-endogenous insulin
- High C-peptide
- Negative autoantibodies
- Low ketone levels (≤33% ketonuria; DKA 5–25%)
Insulin Affects Many Organs
- skeletal muscle fibers
- liver cells
- fat cells
- heart
- eyes
Insulin: Synthesis, Storage, Secretion
- Produced within the pancreas by β cells: islets of Langerhans
- Insulin mRNA is translated as a single chain precursor called preproinsulin
- Removal of signal peptide during insertion into the endoplasmic reticulum generates proinsulin
- Within the endoplasmic reticulum, proinsulin is exposed to several specific endopeptidases that excise the C peptide, thereby generating the mature form of insulin
- Stored as β granules
Mechanism of Insulin Action
- Acts on target tissues to regulate metabolism of carbohydrate, protein, and fats
- Target organs for insulin include the liver, skeletal muscle, and adipose tissue
- Stimulates hepatic glycogen synthesis
Classification of Insulin
- Short acting
- Rapid acting
- Intermediate acting
- Long acting
Mixing Insulin
- Regular Clear Fast Acting First
- NPH Cloudy Long Acting Last
- Humalog/Humulin Mixes
- Fixed-ratio insulins are typically administered as two daily doses with each dose intended to cover two meals and a snack.
- More difficult to achieve complete glycemic control using fixed combinations of insulins.
Insulin Analogues
- Insulin Lispro (Humalog®)
- Insulin Aspart (NovoLog®)
- Insulin Glargine (Lantus®)
- Insulin Detemir (Levemir®)
- Insulin Glulisine (Apidra®)
Rapid-Acting Insulin
- ONSET 5-15 mins
- PEAK .5-4 hrs
- DURATION 3-5 hrs
- Insulin Lispro (Humalog®)
- Insulin Aspart (NovoLog®)
- Insulin Glulisine (Apidra®)
- Action more closely matches the postprandial glucose excursions
- More rapid onset and shorter duration of activity
- Administered 15 minutes before meals
- Clear insulin
- Decrease frequency of hypoglycemia
Short Acting Insulin
- ONSET 30-60 mins
- PEAK 2-5 hrs
- DURATION 6-12 hrs
- Regular (Humulin, Novolin)
- Only IV insulin used to treat diabetic ketoacidosis
- Administered 30–60 minutes before meals
- Administered SQ via syringe, pen, or continuous subcutaneous infusion
- Clear insulin
- Mixing regular insulin with other preparations of insulin, regular insulin should be drawn into syringe first
Intermediate Acting Insulin
- ONSET 1-2 hrs
- PEAK 4-14 hrs
- DURATION 10-24 hrs
- NPH
- Administered once or twice daily
- Slower onset and longer duration
- May be mixed with short- and rapid-acting insulin
- Must be second insulin drawn up in syringe
- Cloudy insulin
- Administered SQ via syringe, pen
Long Acting Insulin
- ONSET 1 hr
- PEAK 6-8 hrs
- DURATION 6-24 hrs
- Levemir
- Given once or twice daily when used as the basal insulin component of therapy
- Has a slower, more prolonged duration than NPH
Initial Insulin Dosing
-Non-DKA patient:
Prepubertal 0.25–0.5 units/kg/day
Pubertal 0.5–0.75 units/kg/day
-Post-DKA patient:
Prepubertal 0.75 units/kg/day
Pubertal 1 unit/kg/day
-
-Total daily dose should be divided as follows:
-TID injection regimen:
2/3 of TDD is given before breakfast (2/3 as NPH and 1/3 as rapid-acting insulin; 1/3 of the remaining TDD is given as predinner rapid-acting insulin (1/3) and prebedtime NPH(2/3)
-BID injection regimen:
2/3 of TDD is given before breakfast and 1/3 of TDD is given before dinner
2/3 of each dose should be given as NPH and 1/3 as rapid-acting insulin
Initial Insulin Dosing
Non-DKA patient:
Prepubertal 0.25–0.5 units/kg/day
Pubertal 0.5–0.75 units/kg/day
-Post-DKA patient:
Prepubertal 0.75 units/kg/day
Pubertal 1 unit/kg/dayInsulin SE
-Primary symptoms of hypoglycemia:
Cardiovascular: pallor, palpitation, tachycardia
Central nervous system: fatigue, headache, hypothermia, loss of consciousness, mental confusion
Dermatologic: redness, urticaria
Endocrine and metabolic: hypoglycemia, hypokalemia
Gastrointestinal: hunger, nausea, numbness of mouth
Local: atrophy or hypertrophy of SubQ fat tissue; edema, itching, pain, or warmth at injection site; stinging
Neuromuscular and skeletal: muscle weakness, paresthesia, tremor
Ocular: transient presbyopia or blurred vision
Miscellaneous: anaphylaxis, diaphoresis, local, and/or systemic hypersensitivity reactions
