DIABETES PHARMACOLOGY: PART 2 INSULIN

Question 1

Major Adverse Effects of Insulin?

5

Answer 1

1. Hypoglycemia
2. Hypokalemia
3. Lipodystrophy
4. Local or systemic allergic reaction
5. Somogyi effect

Question 2

What is the somogyi effect?

2 steps

Answer 2

1. If the blood sugar level drops too low in the early morning hours hormones (such as growth hormone, cortisol, and catecholamines) are released
2. These help reverse the low blood sugar level but may lead to elevated blood sugar levels in the morning

(rebound hyperglycemia because you had a hypoglycemic epidsod. Hormones are released and you think you are hyperglycemic so you think you need more insulin)

Question 3

The somogyi effect will occur in pts that do what?

Why do we need them to check their early morning and late morning sugars?

Answer 3

This may occur if a person who takes insulin doesn’t eat a regular bedtime snack resulting in decreased blood sugar in the early AM

Because we cant give them insulin in the morning if its high because of the hormones released. We will bottom them out even more

Question 4

The dawn phenomenon is what?

3 steps

Answer 4

1. a normal rise in blood sugar as a person’s body prepares to wake up
2. In the early morning hours, growth hormone, cortisol, and catecholamines cause the liver to release large amounts of glucose into the bloodstream.
3. If there is not enough insulin to cover this than the AM glucose will be high

Question 5

What is the main problem and what is the treatment for Smogyi effect?

What is the main problem and what is the treatment for Dawn phenomenon?

Answer 5

Too much insulin

Not enough insulin

Question 6

What are the rapid acting insulin analogs?3

WHat is the short acting insulin?

What are the Intermediate-acting (Basal)? 2

WHat are the Basal Insulin Analogs? 3

Answer 6

1. Lispro 
(Humalog)
2. Aspart
(Novolog)
3. Glulisine
(Apidra)

1. Human Regular***
   (Humulin R and Novolin R)
2. Human NPH**
3. Lente
   (Humulin L
   Novolin L)
4. Glargine (Lantus)
5. Detemir (Levemir)
6. Degludec (Tresiba)
   Available 3/2016

Question 7

What is the difference between the human insulin and the insulin analogs?
(and rapid and longer acting)

Which ones resemble endogenous insulin?

Answer 7

Human insulin (NPH and Regular) do not replicate the time to peak concentration or the duration of action of endogenous insulin secretion

Rapid acting insulin analog preparations have
Faster onset and shorter DOA than regular insulin

Long acting insulin analog preparations have
Longer onset of action and a flatter serum concentration than NPH for basal coverage

Rapid acting and long acting most closely resemble endogenous insulin

Question 8

Compare DOA for NPH human insulin and insulin glargine?

Answer 8

NPH peaks around 4-12 hours and decreases from there. Glargine virtually has no peak and works for a much longer period of time

Question 9

The term “conventional insulin therapy” refers to what?

Answer 9

regular dosing without regard to what the blood sugars are. A1Cs will be higher

Question 10

1. The term “intensive insulin therapy” is used to describe more complex regimens. What is involved?
2. What is conventional insulin?

Answer 10

1. Basal insulin delivery (given as one to two daily injections of intermediate- or long-acting insulin)
   With superimposed doses of short-acting or rapid-acting insulins three or more times daily

This will have better A1C control.

2. regular or NPH insulin, usually given twoce daily before mealtime

Question 11

Basal insulin controls glucose how?
Provides what percent of daily needs?

Bolus insulin limits glucose when?
When do its effects peak?
Procides what percent of daily needs?

Answer 11

Controls glucose production between meals and overnight

Near-constant levels
Usually ~50% of daily needs

(mealtime or prandial)
Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour post-meal
10% to 20% of total daily insulin requirement at each meal

Question 12

Benefits of Intensive Insulin Therapy

5

Answer 12

1. Prevent or slow progression of long-term diabetes complication.
2. Reduce diabetes related heart attacks and strokes by more than 50%.
3. Reduce risk of eye damage by more than 75%.
4. Reduce risk of nerve damage by 60%.
5. Prevent or slow the progression of kidney disease by 50%.

Question 13

Intensive Insulin Therapy Goals:
Blood sugar level before meals?
Blood sugar level two hours after meals?
Hemoglobin A1C?

Answer 13

90-130

less than 180

less than 7%

Question 14

List the onset of action, time to peak effect and duration of action for the following types of insulin:

1. Lispro (Humalog), aspart(Novolog), glulisine (Apidra)?
2. Regular?
3. NPH?
4. Glargine (Lantus)?
5. Detemir (Levemir)?
6. Degludec (Tresiba)?

Answer 14

1. 5 to 15 min
   45 to 75 min
   2 to 4 h
2. About 30 min
   2 to 4 h
   5 to 8 h
3. About 2 h
   6 to 10 h
   14 to 26 h
4. About 2 h
   No peak
   20 to >24 h
5. About 2 h
   No peak
   20 h
6. 42 hours of DOA!

Question 15

How many doses a day for basal insulin?

What do we have to add on to it?

Answer 15

1-2 doses a day

Plus bolus therapy (rapid vs. short acting) 15 min before each meal
OR Premixed intermediate and short acting

Question 16

What are the premixed intermediate and short acting insulins, %NPH/% Regular?
2

Answer 16

1. Humulin 50/50, Humulin 70/30
2. Novolin 50/50, Novolin 70/30

Usually dosed twice daily and not adjusted for current BG and carbohydrate intake

Question 17

Use “Insulin” syringes which provide unit measurements:

1ml=

Answer 17

100U

Question 18

1. Where is the insulin is absorbed fastest in the body?
2. Slowest?
3. Intermediate rate from the arm?
4. Rapidity of insulin absorption varies inversely with what?

Answer 18

1. fastest from the abdominal wall,
2. slowest from the leg and buttock,
3. and at an intermediate rate from the arm;
4. at any of these sites, the rapidity of insulin absorption varies inversely with subcutaneous fat thickness

Question 19

What would we prescribe for someone who just started insulin with type 2?
4

Answer 19

1. 10 U per day or 0.1-0.2 U/kg/day of basal insulin given at night
   Example: Glargine (Lantus) 10 U
2. continue other oral non-insulin meds
3. titrate up every 2Us every three days or so
4. considering adding bolus dosing to cover meals if A1C goal isnt met after FPG is met

Question 20

3, 2, 1 Countdown. Explain this pneumonic?

Answer 20

How about a real easy way of remembering how to initiate long-acting insulin?
Every 3 days, increase by 2 units, until fasting plasma glucose of 100

Question 21

In patients still not at target after basal insulin has been adequately titrated, and the patient is willing to take >1 injections, there are several options:
4

Answer 21

1. basal insulin + GLP-1RA
2. Basal + Adding 1 injection of a rapid acting insulin analogue before the largest meal
3. Basal + Adding 2-3 injections of a rapid acting insulin analogue before 2-3 meals, or
4. Using premixed insulin BID

Question 22

Twice-Daily Split-Mixed Regimen or 
70/30 Conventional Insulins:
1. Dosing is based on what?
2. What kind of insulins are in these?
3. When are doses given? 2
4. How much of the dose is given at these times?

Answer 22

1. Patients weight
2. Give two injections that contain a combination of short or rapid acting and intermediate acting insulin
3. Doses are given before breakfast and before the evening meal
4. 2/3 of dose with breakfast
   1/3 of dose with evening meal

Question 23

Look over charts in lecture.

Answer 23

Slide 31, 34, 35, 36, 38

Question 24

The Basal/Bolus Insulin Concept:
Why is the basal used?
Why is the bolus used?

Answer 24

Suppresses glucose production between meals and overnight

Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour

Question 25

Continuous Subcutaneous Insulin Infusion

provides what kinds of insulin and how are they administered?

Answer 25

Provides continuous SQ infusion of rapid-acting insulin along with manually administered bolus dose before each meal.