Diabetes: Lecture 4 Flashcards
Does insulin technically have max dose?
No
but high risk of hypoglycemia
Has any cardiovascular benefit been shown with insulin?
nah
Spikes of glucose will…. with spikes of insulin
match
One keeps the other lower and in control in normal people
Basal insulin
used to maintain level, cover the glucose that’s been produced over night by the liver
usually constant, about ~50% of basal needs
bolus/Prandial insulin
given at mealtime to prevent the post meal rise in BG
usually about ~50%
Physiological regimen
mimic what we should see in the body but isn’t happening
usually giving a basal insulin dose and then bolus at meal time
Nonphysiological regimen
adding insulin to someone taking orals or GLP1 injectables
When is insulin indicated?
Type 1 = always
Type 2 = monotherapy or in combo with oral/injectable
Gestational diabetes = preferred
In those with decreased eGFR, which should be done with the insulin dose?
Decreased
Short insulin info
Onset: 30-60min
Peak: 2-3hr
Duration: 4-6hr
Intermediate insulin info
Onset: 2-4hr
Peak: 4-8hr
Duration: 10-16hr
Rapid Acting Analog insulin info
Onset: 5-15min
Peak: 30-90min
Duration: 3-5hr
Long Acting Analog insulin info
Onset: 2-5hr
Peak: Flat
Duration: Up to 24hrs
Ultra Long Acting Analog insulin info
Onset: 1hr
Peak: Flat
Duration: > 25hr
Human Regular
given 30 min before meal
Prandial insulin
Analog (Rapid)
Give ~15min before or at 1st bite
Glulisine can be 20min after start of meal
Prandial insulin
Human (intermediate)
NPH
Lasts about ~12hr, twice a day and a basal insulin
Analog (Long) acting names
Glargine
Detemir
Degludec
Which insulin lowers fasting glucose?
Basal insulin
titrated to fasting dose
Human Premixed Insulin
~30min before meal, usually poor lunch coverage
Doses twice a day
Analog Pre-mixed insulin
Can take it right before meal
~Dosed twice a day
usually poor lunch coverage
Insulin concentrations?
U-100
U-200
U-300
Lower volume = more consistent absorption for those with high insulin dose
Pre-mixed insulin advantages
No mixing
convenient and easy to use
usually only 2 injection per day
Pre-mixed insulin disadvantages
no allow for meal flexibility
risk of hypoglycemia if patient skips a meal
cloudy, have to roll cloudy ones. Don’t shake
Most common side effects of insulin?
Weight gain
Hypoglycemia
injection site reactions
Patient barriers to insulin
fear of needles/injections
fear of hypoglycemia or weight gain
Inconvenience
Sense of personal failure and guilt*** #1
Fear can cause complications
Cost
Provider barriers to insulin
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
Basal-bolus regimen
4 daily injections
1 long acting basal
3 rapid acting, 1 for each meal
preferred for Type 1 w/ carb counting
Starting dose for Type 1?
0.5 unit/kg/day typical daily dose
50% basal
50% rapid acting divided into 3 doses
When to add insulin to Type 2 Diabetes?
A1c >10% Glucose >300 Symptoms of Hyperglycemia Evidence of ongoing catabolism Contraindication to GLP1-RA, unacceptable side effects
Starting Basal Insulin Type 2
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
When have we “Over-Basalized”
Fasting Glucose in range but A1c target not met
Hypoglycemia
High Glycemic variability
Elevated bedtime-morning or post-to preprandial glucose differential (>50mg/dL)
When does prandial insulin become more likely?
“Over Basalized”
as daily basal insulin dose exceeds 0.5 units/kg/day
How to proceed if “Over Basalized”
Add Prandial Insulin
4 units or 0.1 unit/kg/day or 10% basal dose w/ biggest meal
which drugs discontinued if adding Prandial Insulin?
DPP4 inhib or Sulfonylurea, continue others
consider decreasing basal dose if A1c getting close to goal or <8%
What to monitor when adding Prandial insulin?
Post prandial BG
Prandial insulin titration
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
What medications to discontinue if on Pre-mixed insulin?
DPP4 inhib and Sulfonylurea
Titration dose of pre-mixed insulin?
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
