Diabetes Lecture 2 Flashcards
Pharmacological Therapy
Insulin
Oral agents
Non-insulin injectables
Functions of Insulin (5)
Regulator of glucose metabolism
Released from pancreatic beta cells in response to elevated blood glucose
Inhibits hepatic glucose production
Facilitates glucose transport into cells (fat, muscles, hepatocytes)
Stimulates glucose storage
Types of Insulin
Rapid Acting Insulin
Short Acting Insulin
Intermediate Acting Insulin
Long Acting Insulin
3 Types of Rapid Acting Insulin
Insulin lispro (humalog) Insulin aspart (novolog) Insulin glulisine (apidra)
Properties of Rapid Acting Insulin
Begins to Work in 5- 15min
Working hardest for 1-2 hours
Stops working effectively after 3-4 hours
1 type of Short Acting Insulin
Regular (Novolin, Humulin)
Properties of Short Acting Insulin
Begins to work in 35-45 min
Working hardest for 2-3 hours
Stops working effectively after 4-8 hours
1 Type of Intermediate Acting Insulin
NPH
Properties of Intermediate Acting Insulin
Begins to work in 120-240 min
Working hardest for 4-8 hours
Stops working effectively after 10-16 hours
2 Types of long acting insulin
Insulin glargine (lantus) Insulin dentimir (levamir)
Properties of Long Acting Insulin
Begins to work in 120 min
Working hardest- same all day
Stops working about 24 hours for Lantus
18-24 for levamir
Insulin Analogs
Targets the post-prandial glucoses
Basal Insulin
Provide peakless and prolonged insulin action
Pro’s of Rapid Acting Insulin
Provides better post-prandial glucose control
Lower frequency of hypoglycemia and severe hypoglycemia in type 1 diabetes
Convenience
Inject right before meal
Can inject after meal
Con’s of Rapid Acting Insulin
Expensive
Given prior to high-fat meal, potential increased risk of early post-meal hypoglycemia
Short duration may provide gaps in insulin supply between meals
Pro’s of Short Acting Insulin
No prescription is needed
Fairly inexpensive
Only insulin that can be used IV
Provides some basal activity which must be taken into account if switch to rapid-acting insulin
Con’s of Short Acting Insulin
Absorbed too slowly to match rate of glucose after meals Postprandial hyperglycemia Inject 30 to 45 minutes prior to meal Relatively prolonged duration of action Late post-meal hypoglycemia
NPH
Dosed twice daily
Peaks, thus can cause hypoglycemia
Some patient variability
Can be mixed with other insulin’s
Glargine
Normally dosed once daily
May not always provide 24 hour coverage (rising blood glucose levels in the evening)
Thus may need to dose twice day
No peak, less hypoglycemia compared to NPH
Equal or less patient variability compared to NPH
Can not be mixed with other insulin’s
No apparent overlap or accumulation
Detemir
Duration of action similar/little longer than NPH but shorter than glargine
May require twice a day dosing
Possibly a smaller peak compared to NPH
Less patient variability compared to NPH
Combination Insulins
75/25 (lispo protamine/lispro)
70/30 (aspart protamine/aspart)
70/30 or 50/50 (NPH/regular)
Dosing Adjustments
Dosing correctly (amount, technique) Diet changes Exercise, activity Weight gain or losses, illness or stress Symptoms of hypoglycemia or hyperglycemia Changes in medication
Carbohydrate based adjustments
500 Rule
500/total daily dose= XYZ grams carbohydrate covered by 1 unit of insulin (rapid acting)
In other words: 1 units of insulin will cover XYG grams of carbohydrates
Post Meal Adjustments
1500 Rule or 1800 Rule
1500/total daily dose= XYZ mg/dL of glucose that will be lowered by 1 unit of insulin
In other words: 1 units of insulin will lower the glucose level by XYZ mg/dL
Add needed amount to prescribed amount when BG elevated before meals
General Rule of Insulin
1 unit of insulin drops glucose by 30-60mg/dL
Choosing Initial Insulin Regimen for Type 2 diabetics
Patient willingness
Patient adaptability
Lifestyle
Glycemic patterns
Somogyi effect
Early morning low blood glucose followed by rebound hyperglycemia
Treat: Reduce dose of insulin
Dawn Phenomenon
Relative resistance to insulin in early morning (due to excessive action of counter-regulatory hormones)
Sick Days for Diabetics
Continue to take their normal diabetic medications/insulin and they may require more insulin than normal
Check glucose levels more often than normal
Stay hydrated
Hypoglycemic Side Effect of Insulin
Daytime: Sweating, tachycardia, palpitations, tremor, headache, confusion, visual disturbances, irritability or other “personality changes”, seizures, unconsciousness
Nighttime: nightmares, night sweats, morning headache
Treatment
Rule of 15: Glucose tablets (take 4…they are grams each…15grams of sugar will raise your blood sugar by 15 points in 15 minutes
Glucose gel is a good option as well
Orange juice
If unconscious; use glucagon pen (family should be trained how to use this)
Other Side Effects of Insulin
Weight gain
Injection site reactions
Fat deposits under skin surface which reduce insulin absorption
Prevent by rotating injection sites
Storage of Insulin
Unopened vials:
Store in refrigerator
Opened vials:
Store at room temperature for up to 28 days
Pre-mixed syringes (NPH mixtures):
Refrigerator up to 21 days
Travel:
Keep it with you, not in luggage
Mixing Insulin
Most insulin types can be mixed in one syringe and be injected together
Always draw up the clear insulin before the cloudy insulin (“clear before cloudy”)
NPH and Regular
NPH and Rapid acting
Insulin glargine can NOT be mixed with anything
Formulations of Insulin
Vial and syringe
Premixed pens
Insulin pumps
