Diabetes Mellitus Type 1

Question 1

Rapid Acting Insulin Preparations- Available Drugs

Answer 1

insulin aspart
insulin lispro
insulin glulisine

Question 2

Rapid Acting Insulin Preparations- Kinetics

Answer 2

amino acid substituted insulin variants that are monomeric for faster absorption

onset= 5-15 min
peak= 45-75 min
duration= 2-4 hr

Question 3

Rapid Acting Insulin Preparations- Clinical Use

Answer 3

prior to meal (immediately before) for control of POSTPRANDIAL HYPERGLYCEMIA

also for acute hyperglycemia

Question 4

Rapid Acting Insulin Preparations- Drug Rxns

Answer 4

drugs w/ hyperglycemic effects:
corticosteroids
Ca channel blockers
thiazide diuretics

Question 5

Regular Insulin- Kinetics

Answer 5

zinc ions added for stability

onset= 30-60 min
peak= 2-4 hrs
duration= 6-8 hrs

Question 6

Regular Insulin- Clinical Use

Answer 6

prior to meal (30-45 min.) for control of POSTPRANDIAL HYPERGLYCEMIA

also for acute hyperglycemia

Question 7

Intermediate Acting Insulin- Available Drugs

Answer 7

NPH INSULIN
lente insulin (discontinued)

Question 8

Intermediate Acting Insulin- Kinetics

Answer 8

conjugated w/ protamine peptide which delays absorption until it is cleaved by tissue proteases

onset= 1.5-2 hrs
peak= 6-10 hrs
duration= 16-24 hrs

Question 9

Intermediate Acting Insulin- Clinical Use

Answer 9

MAINTAIN BASAL INSULIN

overnight coverage

Question 10

Long Acting Insulin- Available Drugs

Answer 10

INSULIN GLARGINE
INSULIN DETMIR
Ultralente insulin (discontinued)

Question 11

Long Acting Insulin- Kinetics

Answer 11

Insulin glargine - amino acid substituted insulin that forms large precipitate in body pH that slows absorption

onset= 2hrs
peak= N/A
duration= 20-24 hrs

Insulin detmir - insulin w/ fatty acid side chain that associates with tissue bound albumin that slows absorption

Question 12

Long Acting Insulin- Clinical Use

Answer 12

MAINTAIN BASAL INSULIN

overnight coverage

Question 13

Insulin Preparations- Mech of Action

Answer 13

replace deficient insulin

replicate normal physiological production of insulin by the pancreas–> basal insulin produced under fasting conditions + postprandial insulin released after a meal

act on tyrosine kinase receptor:
liver- glucose uptake, inhibit glucose production
muscle- glucose uptake; increase AA uptake and protein synthesis
adipose- glucose uptake, inhibit lipolysis, increase TG storage

Question 14

Insulin Preparations- Notes on Administration

Answer 14

SubQ by intermittent injections or continuous infusion

inhaled form discontinued

rotate injection sites (upper arm, thigh, abdomen, buttock) to avoid lipodystrophy

Question 15

Insulin Preparations- Side Effects/Contraindications

Answer 15

MILD HYPOGLYCEMIA:
tremor, palpitations, sweating, intense hunger

MODERATE HYPOGLYCEMIA:
headache, mood change, irritability, decreased attention, drowsiness, patients may require assistance

SEVERE HYPOGLYCEMIA:
unresponsiveness, unconsciousness, convulsions, patients require assistance, death

Question 16

Conventional Insulin Therapy- Typical Combination

Answer 16

NPH Insulin + Regular Insulin

Question 17

NPH Insulin + Regular Insulin- Mech of Action

Answer 17

mimic normal insulin action with basal insulin + postprandial peaks

Question 18

NPH Insulin + Regular Insulin- Kinetics

Answer 18

twice daily mixed injections- before breakfast and before dinner

Question 19

NPH Insulin + Regular Insulin- Clinical Use

Answer 19

DM type 1 or late stage type 2

DM type 2 requires larger doses of insulin than type 1 due to insulin resistance

Question 20

NPH Insulin + Regular Insulin- Side Effects/Contraindications

Answer 20

risk of hypoglycemia between lunch and dinner, and again between dinner and breakfast due to NPH peaks between meals

risk of hyperglycemia in the morning due to dawn phenomenon

Question 21

Intensive Insulin Therapy- Typical Combination

Answer 21

Rapid Insulin + NPH or Glargine

Question 22

Rapid Insulin + NPH or Glargine- Mech of Action

Answer 22

provide a more physiologic profile or insulin by administration

Question 23

Rapid Insulin + NPH or Glargine- Kinetics

Answer 23

once or twice daily basal insulin plus pre meal boluses of rapid acting insulin to control postprandial glucose

Question 24

Rapid Insulin + NPH or Glargine- Clinical Use

Answer 24

DM type 1 or late stage type 2

determine dose of premeal bolus by blood glucose level, size and composition of the meal, and degree of anticipated activity

Question 25

Rapid Insulin + NPH or Glargine- Side Effects/Contraindications

Answer 25

hypoglycemia
requires significant patient commitment and effort
higher cost than conventional therapy
higher risk of adverse effects than conventional therapy