Diabetes: Lecture 4

Question 1

Does insulin technically have max dose?

Answer 1

No

but high risk of hypoglycemia

Question 2

Has any cardiovascular benefit been shown with insulin?

Answer 2

nah

Question 3

Spikes of glucose will…. with spikes of insulin

Answer 3

match

One keeps the other lower and in control in normal people

Question 4

Basal insulin

Answer 4

used to maintain level, cover the glucose that’s been produced over night by the liver

usually constant, about ~50% of basal needs

Question 5

bolus/Prandial insulin

Answer 5

given at mealtime to prevent the post meal rise in BG

usually about ~50%

Question 6

Physiological regimen

Answer 6

mimic what we should see in the body but isn’t happening

usually giving a basal insulin dose and then bolus at meal time

Question 7

Nonphysiological regimen

Answer 7

adding insulin to someone taking orals or GLP1 injectables

Question 8

When is insulin indicated?

Answer 8

Type 1 = always
Type 2 = monotherapy or in combo with oral/injectable
Gestational diabetes = preferred

Question 9

In those with decreased eGFR, which should be done with the insulin dose?

Answer 9

Decreased

Question 10

Short insulin info

Answer 10

Onset: 30-60min
Peak: 2-3hr
Duration: 4-6hr

Question 11

Intermediate insulin info

Answer 11

Onset: 2-4hr
Peak: 4-8hr
Duration: 10-16hr

Question 12

Rapid Acting Analog insulin info

Answer 12

Onset: 5-15min
Peak: 30-90min
Duration: 3-5hr

Question 13

Long Acting Analog insulin info

Answer 13

Onset: 2-5hr
Peak: Flat
Duration: Up to 24hrs

Question 14

Ultra Long Acting Analog insulin info

Answer 14

Onset: 1hr
Peak: Flat
Duration: > 25hr

Question 15

Human Regular

Answer 15

given 30 min before meal

Prandial insulin

Question 16

Analog (Rapid)

Answer 16

Give ~15min before or at 1st bite

Glulisine can be 20min after start of meal

Prandial insulin

Question 17

Human (intermediate)

Answer 17

NPH

Lasts about ~12hr, twice a day and a basal insulin

Question 18

Analog (Long) acting names

Answer 18

Glargine
Detemir
Degludec

Question 19

Which insulin lowers fasting glucose?

Answer 19

Basal insulin

titrated to fasting dose

Question 20

Human Premixed Insulin

Answer 20

~30min before meal, usually poor lunch coverage

Doses twice a day

Question 21

Analog Pre-mixed insulin

Answer 21

Can take it right before meal
~Dosed twice a day
usually poor lunch coverage

Question 22

Insulin concentrations?

Answer 22

U-100
U-200
U-300

Lower volume = more consistent absorption for those with high insulin dose

Question 23

Pre-mixed insulin advantages

Answer 23

No mixing
convenient and easy to use
usually only 2 injection per day

Question 24

Pre-mixed insulin disadvantages

Answer 24

no allow for meal flexibility
risk of hypoglycemia if patient skips a meal

cloudy, have to roll cloudy ones. Don’t shake

Question 25

Most common side effects of insulin?

Answer 25

Weight gain Hypoglycemia injection site reactions

Question 26

Patient barriers to insulin

Answer 26

fear of needles/injections fear of hypoglycemia or weight gain Inconvenience Sense of personal failure and guilt*** #1 Fear can cause complications Cost

Question 27

Provider barriers to insulin

Answer 27

Lack of time and resources to supervise treatment Weight gain Hypoglycemia Perception that patients resist clinical inertia = things go on too long, stay same and don't improve

Question 28

Basal-bolus regimen

Answer 28

4 daily injections 1 long acting basal 3 rapid acting, 1 for each meal **preferred for Type 1 w/ carb counting**

Question 29

Starting dose for Type 1?

Answer 29

0.5 unit/kg/day typical daily dose 50% basal 50% rapid acting divided into 3 doses

Question 30

When to add insulin to Type 2 Diabetes?

Answer 30

``` A1c >10% Glucose >300 Symptoms of Hyperglycemia Evidence of ongoing catabolism Contraindication to GLP1-RA, unacceptable side effects ```

Question 31

Starting Basal Insulin Type 2

Answer 31

10 units once daily or 0.1-0.2 unit/kg/day continue orals/injectables on same dose titrate using fasting BG, 2-4 units once or twice weekly until target met

Question 32

When have we "Over-Basalized"

Answer 32

Fasting Glucose in range but A1c target not met Hypoglycemia High Glycemic variability Elevated bedtime-morning or post-to preprandial glucose differential (>50mg/dL)

Question 33

When does prandial insulin become more likely? | "Over Basalized"

Answer 33

as daily basal insulin dose exceeds 0.5 units/kg/day

Question 34

How to proceed if "Over Basalized"

Answer 34

Add Prandial Insulin 4 units or 0.1 unit/kg/day or 10% basal dose w/ biggest meal

Question 35

which drugs discontinued if adding Prandial Insulin?

Answer 35

DPP4 inhib or Sulfonylurea, continue others consider decreasing basal dose if A1c getting close to goal or <8%

Question 36

What to monitor when adding Prandial insulin?

Answer 36

Post prandial BG

Question 37

Prandial insulin titration

Answer 37

1-2 units or 10-15% once or twice weekly until target is met If still not at goal, work towards basal/bolus therapy and injection with each meal

Question 38

What medications to discontinue if on Pre-mixed insulin?

Answer 38

DPP4 inhib and Sulfonylurea

Question 39

Titration dose of pre-mixed insulin?

Answer 39

adjust dose by 1-2 units or 10-15% once or twice weekly until targets are met if A1c uncontrolled, consider changing to something else or basal bolus regimen