Diabetes Mellitus 3 and 4

Question 1

Insulin regimens:

Answer 1

1. Once or twice daily insulin +/- oral therapy for type 2 diabetes
2. Intensification of therapy for all type 1 and many type 2 diabetes patientes: basal/bolus insulin concept

Question 2

Insulin Treatment of Type 2 Diabetes:

Answer 2

1. Begin once daily insulin and continue oral meds
2. Begin twice (or 3x) daily insulin +/- oral meds
3. Intensification (basal insulin + acting with meals) needed with progressive decline in beta cell mass

Question 3

Split-Mix Insulin therapy:

Answer 3

Advans: 1. relatively easy to use 2. cover insulin requirements through most of day 3. lower cost with NPH and regular insulin;
disadvans: 1. not very physio 2. greater likelihood of nocturnal hypoglycemia given peak of presupper NPH 3. greater chance of fasting hyperglycemia

Question 4

When is full day insulin coverage indicated? Why is it designed?

Answer 4

When sufficient beta-cell dysfunction has occurred so that adequate control has not been achieved with non-insulin treatment(s) +/- basal insulin treatment and there is a need for both basal and prandial insulin;
mimic normal insulin secretory patterns

Question 5

Basal/Bolus insulin concept:

Answer 5

1. Basal insulin: suppresses glucose production b/w meals and overnight; usually 40-50 % of daily needs
2. Bolus insulin: matched to carb intake, premeal glucose, anticipated activity; limits hyperglycemia after meals; usually 10-20% of total daily insulin requirement at each meal

Question 6

Desired characteristics of replacement basal insulin:

Answer 6

1. mimics natural pancreatic basal insulin secretory pattern
2. no distinct peak effect
3. continued effect over 24 hrs
4. minimizes risk of nocturnal hypoglycemia
5. administered once daily for optimal patient compliance
6. reliable absorption pattern

Question 7

Basal/bolus insulin absorption pattern: standard insulin prep, vs. rapid-acting/long-acting analogs:

Answer 7

1. Regular and NPH

2. Aspart, lispro, glulisine/glargine or detemir

Question 8

Weight gain:

Answer 8

1. insulin therapy reverses catabolic effects of diabetes (glycosuria reduced, normal fuel-storage mechs restored)
2. Risk of hypoglycemia often causes patients to increase caloric intake and avoid exercise
3. Risk of weight gain decreases with more physiologic insulin administration

Question 9

Benefits and disadvantages of continuous subcutaneous insulin infusion (CSII) systems:

Answer 9

Benefits: uses ONLY rapid-acting insulin; can program basal profiles and basal temporary rates; greater flexibility of lifestyle; dose calculator function; bolus history; ca comm with CGMS
Disadvan: risk of ketosis and DKA; need to be motivated and educated; costly!!

Question 10

OmniPod disposable pump:

Answer 10

1. NO TUBING!!

2. Automated CANNULA insertion

Question 11

Pump basics:

Answer 11

Basal: control glucose levels overnight and between meals (when not eating); insulin delivered every few min in small amounts; typically 40-50% of total daily insulin dose
Bolus doses: covers meals and snacks; correct high glucose levels!!

Question 12

Recs for glucose monitoring:

Answer 12

If on multiple-dose insulin (MDI) or insulin pump therapy should do SMBG:

1. prior to meals and snacks
2. occasionally postprandially
3. at bedtime (eat snack to avoid hypoglycemic episode at night)
4. prior to exercise
5. when they suspect low blood glucose
6. after treating low blood glucose until they are normoglycemic
7. prior to critical tasks such as driving

Question 13

Candidates for Professional Continuous Glucose Monitoring:

Answer 13

1. repeated hypoglycemia
2. hypoglycemic unawareness
3. discrepancies b/w A1C and SMBG
4. Pregnancy
5. Unable to achieve goals

Pregnancy is a HURDle

Question 14

Continuous Monitoring:

Answer 14

Benefits: alarms to prevent lows and highs; knowing where you are; trends with arros, graphs; comm with insulin pump;
Limitations: expense, accuracy, data gaps, need calibration

Question 15

REAL-Time System:

Answer 15

1. glucose sensor inserted sub-Q
2. glucose sensor connected to transmitter
3. glucose sensor sends glucose values to the transmitter
4. transmitter sends these values wirelessly to the insulin pump every 5 min, where data can be viewed and acted on in real-time

Question 16

Treatment of type 1 diabetes:

Answer 16

1. diet, physical activity, education
2. basal/bolus insulin therapy with multiple daily injections or insulin pump therapy
3. consider sensor-augmented insulin therapy

Question 17

Treatment of type 2 diabetes:

Answer 17

1. Diet, exercise, and education
2. Metformin (optimal 1st-line drug)
3. Combo therapy with oral/injectable agents
4. Some require insulin therapy;
   individualize therapy for elderly, those with short life span, co-morbid conditions;
   comprehensive CVD risk reduction: BP control, statin therapy, smoking cessation

Question 18

Intensive insulin therapy: basal/bolus

Answer 18

1. overnight period (look for hypoglycemia and hyperglycemia)
2. look at pre-prandial periods
3. look at post-prandial periods