Diabetes Type 1 Flashcards

Question

What are the long acting- basal insulin?

Answer 1

Levemir® (detemir) | Lantus® (glargine

Answer 2

Long acting/basal insulin An attached fatty acid side chain binds to interstitial albumin at the SC site Binds to albumin again in the capillary Must dissociate from albumin to bind to insulin receptors

Answer 3

Long acting/basal insulin Soluble at a pH of 4 Forms microprecipitates when injected into the body Slowly dissolves into monomers which are absorbed

Answer 4

``` Long acting/basal insulin Onset: 2 hrs Peak: 6 to 9 hrs (blunted) Duration: ~24 hours (0.4 units/kg) ~14 hours when dosed 0.2 units/kg ```

Answer 5

Long acting/basal insulin Onset: 4 to 5 hrs Peak: none or blunted Duration: 22+ hrs

Answer 6

Intermediate-acting insulin NPH Onset: 1 to 4 hrs Peak: 6 to 10 hrs Duration 12-18 hours NPH is a suspension Must be rolled or inverted 10 times before use to resuspend Can be used as a basal insulin when dosed multiple times a day

Answer 7

``` Short acting insulin- regular Can be mixed in same syringe with NPH Onset: ½ to 1 hour Peak: 2 to 5 hrs Duration: 4 to 6 hrs ``` Inject ~30 minutes before eating Can be inconvenient- requires more meal planning Delayed onset useful in patients with gastroparesis

Answer 8

Rapid-acting insulin Onset 5-15 minutes Peak: ½ to 1 ½ hrs Duration 3.5- 5 hours More closely mimics the body’s response to glucose absorption Should be injected immediately before eating Can be mixed with NPH, but must inject within 5 minutes (doesn’t have as long of stability so must be stored)

Answer 9

NPH + Regular -70/30 (NPH/R) :Novolin® 70/30 Humulin® 70/30 NPH-like insulin + Rapid-acting Aspart Protamine/Aspart Novolog Mix® 70/30 Neutral Protamine lispro/lispro Humalog Mix® 75/25 Humalog Mix 50/50

Answer 10

Cloudy appearance: mix (DONT ROLL) before administering | Onset is 5 to 15 minutes (give immediately before meal)

Answer 11

Cloudy appearance: mix (DONT ROLL) before administering | Onset- 1/2 to 1 hour (give 30 minutes before meals)

Answer 12

``` Hypoglycemia: blood glucose < 70 mg/dL Result of: Excess of insulin Decrease or delay in meals Increase in exercise Illness ```

Answer 13

Tremors, palpitations, sweating Excessive hunger Headache, mood changes, irritability Unconsciousness, seizures

Answer 14

15 g of glucose….wait 15 min If blood glucose still <70 mg/dL take another 15 g Repeat until blood glucose is in normal range Eat a meal or snack to prevent recurrence

Answer 15

Tablets: 5g/tab Gel: 15 g/tube

Answer 16

``` Food ( amt = 15g) ½ cup juice or regular soda 3 graham crackers 6 saltines 1 Tbsp syrup or honey 1 cup skim milk 2 Tbsp raisins ```

Answer 17

``` Hypoglycemic unawareness Weight gain Lipohypertrophy Hypokalemia Allergic reaction at injection site-rare Insulin antibodies- rare ```

Answer 18

Secretion of glucagon and epinephrine are blunted Reduced symptoms of hypoglycemia Symptoms still might occur but at lower blood glucose levels Less time to react and treat

Answer 19

If patient is unconscious use a glucagon kit to treat hypoglycemia 1 mg IM Patient should respond within 15 minutes Can be repeated if no response

Answer 20

-Route of administration affects rate of absorption IV > IM > SC -Rates of absorption vary from site to site Abdomen (Fastest) > arm > thigh > buttocks (Slowest) -Patient should be consistent in the area they are injecting but still rotate the point of injection within injecting, that site -Blood flow to the area enhances absorption Rubbing injection area, skin temperature, exercise

Answer 21

Most insulins can be stored at room temperature 15-30°C (59-86°F) up to 28 days

Answer 22

The Mix pens

Answer 23

Continuous Subcutaneous Insulin Infusion Delivers microliter amounts of insulin continuously as a basal insulin Delivers insulin via flexible tubing connected to a catheter inserted subcutaneously Activate the pump before a meal to deliver a bolus Battery operated device Insulin reservoir-varying sizes

Answer 24

-Synthetic analog of human amylin -Amylin is co-secreted with insulin from the pancreas in response to a meal -3 primary mechanisms of amylin Suppresses postprandial glucagon secretion Regulates the rate of gastric emptying Reduces food intake -Amylin is deficient in both type 1 and type 2 diabetes

Answer 25

FDA approved for Type 1 or 2 diabetes in patients on optimal insulin therapy who are still not at goal Efficacy: A1C ~0.1-0.4% in type 1 diabetes

Answer 26

Type 1 dosing: 15 mcg SC before meals Meals must be >250 kcals or >30 g carbohydrates Titrate at 15 mcg increments to a max of 60 mcg before meals SymlinPen™ 60: for doses of 15, 30, 45, or 60 mcg SymlinPen™ 120: for doses of 60 or 120 mcg Administered in conjunction with mealtime insulin

Answer 27

When starting pramlintide reduce pre-prandial insulin by 50%

Answer 28

Gastroparesis Hypoglycemic unawareness Recurrent episodes of hypoglycemia in the last 6 months A1C > 9% Poor adherence to insulin or self-monitoring

Answer 29

HYPOGLYCEMIA- BLACK BOX WARNING (usually occurs within 3hrs of injection, reason you reduce preprandial insulin by 50% at initiation) Nausea Titrate dose slowly

Answer 30

Delayed gastric emptying | Administer oral meds 1 hr pre or 2 hr post pramlintide

Answer 31

A1C < 7.0% Fasting glucose 70-130 mg/dl Peak postprandial glucose <180 mg/dl 1-2 hours after the start of the meal

Answer 32

A1C < 6.5% Fasting glucose < 110 mg/dl 2-h postprandial glucose <140 mg/dl

Answer 33

1. Use of multiple dose insulin injections 3-4 injections/day of basal and prandial insulin 2. Matching prandial insulin to: Carbohydrate intake Premeal BG And anticipated activity 3. Use of insulin analogs as prandial insulin

Answer 34

Long-Acting Basal with Rapid-Acting Bolus Minimum of 4 injections Basal administered once/day typically at bedtime Rapid acting bolus given just before meals

Answer 35

-NPH Basal with Rapid Acting Bolus Limited use in type 1 Basal doesn’t last 24 hours Greater risk for hypoglycemia: peak from NPH Less expensive regimen -Mixed insulin before breakfast and dinner Very difficult to adjust the dose if it is pre-mixed -Pre-breakfast NPH + regular, pre-dinner regular, and bedtime NPH -Detemir/glargine once or twice daily with regular insulin before meals

Answer 36

Initial insulin dosing for type I is weight based ~0.4-1 units/kg/day ~50% of Insulin total daily dose (TDD) is basal insulin Remaining ~50% is given as prandial insulin Max of 50 units can be absorbed/injection site

Answer 37

- When using rapid-acting insulin- inject immediately before the meal - When using regular insulin- inject 30-45 minutes before the meal 2 parts to prandial insulin dosing: 1. Insulin to carbohydrate ratio (I:C) Grams of carbohydrate 1 unit of insulin will cover 2. Correction factor (CF) Number of mg/dL the blood glucose will drop after injecting 1 unit of rapid-acting or regular insulin

Answer 38

Typical starting I:C is 1:15 1 unit of insulin “covers” 15 grams of carbs OR…use a formula to determine the I:C 500 / TDD = # of carbs covered by 1 unit of insulin (TDD = Total daily dose of insulin) Example: TDD= 25 units 500/25 = 20 (I:C = 1:20)

Answer 39

Limit patient to a specific # of carb servings/meal e.g. can have 4 carb servings or 60 grams of carbs/meal Patient has a set insulin dose

Answer 40

Patient counts the grams of carbohydrates in the meal and injects the appropriate amount of insulin according to the I:C Remind patients to look at serving size and Total Carbohydrates

Answer 41

Number of mg/dL the blood glucose will drop after injecting 1 unit of rapid-acting or regular insulin Use the CF when the patients blood glucose is elevated before the meal This insulin will be added to the amount required to cover the carbs that will be consumed A typical starting CF dose is 1:50 mg/dL 1 unit of insulin for every 50 mg/dL above 100 Correct to 100 mg/dL because it is the mid-point target blood glucose (between 70 and 130 mg/dL)

Answer 42

When patterns are out of range

Answer 43

Increase bedtime basal insulin dose 1-2 units every 3 days until fasting blood sugar <130mg/dL Other causes of fasting hyperglycemia Dawn phenomenon: increased insulin requirement late in the sleep cycle (nocturnal hyperglycemia) Somogyi phenomenon: nocturnal hypoglycemia followed by rebound hyperglycemia

Answer 44

-During hypoglycemia counterregulatory hormones are released Glucagon, epinephrine, growth hormone, cortisol Stimulates hepatic glucose production- can lead to rebound hyperglycemia -Measure blood glucose levels between 2 and 4:00 AM and then again at 7:00 am If they are 180-200 mg/dL rebound hyperglycemia may have occurred -More common when intermediate insulins are used with dinner -Less risk of nocturnal hypoglycemia with long-acting basal insulins

Answer 45

Increased insulin requirement in the early morning ~1-3:00 am due to a surge of growth-hormone release If the patient’s insulin levels are starting to drop at this time, it will result in morning fasting hyperglycemia NPH is effective due to its peak

Answer 46

1-2 hours after eating Not enough insulin was given with the meal Increase the pre-meal insulin dose Trial and error to determine if the I:C ratio or the CF need increased

Answer 47

Adjust the I:C by 2-5 grams of carbs when the postprandial blood glucose is consistently > 180 mg/dL If I:C is 1:15 and the 2-h post-prandial blood glucose levels are 210… Increase the I:C to ~1:12 Verify that the patient is correctly counting the carbs! If I:C is 1:15 and the patient is frequently hypoglycemic 2 hours after eating… Decrease the I:C to ~1:20

Answer 48

Exercise-induced hypoglycemia occurs as a result of ↑ glucose uptake and utilization by the muscle

Answer 49

- Planned exercise: decrease pre-prandial insulin dose before the exercise - Unplanned exercise: consume an additional 15-30 g of carbs for each 30 min of exercise - Might need to decrease pre-prandial insulin dose for the meal after exercising

Answer 50

-Insulin requirements increase during illness -Risk for diabetic ketoacidosis (DKA) -Patient needs to continue their usual insulin doses If able to eat might need an additional unit/15 g of carbs -Check blood glucose and urine ketones -Always test urine ketones if blood glucose is consistently over 240 mg/dL -Persistent large ketones is an early sign of DKA

Answer 51

Hypoglycemia- BG <50mg/dL Ketoacidosis-Without insulin body must obtain energy via lipolysis leading to ketone bodies DKA is a reversible but potentially life threatening complication Often precipitated by illness, incorrect insulin dosing (or oral DM meds)

Answer 52

``` Develop rapidly Fruity or acetone breath N+V Dehydration- typically 6L or more Polyuria Polydipsia Deep, rapid breathing Lethargy, HA, weakness ```

Answer 53

Hyperglycemia (> 250mg/dL) Ketosis (anion gap > 10) Acidosis (arterial pH < 7.25)

Answer 54

-Reverse underlying metabolic abnormalities Rehydrate patient -Replacement with NS at 1L/hr (a lot of fluid to replace) -Normalize serum glucose (use a regular insulin) Regular insulin at 0.1-0.2 unit/kg/hr by CI (continuous infusion)