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Therapeutics II > Diabetes Kania Part 2 > Flashcards

Diabetes Kania Part 2 Flashcards

1
Q

What are the clinical uses of insulin?

A

-Type 1 and type 2 diabetes
-Hyperkalemia
-Gestational diabetes

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2
Q

What can increase insulin absorption and action

A

-Heat
-Exercise/massage

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2
Q

Which routes of administration are the fastest

A

IV>IM>SQ

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2
Q

How to mix short-acting and NPH insulin together

A

Draw up regular insulin before NPH and make sure none of the regular insulin gets in the NPH vial

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2
Q

Possible sites of injection of insulin

A

-Stomach (fastest)
-Buttocks
-Thigh

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2
Q

Ultra-short acting insulins

A

Aspart, Lispro, Glulisine

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2
Q

Short-acting insulins

A

Regular

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2
Q

Intermediate insulins

A

NPH

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2
Q

Long-acting insulins

A

Glargine, detemir

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2
Q

Ultra long-acting

A

Degludec

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2
Q

Aspart onset

A

10-20 min

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2
Q

Lispro onset

A

10-20 min

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3
Q

Glulisine onset

A

10-20 min

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3
Q

Regular onset

A

30-60 min

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3
Q

NPH onset

A

2-4 hours

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3
Q

Glargine onset

A

2-4 hours

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3
Q

Detemir onset

A

1.5-4 hours

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3
Q

Degludec onset

A

1 hour

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3
Q

Aspart peak

A

30-90 min

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4
Q

Lispro peak

A

30-90 min

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5
Q

Glulisine peak

A

30-90 min

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6
Q

Regular peak

A

2-4 hours

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7
Q

NPH peak

A

4-10 hours

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8
Q

Glargine peak

A

No peak

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9
Q

Detemir peak

A

6-14 hours

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10
Q

Degludec peak

A

No peak

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11
Q

Aspart duration

A

3-5 hours

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12
Q

Lispro duration

A

3-5 hours

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13
Q

Glulisine duration

A

3-5 hours

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14
Q

Regular duration

A

5-8 hours

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15
Q

NPH duration

A

8-12 hours

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16
Q

Glargine duration

A

20-24 hours

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17
Q

Detemir duration

A

16-20 hours

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18
Q

Degludec duration

A

over 24 hours (~42 hours)

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19
Q

What insulins is NPH compatible when mixed with?

A

short-acting and ultra short-acting insulin

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20
Q

What is long/ultra long-acting insulin compatible when mixed with?

A

Nothing

21
Q

How long can insulin vials be kept at room temperature?

A

28 days for all insulin vials except for Levemir which is 42 days

22
Q

How should insulin that is not in use be stored?

A

-In the refrigerator and do NoT freeze
-Opened insulin must always be discarded after 28 days no matter how it is stored

23
Q

How long is insulin good for in prefilled syringes?

A

-28 days with refrigeration as long as it is not mixed
-10-28 days at room temperature (highly variable)

24
Q

How long is regular insulin mixed with NPH good for?

A

-Stable for 7 days in the fridge
-Draw up short-acting insulin first

25
Q

How long is aspart, glulisine, or lispro mixed with NPH good for?

A

Must be given immediately upon mixture

26
Q

What are five complications that could occur from insulin therapy?

A

-Hypoglycemia
-Weight gain
-Lipohypertrophy
-Lipoatrophy
-Allergic reactions

27
Q

What can cause insulin-induced hypoglycemia?

A

-Increased insulin dosage
-Decreased caloric intake
-Increased muscle utilization
-Excessive alcohol

28
Q

What is level 1 hypoglycemia?

A

Glucose levels between 54-70 mg/dL

29
Q

What is level 2 hypoglycemia?

A

Glucose less than 54 mg/dL

30
Q

What is level 3 hypoglycemia?

A

A severe event with altered mental and/or physical functioning needing another person for recovery

31
Q

Signs and symptoms of hypoglycemia

A

-Tremors
-Diaphoresis
-Anxiety
-Dizziness
-Hunger
-Tachycardia
-Blurred vision
-Weakness/drowsiness
-Headache
-Irritability
-Confusion
-Slurred speech
-(beta-blockers can mask the symptoms of hypoglycemia)

32
Q

What is the rule of 15’s?

A

-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

33
Q

What are some food items that contain 15 gm of fast-acting carbohydrates?

A

-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

34
Q

How to treat level 2 or 3 hypoglycemic patients

A

-3 mg intranasal Baqsimi
-1 mg SQ, IM, or IV glucagon
-0.6 mg SQ dasiglucagon

35
Q

Advantages of ultra short-acting insulin

A

-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

36
Q

Disadvantages of ultra short-acting insulin

A

-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

37
Q

Advantages of long-acting/ultra long-acting insulin

A

-Provides 24+ hour coverage with a constant absorption pattern and no pronounced peak
-May be beneficial in patients suffering from nocturnal hypoglycemic episodes

38
Q

Disadvantages of long-acting/ultra long-acting insulin

A

-Possible associations of glargine with an increased risk of cancer
-Can NOT be mixed with other insulins

39
Q

How do you change from daily NPH to glargine/detemir/degludec?

A

Keep dosing the same

40
Q

How do you change from BID NPH to glargine/detemir/degludec?

A

Decrease dose by 20%

41
Q

How do you change from BID NPH to U-300 glargine?

A

Decrease dose by 20%

42
Q

How do you change from daily glargine or detemir to daily U-300 glargine?

A

It is a 1:1 conversion but patients may need an increased dose of the U-300 glargine

43
Q

How do you convert from basal insulin to U-200 insulin degludec?

A

It is a 1:1 conversion

44
Q

How do you convert from lispro U-100 to lispro U-200?

A

It is a 1:1 conversion

45
Q

How do you convert from a U-100 basal-bolus regimen to a U-500 regimen?

A

-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%

46
Q

Example of BID dosing using a U-500 regimen

A

60% of TDD at breakfast and 40% at dinner

47
Q

Examples of TID dosing using a U-500 regimen

A

-40% of TDD at breakfast, 30% at lunch, and 30% at dinner
-40% of TDD at breakfast, 40% at lunch, and 20% at dinner

48
Q

Average daily dose of insulin for a type 1 patient

A

0.5-0.6 U/kg/day (actual body weight)

49
Q

Starting insulin dosing for a patient who is newly diagnosed with type 1 diabetes

A

0.1-0.4 units/kg/day (honeymoon phase)

50
Q

How often should patients test blood glucose

A

4 times daily before meals and at bedtime and occasionally at 3 AM to assess insulin dosages

51
Q

How is a typical basal regimen dosed?

A

-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

52
Q

How is a typical bolus regimen dosed?

A

-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

53
Q

How is insulin used in treatment of type 2 patients?

A

-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

54
Q

Starting dose of insulin for type 2 patients

A

-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

55
Q

How to adjust insulin dosing in type 2 patients

A

-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

56
Q

How is basal insulin dosed in a type 2 patient?

A

Basal is provided by either 1-2 doses of glargine, detemir, or degludec or 1-2 doses of NPH

57
Q

When to consider adding bolus insulin doses in type 2 patients

A

Addition of bolus should always be considered, but especially if the patient is on 0.5 units/kg/day of insulin or more

58
Q

How to start bolus dosing in type 2 patients

A

-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

59
Q

How do you write an insulin to carb ratio?

A

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)

60
Q

What is the rule of 500?

A

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)

61
Q

What is the rule of 1800?

A

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)

62
Q

How do you treat fasting hyperglycemia?

A

-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

63
Q

How do you treat pre-lunch hyperglycemia?

A

Add/increase short-acting to morning dose/breakfast

64
Q

How do you treat pre-dinner hyperglycemia?

A

Increase AM intermediate/long-acting dose or add/increase short-acting at pre-lunch

65
Q

How do you treat bedtime hyperglycemia?

A

Add/increase short-acting to pre-dinner dose

66
Q

How do you treat fasting hypoglycemia?

A

Decrease the evening insulin dose (check timing of AM test and dose); if on basal-bolus regimen, decrease basal

67
Q

How do you treat pre-lunch hypoglycemia?

A

Decrease/omit short-acting insulin dose in the AM

68
Q

How do you treat pre-dinner hypoglycemia?

A

Decrease lunch bolus dose or AM intermediate or long-acting dose

69
Q

How do you treat bedtime hypoglycemia?

A

-Add bedtime snack
-Decrease pre-dinner dose of short-acting insulin
-Decrease pre-dinner dose of intermediate insulin if given earlier in the afternoon

70
Q

What is the Somogyi effect?

A

Nocturnal hypoglycemia with rebound hyperglycemia

71
Q

How do you treat the Somogyi effect?

A

-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

72
Q

When to change to concentrated forms

A

Many practitioners consider them when the total daily dose of insulin is 200-300 units/day

Therapeutics II (33 decks)

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