Diabetes - Part 3 Flashcards by Reagan Blatz

What is insulin?

A hormone secreted from pancreatic beta cells to help regulate blood glucose

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How was the first human insulin created?

Using rDNA technology

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What is the structure of insulin?

Consists of 51 amino acids in 2 chains (A and B) linked by 2 disulfide bonds

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Basal insulin

Beta cells secrete small amounts of insulin throughout the day
(Background insulin)

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Bolus insulin

At mealtime, insulin is rapidly released in response to food
(Mealtime or prandial insulin)

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What are the Bolus insulins?

Rapid acting insulin analogues (clear)
Short acting insulins (clear)

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What are the short acting insulins?

Insulin regular (Humulin-R, Novolin ge Toronto, Hyperion R)

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When do you administer short acting insulins?

30-45 minutes prior to meals

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What is the time for onset, peak and DoA for short acting insulins?

Onset: ~30 minutes
Peak: ~2-3 hours
DoA: ~6 hours

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What are the rapid acting insulin analogues?

Insulin lispro (humalog, admelog)
Insulin aspart (novorapid, Kirsty, Trurapi)
Insulin aspart (Fiasp)
Insulin glulisine (apidra)

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When are RAIA administered?

With or just prior (0-15min) to meals

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What is the onset, peak, and DOA for RAIAs?

Onset: 4-20 minutes
Peak: 0.5-2 hours
DoA: 3-5 hours

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What are the advantages to RAIAs?

More rapid absorption
Convenience
Better PPG control
Decrease hypoglycemia
BUT they do cost more and have similar effectiveness

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What is humalog (insulin lispro) 200U/ml and how should it be administered?

It’s a more concentrated formulation for those who require higher doses.
Should ONLY be injected using a KwikPen to avoid overdose causing severe low blood sugar.

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What is insulin regular U-500(entuzity)?

A very concentrated form of insulin (500U/ml)
For those who require >200U/d
Given 2-3 times per day

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When is Entuzity (U-500) administered?

30 min before a meal because it is short acting

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What is the onset, peak and DoA of entuzity (u-500)?

Onset: ~15 minutes
Peak: ~4-8 hours
DoA: ~17-24 hours

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What are the basal insulins?

Intermediate acting (cloudy)
Long acting insulin (clear)

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What are the intermediate acting insulins?

Insulin neutral protamine hagedorn(NPH) (humulin N, novolin ge NPH, Hyperion NPH)

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What are the long acting insulins?

Insulin detemir U-100 (levemir)
Insulin glargine U-100(lantus)
Insulin glargine U-300(Toujeo)
Insulin degludec U-100, U-200(tresiba)

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What is the onset, peak and DoA for intermediate acting?

Onset: 1-2 hours
Peak: 5-8 hours
Duration: up to 18 hours

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What is the onset, peak and DoA for long acting insulins?

Onset: 90 minutes
Peak: peakless
Duration:
- detemir 16-24 hours
- U-100 glargine 24 hours
- U-300 glargine >30 hours
- degludec 42 hours

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How often is intermediate acting insulins administered?

Once or twice daily

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What must you do with intermediate acting insulins before use?

Hand-roll and invert 10X to re-suspend since they are a suspension

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What are the advantages of LAIAs?

Peakless More consistent / less variable BG Less hypoglycemia BUT they cost more and have similar efficacy

What is the protocol for switching from insulin glargine (lantus) OD to newer insulins?

Use the same dose

What is the protocol for switching from insulin NPH BID to newer basal insulins?

Reduce by 20%

What are the most expensive injection pens?

Toujeo

What is the cheapest insulin pen?

Humulin N KwikPen

How can insulin be delivered?

Syringes and vials Insulin pens Insulin pumps

What is the traditional method for insulin delivery and its pros?

Syringes and vials - least expensive - people are used to it - may prefer less injections so they can combine some insulins in the same syringe

What syringe would you use for a does of 30U, 31-50U, and 51-100U?

30 units - 3/10 cc with half unit marking 31-50 units - 1/2 cc 51-100 units - 1cc

What are the pros to insulin pens?

Portable / convenient / easier to use Good if dexterity/visually impaired Allows for precision dosing

What is an insulin pump called?

Continuous subcutaneous insulin infusion (CSII)

What is an insulin pump?

A small computerized device that delivers insulin continuously 24 hours a day

What type of insulin does and insulin pump use?

RAIA - deceivers it continuously and increased amounts when a Bolus is required

What are the adverse effects of insulin?

Hypoglycemia Weight gain Localized fat Hypertrophy Blurry vision - usually temporary Allergic reactions (rare)

What factors affect insulin absorption?

Injection site Exercise of injected area = increase Massage - vigorous massage = increase Temp - heat = increase Lipohypertrophy = delays Dose - larger dose = delays Renal function - renal failure = decrease Depth of injection - IV > IM > SC

What area of the body is insulin absorbed the fastest?

Abdomen, then arm, thigh and slowest from butt

What is it important to do when injecting?

Rotate between injection sites

What are the steps for injecting insulin with a syringe?

1. Pull in air 2. Push air into the bottle 3. Pull in and push out a little insulin to remove air bubbles 4. Pull exact dose of insulin into the syringe

What length of syringe is recommended?

6mm - can use with or without skin lift

What to do when mixing insulin N + R in the same syringe

Must always draw up the quick-acting insulin first - fill syringe with air up to # of units needed of NPH - push air into vial and remove needle - fill syringe with air to # of units needed of R - push air into vial and draw up desired number of units of R - insert needle back into NPH vial and draw up desired units of NPH - make sure there are no air bubbles by tapping

How do you use a pen?

Prime the pen Dial up amount of insulin required Inject at 90º

How is insulin stored?

If unopened - in fridge When in use - room temp

When should you discard in use insulin?

After 28-56 days

What should you avoid when storing insulin?

Freezing, extreme heat and direct sunlight

Which insulin cannot be mixed in syringe with any other insulin?

LAIA

What is the usual split for insulin in T1 or those who are on MDI with T2?

Basal: 40-50% Bolus:50-60%

What is the dosing for T1 in units/kg for: initial dose, honeymoon phase, and ketosis or acute illness?

Initial: 0.5-0.6 (usually 0.5) Honeymoon: 0.1-0.4 Ketosis or acute illness: 0.5-1.0 (usually 1.0)

What is the dosing for T2 in units/kg for: initial dose, and with insulin resistance?

Initial: 0.1 (or more commonly 10U of basal insulin hs) Resistance: up to 2.5U/kg (or greater)

What is MDI?

Multiple daily injections - a regimen of Bolus injections of insulin before each meal + an evening basal insulin

What is a typical C:I ratio?

15:1 - 15h CHO: 1 unit insulin

How can the initial C:I be estimated?

By diving 500 or 550 by the total daily dose (TDD) of insulin

What is the correction factor?

The expected amount that 1 unit of insulin will normally decrease the BG by Typically 1U of insulin will decrease BG by 2-3mmol/L over the next 2-4 hours

How do we estimate the initial CF?

100 / TTD Ex. If TTD = 40U/day CF would be 100/4 = 2.5

What is the formula if someone’s premeal BG is off?

Current glucose - target glucose / CF Ex. Current is 11.1 but target is 5.6 and the CF is 2.5 Answer: add 2 Units

What are the general rules when interpreting BG / adjusting dose?

Fix the lows first - 1U of insulin can be expected to decrease BG ~2-3 molecules/L Only adjust 1 dose at a time Make dose adjustments every few days based on glucose trends

When evaluating morning hyperglycemia what is the somogyi effect?

Glucose is <4mmol/L

When evaluating morning hyperglycemia what is the dawn phenomenon?

Glucose is >4mmol/L

What are some signs of nocturnal hypoglycemia?

Nightmares, restless sleep, sweating, headache in am, hunger

If someone’s readings are off how do we fix it?

We change the dose of the insulin given before the time that the highs or lows are being experienced Ex. If high in the morning - increase bedtime dose, if low at bedtime - decrease supper time dose