Diabetes Management Flashcards
How much HbA1c lowering can insulin achieve?
Up to 2.5%
MOA of insulin? (regarding glucose, fat, and protein)
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
What are the types of insulin? (7)
- Ultra-shorting acting
- Rapid-acting
- Short-acting
- Intermediate-acting
- Long-acting
- Ultra-long acting
- Mixed insulin
Name the types of rapid-acting and short-acting insulin
Rapid acting: Aspart, Lispro, Glulisine
Short-acting: Regular insulin
Rapid-acting: target BG, onset of insulin, duration of action and how long before meals to inject?
Target BG: PPG
Onset of insulin: 5-15 min
DOA: 3-5h (peak is 1-2h)
Inject 5 mins before meals
Short-acting: target BG, onset of insulin, duration of action and how long before meals to inject?
Target BG: PPG
Onset of insulin: 30-60 min
DOA: 6-8h (peak 2-4h)
Inject 30 mins before meals
Name the types of intermediate-acting and long-acting insulin
Intermediate-acting: NPH
Long-acting insulin: Detemir, Glargine
Intermediate-acting: target BG, onset of insulin, duration of action and how long before meals to inject?
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
Long-acting: target BG, onset of insulin, duration of action and how long before meals to inject?
Compare detemir and glargine
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
Name the types of ultra-long acting insulin
Insulin degludec and glargine U-300
Degludec- duration of action and when to administer?
Peakless with DOA of 42 hours
Inject OD at any time of day
Glarine U-300- duration of action and when to administer?
Peakless with DOA of 36h
Inject OD at same time everyday
State the 4 types of pre-mix insulin and their proportions
- Novomix (30% aspart, 70% aspart protamine)
- Humalog (25% lispro, 75% lispro protamine)
- Humalog (50% lispro, 50% protamine)
- Mixtard (30% regular, 70% NPH)
Advantages (3) and disadvantages (1) of pre-mixed insulin products?
Advantages:
- Benefits pts with difficulty measuring and mixing insulin
- Meal/ snack AND basal coverage
- Less injections
Disadvantages:
- Challenging to titrate and adjust dose
When insulin is started, what should we do regarding metformin?
Continue metformin
When insulin is started, what should we do regarding TZDs?
Discontinue or reduce dose (due to increased risk of hypoglycemia with insulin)
When insulin is started, what should we do regarding SUs?
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
When insulin is started, what should we do regarding SGLT2i?
Discontinue
When GLP-1 agonist injectable is started, what should we do regarding DPP-4i?
Discontinue
What is the general rule of thumb for insulin dosing conversion?
Most insulin conversions are 1:1 unit
Reduce the dose by 10-20% if the pt is at high risk of hypoglycemia
For insulin dosing conversions, what are some exceptions where you MUST decrease dose?
- Switching from twice daily NPH to once daily glargine/ detemir: decrease by 20%
- Switching from U-300 glargine to alternative basal insulin analog: decrease by 20%
ADEs of insulin? (6)
How should we manage this?
(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)
Name the 3 GLP-1 receptor agonists (LDS)
- Liraglutide (SC)
- Dulaglutide (SC)
- Semaglutide (PO and SC)
ADEs of GLP-1 receptor agonists?
Is dose adjustments needed for renal impairments?
- Headache
- N/V
- Acute pancreatitis
- Acute cholecystitis
- Injection site reactions
- **Thyroid C-cell tumors
Comment on the administration and dosing for Liraglutide
Administration: SC injection OD regardless of meals
Dosing: 0.6mg initial then titrate to 1.2mg after 1 week. Can increase to 1.8mg
Comment on the administration and dosing for Dulaglutide
Administration: SC injection oiw regardless of meals
Dosing: 0.75mg then titrate to 1.5mg after 4 weeks. Can increase to 3mg/ 4.5mg
Comment on the administration and dosing for Semaglutide (SC)
Administration: SC injection oiw regardless of meals
0.25mg then titrate to 0.5mg after 4 weeks. Can increase to 1mg
Comment on the administration and dosing for Semaglutide (PO)
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
How much does GLP-1 receptor agonist decrease HbA1c levels by?
1-2%
Advantages and disadvantages of GLP-1 receptor agonist?
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
When will GLP-1 receptor agonist be used?
Recommended over insulin as first-line injectable when greater glucose lowering is needed
When do we give basal bolus insulin and when do we give pre-mix insulin?
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
