Diabetes Pharm Part 2

Question 1

Insulin

-major adverse effects

Answer 1

• hypoglycemia
• hypokalemia
• lidodystrophy (lumps and bumps at injection site)
• local or systemic allergic reaction
• Somogyi effect

Question 2

What is the Somogyi effect? When might this occur?

Answer 2

• aka: rebound hyperglycemia
• In pts that are on insulin, if the blood sugar level drops too low in the early morning hours (around 4 am), hormones (GH, cortisol, and catecholamines) are released to keep you from dying. These help reverse the low blood sugar but lead to elevated blood sugar levels in the morning.
• May occur if a person who take insulin doesnt eat a regular bedtime snack resulting in decreased blood sugar in the early AM.

(In Somogyi, the real problem is too much insulin so be very careful anoud high morning blood sugars. If you give insulin the pt could die)

Question 3

What is the Dawn Phenomenon?

Answer 3

• A NORMAL rise in blood sugar as a person’s body prepares to wake up
• in the early morning hours, GH, cortisol, and catecholamines cause the liver to release large amounts of glucose into the bloodstream
• if there is not enough insulin to cover this than the AM glucose will be high

(opposite problem of Somogyi, not enough blood sugar)

Question 4

How to distinguish between Somogyi and Dawn

Answer 4

*both will result in increased AM glucose

• Check blood sugar levels at bedtime, around 2-3 AM, and at your normal wake up time for several nights.
• if blood sugar is low around 2-3 AM, suspect the Somogyi effect
• if blood sugar is normal or high, suspect Dawn

Question 5

What is the difference between the human insulin and the insulin analogs?

Answer 5

• Human insulin (NPH and regular) do NOT replicate the time to peak concentration or the duration of action (DOA) of endogenous insulin secretion
• Rapid acting insulin analog preparations have faster onset and shorter DOA than regular insulin
• long acting insulin analog preparations have a longer onset of action and a flatter serum concentration that NPH for basal coverage

Question 6

What is “conventional insulin therapy”?

What is “intensive insulin therapy”?

Answer 6

conventional insulin therapy: prescribed dosing without adjusting for blood sugar such as single daily injections or two injections daily

intensive insulin therapy: more complex regimens, basal insulin delivery (intermediate or long acting insulin) WITH superimposed doses of short acting or rapid-acting insulins three or more times daily

Question 7

Basal vs bolus insulin

Answer 7

Basal

• controls glucose production between meals and overnight (suppresses glucose production between meals and overnight)
• near constant levels
• usually 50% of daily needs

Bolus

• limits hyperglycemia after meals
• immediate rise and sharp peak at 1 hour post meal
• 10-20% of total daily insulin requirement at each meal

Question 8

Benefits of intensive insulin therapy

Answer 8

• prevent or slow progression of long-term diabetes complication and kidney disease
• reduce diabetes related heart attacks and strokes by more than 50%
• reduce risk of eye damage, nerve damage

Question 9

Intensive insulin therapy goals

Answer 9

• blood sugar level before meals: 90-130
• blood sugar level two hours after meals: less than 180
• A1C: less than 7%

Question 10

What insulin types have the most rapid onset of action?

Answer 10

Most rapid Onset of Action: Lispro (Humalog), aspart (Novolog), glulisine (apidra), 5-15 min

Question 11

Onset of action, time to peak effect, and duration of action of:
Humalog/Novolog/Apidra
Regular
NPH
Glargine (Lantus)
Detemir (Levemir)

Answer 11

Humalog/Novolog/Apidra- OA: 5-15 min, peak:45-75 min, duration:2-4 hours
Regular- OA: 30 min, peak: 2-4 h, duration:5-8h
NPH- OA: 2h, peak: 6-10 h, duration: 14-26h
Glargine (Lantus)- OA: 2h, peak: none, duration:20 to more than 24h
Detemir (Levemir)- OA: 2h, peak: none, duration: 20h

Question 12

Describe insulin therapy (simplified)

Answer 12

• basal insulin (1-2 doses a day)
• PLUS bolus therapy (rapid or short acting) 15 min before each meal

OR

• Premixed intermediate and short acting
• -Humulin 50(NPH)/50(regular), 70/30, Novolin 50/50, 70/30
• -Usually dosed twice daily and not adjusted for current BG and carbohydrate intake

Question 13

How many units does a 1ml syringe provide?

Answer 13

100 U, so a .3ml syringe would hold 30U

Question 14

Where is insulin absorbed the fastest? What are some other sites?

Answer 14

• absorbed fastest from the abdominal wall
• slowest from the leg and buttock
• arm is intermediate

Question 15

How long is insulin good for at room temp? refrigeration?

Answer 15

1 month at room temp and 3 mo under refrigeration

*do not freeze

Question 16

Describe the 3, 2, 1 countdown for initiating long-acting insulin

Answer 16

• every 3 days, increase by 2 units, until fasting plasma glucose of 100
• then comes critical thinking and adjustment of dose based in patient response

For T2D, continue other oral non-insulin meds, self blood glucose monitoring is important

Question 17

describe the twice-daily split-mixed regimen or 70/30 conventional insulins

Answer 17

• dosing based on pt weight
• Give two injections that contain a combination of short or rapid acting and intermediate acting insulin
• doses are given before morning and evening meals
• 2/3 dose with breakfast, 1/3 dose with evening meal

Question 18

How is T1D insulin therapy dosed?

Answer 18

it is weight based dosing 0.5- 0.6 U/kg/day

*T1D need intensive therapy with a combo of rapid/bolus doses of insulin daily (usually 4 doses)

Question 19

How does continuous subcutaneous insulin infusion work?

Answer 19

• small battery operated programmable pump
• Provides continuous SQ infusion of rapid-acting insulin along with manually administered bolus dose before each meal
• pt self monitors preprandial glucose levels to adjust the bolus dose
• some have alarms