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PR3152 Finals > Diabetes Management > Flashcards

Diabetes Management Flashcards

1
Q

How much HbA1c lowering can insulin achieve?

A

Up to 2.5%

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2
Q

MOA of insulin? (regarding glucose, fat, and protein)

A

Glucose: Facilitate uptake of glucose in muscle and adipose tissue and inhibit hepatic glucose output (glycogenolysis and gluconeogenesis)

Fat: enhance fat storage (lipogenesis) and inhibit mobilisation of fat for energy in adipose tissue (lipolysis and free fatty acid oxidation)

Protein: increase protein synthesis and inhibit proteolysis in muscle tissue

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3
Q

What are the types of insulin? (7)

A
  1. Ultra-shorting acting
  2. Rapid-acting
  3. Short-acting
  4. Intermediate-acting
  5. Long-acting
  6. Ultra-long acting
  7. Mixed insulin
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4
Q

Name the types of rapid-acting and short-acting insulin

A

Rapid acting: Aspart, Lispro, Glulisine

Short-acting: Regular insulin

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5
Q

Rapid-acting: target BG, onset of insulin, duration of action and how long before meals to inject?

A

Target BG: PPG

Onset of insulin: 5-15 min

DOA: 3-5h (peak is 1-2h)

Inject 5 mins before meals

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6
Q

Short-acting: target BG, onset of insulin, duration of action and how long before meals to inject?

A

Target BG: PPG

Onset of insulin: 30-60 min

DOA: 6-8h (peak 2-4h)

Inject 30 mins before meals

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7
Q

Name the types of intermediate-acting and long-acting insulin

A

Intermediate-acting: NPH

Long-acting insulin: Detemir, Glargine

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8
Q

Intermediate-acting: target BG, onset of insulin, duration of action and how long before meals to inject?

A

Target BG: FPG

Onset of insulin: 1-2h

DOA: 10-16h (peak 6-12h); 2 injections for 24h coverage

Inject regardless of meal timings, at same time everyday

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9
Q

Long-acting: target BG, onset of insulin, duration of action and how long before meals to inject?

Compare detemir and glargine

A

Both act on FPG

Detemir onset: 0.8-2h

DOA: 12h for 0.2units/kg, 20-24h for 0.4units/kg (2 injections better coverage)

Glargine onset: 1.5h

DOA: 1 injection for 24h

Both: Inject regardless of meal timings, at same time everyday

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10
Q

Name the types of ultra-long acting insulin

A

Insulin degludec and glargine U-300

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11
Q

Degludec- duration of action and when to administer?

A

Peakless with DOA of 42 hours
Inject OD at any time of day

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12
Q

Glarine U-300- duration of action and when to administer?

A

Peakless with DOA of 36h
Inject OD at same time everyday

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13
Q

State the 4 types of pre-mix insulin and their proportions

A
  1. Novomix (30% aspart, 70% aspart protamine)
  2. Humalog (25% lispro, 75% lispro protamine)
  3. Humalog (50% lispro, 50% protamine)
  4. Mixtard (30% regular, 70% NPH)
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14
Q

Advantages (3) and disadvantages (1) of pre-mixed insulin products?

A

Advantages:
- Benefits pts with difficulty measuring and mixing insulin
- Meal/ snack AND basal coverage
- Less injections

Disadvantages:
- Challenging to titrate and adjust dose

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15
Q

When insulin is started, what should we do regarding metformin?

A

Continue metformin

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16
Q

When insulin is started, what should we do regarding TZDs?

A

Discontinue or reduce dose (due to increased risk of hypoglycemia with insulin)

17
Q

When insulin is started, what should we do regarding SUs?

A

Discontinue or reduce dose by 50% when basal insulin is started (if pt at risk of hypoglycemia).

Discontinue if postprandial insulin started or on premix regimen. Effectiveness will gradually wear off and may have to completely rely on insulin

18
Q

When insulin is started, what should we do regarding SGLT2i?

A

Discontinue

19
Q

When GLP-1 agonist injectable is started, what should we do regarding DPP-4i?

A

Discontinue

20
Q

What is the general rule of thumb for insulin dosing conversion?

A

Most insulin conversions are 1:1 unit

Reduce the dose by 10-20% if the pt is at high risk of hypoglycemia

21
Q

For insulin dosing conversions, what are some exceptions where you MUST decrease dose?

A
  1. Switching from twice daily NPH to once daily glargine/ detemir: decrease by 20%
  2. Switching from U-300 glargine to alternative basal insulin analog: decrease by 20%
22
Q

ADEs of insulin? (6)

How should we manage this?

A

(1) Hypoglycemia (BG ≤ 4.0 mmol/L):
- S/sx: blurry vision, sweating, tremor, hunger, confusion, anxiety, shaking, rapid heart beat, dizziness, headache, weakness & fatigue, irritability
- Nocturnal: nightmares, restless sleep, profuse sweating, morning headache

Manage with the 15-15-15 rule

(2) Weight gain (more than SUs), but benefits of glycemic control outweight weight gain

Manage with diet, exercise

(3) Lipodystrophy: lipoatrophy with immune response and lipohypertrophy with not rotating injection sites

(4) Local allergic reaction

(5) Systemic allergic reaction (rare)

(6) Insulin resistance (rare)

23
Q

Name the 3 GLP-1 receptor agonists (LDS)

A
  1. Liraglutide (SC)
  2. Dulaglutide (SC)
  3. Semaglutide (PO and SC)
24
Q

ADEs of GLP-1 receptor agonists?

Is dose adjustments needed for renal impairments?

A
  • Headache
  • N/V
  • Acute pancreatitis
  • Acute cholecystitis
  • Injection site reactions
  • **Thyroid C-cell tumors
25
Q

Comment on the administration and dosing for Liraglutide

A

Administration: SC injection OD regardless of meals

Dosing: 0.6mg initial then titrate to 1.2mg after 1 week. Can increase to 1.8mg

26
Q

Comment on the administration and dosing for Dulaglutide

A

Administration: SC injection oiw regardless of meals

Dosing: 0.75mg then titrate to 1.5mg after 4 weeks. Can increase to 3mg/ 4.5mg

27
Q

Comment on the administration and dosing for Semaglutide (SC)

A

Administration: SC injection oiw regardless of meals

0.25mg then titrate to 0.5mg after 4 weeks. Can increase to 1mg

28
Q

Comment on the administration and dosing for Semaglutide (PO)

A

Administration: PO OD 30 mins before first meal of day (omeprazole enhances bioavailability)

3mg then titrate to 7mg after 30 days. Can increase to 14mg

29
Q

How much does GLP-1 receptor agonist decrease HbA1c levels by?

A

1-2%

30
Q

Advantages and disadvantages of GLP-1 receptor agonist?

A

Advantages:
- ↓ HbA1c by 1-2%
- Weight loss (good for overweight pts due to n/v ADEs)
- Does not cause hypoglycemia
- ASCVD benefits (SC forms)
- CKD benefits (minimal for SC)

Disadvantages:
- $$$
- Not for pts with Hx of pancreatitis or with family Hx of thyroid Ca

31
Q

When will GLP-1 receptor agonist be used?

A

Recommended over insulin as first-line injectable when greater glucose lowering is needed

32
Q

When do we give basal bolus insulin and when do we give pre-mix insulin?

A

Basal bolus:
- T1DM with severe insulin deficiency
- Long duration of T2DM
- Specific situations that require tight BG control: (1) pts undergoing coronary artery bypass grafting, or (2) gestational diabetes with inadequate glycemic control

Pre-mix:
- T2DM pts who are insulin deficient but not keen for basal-bolus
- Uncontrolled hyperglycemia
- T1DM pts who are not keen for basal-bolus

33
Q
A

PR3152 Finals (8 decks)

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