Diabetes Kania Part 2 Flashcards
What are the clinical uses of insulin?
-Type 1 and type 2 diabetes
-Hyperkalemia
-Gestational diabetes
What can increase insulin absorption and action
-Heat
-Exercise/massage
Which routes of administration are the fastest
IV>IM>SQ
How to mix short-acting and NPH insulin together
Draw up regular insulin before NPH and make sure none of the regular insulin gets in the NPH vial
Possible sites of injection of insulin
-Stomach (fastest)
-Buttocks
-Thigh
Ultra-short acting insulins
Aspart, Lispro, Glulisine
Short-acting insulins
Regular
Intermediate insulins
NPH
Long-acting insulins
Glargine, detemir
Ultra long-acting
Degludec
Aspart onset
10-20 min
Lispro onset
10-20 min
Glulisine onset
10-20 min
Regular onset
30-60 min
NPH onset
2-4 hours
Glargine onset
2-4 hours
Detemir onset
1.5-4 hours
Degludec onset
1 hour
Aspart peak
30-90 min
Lispro peak
30-90 min
Glulisine peak
30-90 min
Regular peak
2-4 hours
NPH peak
4-10 hours
Glargine peak
No peak
Detemir peak
6-14 hours
Degludec peak
No peak
Aspart duration
3-5 hours
Lispro duration
3-5 hours
Glulisine duration
3-5 hours
Regular duration
5-8 hours
NPH duration
8-12 hours
Glargine duration
20-24 hours
Detemir duration
16-20 hours
Degludec duration
over 24 hours (~42 hours)
What insulins is NPH compatible when mixed with?
short-acting and ultra short-acting insulin
What is long/ultra long-acting insulin compatible when mixed with?
Nothing
How long can insulin vials be kept at room temperature?
28 days for all insulin vials except for Levemir which is 42 days
How should insulin that is not in use be stored?
-In the refrigerator and do NoT freeze
-Opened insulin must always be discarded after 28 days no matter how it is stored
How long is insulin good for in prefilled syringes?
-28 days with refrigeration as long as it is not mixed
-10-28 days at room temperature (highly variable)
How long is regular insulin mixed with NPH good for?
-Stable for 7 days in the fridge
-Draw up short-acting insulin first
How long is aspart, glulisine, or lispro mixed with NPH good for?
Must be given immediately upon mixture
What are five complications that could occur from insulin therapy?
-Hypoglycemia
-Weight gain
-Lipohypertrophy
-Lipoatrophy
-Allergic reactions
What can cause insulin-induced hypoglycemia?
-Increased insulin dosage
-Decreased caloric intake
-Increased muscle utilization
-Excessive alcohol
What is level 1 hypoglycemia?
Glucose levels between 54-70 mg/dL
What is level 2 hypoglycemia?
Glucose less than 54 mg/dL
What is level 3 hypoglycemia?
A severe event with altered mental and/or physical functioning needing another person for recovery
Signs and symptoms of hypoglycemia
-Tremors
-Diaphoresis
-Anxiety
-Dizziness
-Hunger
-Tachycardia
-Blurred vision
-Weakness/drowsiness
-Headache
-Irritability
-Confusion
-Slurred speech
-(beta-blockers can mask the symptoms of hypoglycemia)
What is the rule of 15’s?
-To treat hypoglycemia, start with 15 gm of fast-acting carbohydrates then wait 15 minutes and check blood sugar
-If blood sugar is not greater than 70 mg/dL after 15 minutes then repeat with another 15 gm of fast-acting carbohydrates
-Use 30 gm of fast-acting carbohydrates if blood sugar is below 50 mg/dL
-After this follow-up with a complex carbohydrate meal
What are some food items that contain 15 gm of fast-acting carbohydrates?
-4 oz of orange juice
-6 oz of non-diet soda
-5-6 lifesavers
-2 tsp of sugar
-1 tbsp of honey
-3 glucose tablets or gel
How to treat level 2 or 3 hypoglycemic patients
-3 mg intranasal Baqsimi
-1 mg SQ, IM, or IV glucagon
-0.6 mg SQ dasiglucagon
Advantages of ultra short-acting insulin
-More closely simulates physiologic insulin secretion relative to meals
-Decreases post-prandial hypoglycemia and superior post-prandial lowering of blood sugars
-Fewer overall occurrences of hypoglycemia
-Greater flexibility
Disadvantages of ultra short-acting insulin
-Risk of hypoglycemia if no meal within 15 minutes of dose
-Will need to combine with a longer acting insulin for optimal blood sugar control
-If mixed with another insulin, give immediately after mixing
-Hyperglycemia/ketosis may occur more rapidly if insulin delivery is interrupted
Advantages of long-acting/ultra long-acting insulin
-Provides 24+ hour coverage with a constant absorption pattern and no pronounced peak
-May be beneficial in patients suffering from nocturnal hypoglycemic episodes
Disadvantages of long-acting/ultra long-acting insulin
-Possible associations of glargine with an increased risk of cancer
-Can NOT be mixed with other insulins
How do you change from daily NPH to glargine/detemir/degludec?
Keep dosing the same
How do you change from BID NPH to glargine/detemir/degludec?
Decrease dose by 20%
How do you change from BID NPH to U-300 glargine?
Decrease dose by 20%
How do you change from daily glargine or detemir to daily U-300 glargine?
It is a 1:1 conversion but patients may need an increased dose of the U-300 glargine
How do you convert from basal insulin to U-200 insulin degludec?
It is a 1:1 conversion
How do you convert from lispro U-100 to lispro U-200?
It is a 1:1 conversion
How do you convert from a U-100 basal-bolus regimen to a U-500 regimen?
-U-500 replaces both basal and bolus insulin types
-Calculate the patient’s total daily dose
-If A1C is greater than 8% then consider a 1:1 conversion
-If A1C is 8% or less then reduce the dosage by 20%
Example of BID dosing using a U-500 regimen
60% of TDD at breakfast and 40% at dinner
Examples of TID dosing using a U-500 regimen
-40% of TDD at breakfast, 30% at lunch, and 30% at dinner
-40% of TDD at breakfast, 40% at lunch, and 20% at dinner
Average daily dose of insulin for a type 1 patient
0.5-0.6 U/kg/day (actual body weight)
Starting insulin dosing for a patient who is newly diagnosed with type 1 diabetes
0.1-0.4 units/kg/day (honeymoon phase)
How often should patients test blood glucose
4 times daily before meals and at bedtime and occasionally at 3 AM to assess insulin dosages
How is a typical basal regimen dosed?
-Basal is provided by either 1-2 doses of glargine, detemir, or degludec or 1-2+ doses of NPH
-50-70% of the insulin requirements are given at basal insulin
How is a typical bolus regimen dosed?
-Bolus or prandial dosing is provided by meal-time short-acting or ultra short-acting insulins
-30-50% of the insulin requirements are divided among the meals as bolus insulin
-Doses can be adjusted based on carbohydrate content of meals; a good starting point is 1 unit for every 15 gm of carbs
How is insulin used in treatment of type 2 patients?
-Usually, long-acting or intermediate insulin is used in combination with non-insulin agents
-Bedtime insulin is usually added to previous non-insulin therapies
-Helps suppress hepatic glucose production at night
-Eventually, some orals may be discontinued, especially once a basal/bolus regimen is started
Starting dose of insulin for type 2 patients
-ADA: 0.1-0.2 units/kg/day or 10 units/day
-AACE: If A1C is less than 8% then start 0.1-0.2 units/kg/day but if A1C is greater than 8% then start 0.2-0.3 units/kg/day
How to adjust insulin dosing in type 2 patients
-ADA: increase the dose by 2 units every 3 days to reach fasting blood sugar goal (80-130)
-AACE: titrate every 2-3 days based on blood glucose level
-greater than 180 mg/dL: add 20% of TDD
-140-180 mg/dL: add 10% of TDD
-110-139 mg/dL: add 1 unit
-less than 70 mg/dL: decrease by 10-20% of TDD
-less than 40 mg/dL: decrease by 20-40% of TDD
How is basal insulin dosed in a type 2 patient?
Basal is provided by either 1-2 doses of glargine, detemir, or degludec or 1-2 doses of NPH
When to consider adding bolus insulin doses in type 2 patients
Addition of bolus should always be considered, but especially if the patient is on 0.5 units/kg/day of insulin or more
How to start bolus dosing in type 2 patients
-Usually can start with 10% of basal dose or 4-5 units of ultra-short or short-acting insulin with largest meal
-May start with one meal at a time or all three based on the severity of the readings and willingness of the patient
-Adjust dose by 10-15% every 3-4 days
-Can pull some from the basal dose if needed to prevent hypoglycemia
-May also provide a carb ratio of 1-2 units of insulin for every 15 grams of carbs in a meal
How do you write an insulin to carb ratio?
Units of insulin:grams of carbs for a meal (ex. 6 units of insulin for 60 grams of carb would be 6:60 which is the same as 1:10)
What is the rule of 500?
Take 500/total daily insulin dose and this will equal the number of grams of carbohydrates for 1 unit of insulin (ex. 40 units of insulin would be 500/40=12.5 so 1 unit of insulin will be needed for 12.5 gm of carbs)
What is the rule of 1800?
1800/total daily dose of insulin = number of mg/dL blood glucose will drop for every 1 unit of insulin (ex. if a patient is taking 90 units of insulin then 1800/90=20 mg/dL decrease in blood sugar)
How do you treat fasting hyperglycemia?
-Evaluate the causes:
-Bedtime eating
-Too small of a dose of insulin
-Somogyi effect
-If the patient is on once daily long-acting or intermediate insulin, then increase the dose or consider dividing into BID dosing, if applicable
-If the patient is on split dose BID, then increase pre-supper or bedtime dose of insulin
-If the patient is on basal-bolus, increase the basal or the PM bolus depending upon bedtime blood sugar reading
How do you treat pre-lunch hyperglycemia?
Add/increase short-acting to morning dose/breakfast
How do you treat pre-dinner hyperglycemia?
Increase AM intermediate/long-acting dose or add/increase short-acting at pre-lunch
How do you treat bedtime hyperglycemia?
Add/increase short-acting to pre-dinner dose
How do you treat fasting hypoglycemia?
Decrease the evening insulin dose (check timing of AM test and dose); if on basal-bolus regimen, decrease basal
How do you treat pre-lunch hypoglycemia?
Decrease/omit short-acting insulin dose in the AM
How do you treat pre-dinner hypoglycemia?
Decrease lunch bolus dose or AM intermediate or long-acting dose
How do you treat bedtime hypoglycemia?
-Add bedtime snack
-Decrease pre-dinner dose of short-acting insulin
-Decrease pre-dinner dose of intermediate insulin if given earlier in the afternoon
What is the Somogyi effect?
Nocturnal hypoglycemia with rebound hyperglycemia
How do you treat the Somogyi effect?
-Check blood sugar and ask about signs and symptoms
-Add a bedtime snack
-If applicable, move NPH from dinner to bedtime or decrease long-acting dose at bedtime
When to change to concentrated forms
Many practitioners consider them when the total daily dose of insulin is 200-300 units/day
