DIABETES PHARMACOLOGY: PART 2 INSULIN Flashcards
Major Adverse Effects of Insulin?
5
- Hypoglycemia
- Hypokalemia
- Lipodystrophy
- Local or systemic allergic reaction
- Somogyi effect
What is the somogyi effect?
2 steps
- If the blood sugar level drops too low in the early morning hours hormones (such as growth hormone, cortisol, and catecholamines) are released
- 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)
The somogyi effect will occur in pts that do what?
Why do we need them to check their early morning and late morning sugars?
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
The dawn phenomenon is what?
3 steps
- a normal rise in blood sugar as a person’s body prepares to wake up
- In the early morning hours, growth hormone, 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
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?
Too much insulin
Not enough insulin
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
1. Lispro (Humalog) 2. Aspart (Novolog) 3. Glulisine (Apidra)
- Human Regular***
(Humulin R and Novolin R) - Human NPH**
- Lente
(Humulin L
Novolin L) - Glargine (Lantus)
- Detemir (Levemir)
- Degludec (Tresiba)
Available 3/2016
What is the difference between the human insulin and the insulin analogs?
(and rapid and longer acting)
Which ones resemble endogenous insulin?
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
Compare DOA for NPH human insulin and insulin glargine?
NPH peaks around 4-12 hours and decreases from there. Glargine virtually has no peak and works for a much longer period of time
The term “conventional insulin therapy” refers to what?
regular dosing without regard to what the blood sugars are. A1Cs will be higher
- The term “intensive insulin therapy” is used to describe more complex regimens. What is involved?
- What is conventional insulin?
- 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.
- regular or NPH insulin, usually given twoce daily before mealtime
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?
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
Benefits of Intensive Insulin Therapy
5
- Prevent or slow progression of long-term diabetes complication.
- Reduce diabetes related heart attacks and strokes by more than 50%.
- Reduce risk of eye damage by more than 75%.
- Reduce risk of nerve damage by 60%.
- Prevent or slow the progression of kidney disease by 50%.
Intensive Insulin Therapy Goals:
Blood sugar level before meals?
Blood sugar level two hours after meals?
Hemoglobin A1C?
90-130
less than 180
less than 7%
List the onset of action, time to peak effect and duration of action for the following types of insulin:
- Lispro (Humalog), aspart(Novolog), glulisine (Apidra)?
- Regular?
- NPH?
- Glargine (Lantus)?
- Detemir (Levemir)?
- Degludec (Tresiba)?
- 5 to 15 min
45 to 75 min
2 to 4 h - About 30 min
2 to 4 h
5 to 8 h - About 2 h
6 to 10 h
14 to 26 h - About 2 h
No peak
20 to >24 h - About 2 h
No peak
20 h - 42 hours of DOA!
How many doses a day for basal insulin?
What do we have to add on to it?
1-2 doses a day
Plus bolus therapy (rapid vs. short acting) 15 min before each meal
OR Premixed intermediate and short acting
What are the premixed intermediate and short acting insulins, %NPH/% Regular?
2
- Humulin 50/50, Humulin 70/30
- Novolin 50/50, Novolin 70/30
Usually dosed twice daily and not adjusted for current BG and carbohydrate intake
Use “Insulin” syringes which provide unit measurements:
1ml=
100U
- Where is the insulin is absorbed fastest in the body?
- Slowest?
- Intermediate rate from the arm?
- Rapidity of insulin absorption varies inversely with what?
- fastest from the abdominal wall,
- slowest from the leg and buttock,
- and at an intermediate rate from the arm;
- at any of these sites, the rapidity of insulin absorption varies inversely with subcutaneous fat thickness
What would we prescribe for someone who just started insulin with type 2?
4
- 10 U per day or 0.1-0.2 U/kg/day of basal insulin given at night
Example: Glargine (Lantus) 10 U - continue other oral non-insulin meds
- titrate up every 2Us every three days or so
- considering adding bolus dosing to cover meals if A1C goal isnt met after FPG is met
3, 2, 1 Countdown. Explain this pneumonic?
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
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
- basal insulin + GLP-1RA
- Basal + Adding 1 injection of a rapid acting insulin analogue before the largest meal
- Basal + Adding 2-3 injections of a rapid acting insulin analogue before 2-3 meals, or
- Using premixed insulin BID
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?
- Patients weight
- Give two injections that contain a combination of short or rapid acting and intermediate acting insulin
- Doses are given before breakfast and before the evening meal
- 2/3 of dose with breakfast
1/3 of dose with evening meal
Look over charts in lecture.
Slide 31, 34, 35, 36, 38
The Basal/Bolus Insulin Concept:
Why is the basal used?
Why is the bolus used?
Suppresses glucose production between meals and overnight
Limits hyperglycemia after meals
Immediate rise and sharp peak at 1 hour
Continuous Subcutaneous Insulin Infusion
provides what kinds of insulin and how are they administered?
Provides continuous SQ infusion of rapid-acting insulin along with manually administered bolus dose before each meal.
