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3152 Endocrine (DM + Thyroid) > DM Insulin > Flashcards

DM Insulin Flashcards

1
Q

[INSULIN]
What is insulin MOA?

A

Regulation of carbohydrates, fats, and amino acids

  • Facilitate uptake of GLUCOSE in muscle and adipose tissue, inhibit hepatic glucose output (decrease gluconeogenesis, decrease glycogenolysis)
  • Enhance FAT storage (lipogenesis), inhibit mobilization of fat for energy in adipose tissue (decrease lipolysis)
  • Increase PROTEIN synthesis, inhibit proteolysis in muscle tissue
  • Increase glycogenesis
  • Increase insulin secretion
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2
Q

[INSULIN]
What are the drug of choice in pregnant DM patients?

A

Metformin + Insulin

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3
Q

[INSULIN]
Insulin is most effective in lowering blood glucose, and can lower HbA1c up to ____%

A

2.5%

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4
Q

[INSULIN]
Onset and duration of action is ________ b/w individuals and within individual

A

highly variable

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5
Q

[INSULIN]
What is the absorption profile of insulin?
How does it vary across different insulin injection sites?

A

After SC injection, forms a depot before distribution
(Depot formation is the rate limiting step)

Absorption (fastest to slowest): Abdomen (2 inch circle around navel) > outer upper arms > top and outer thighs > buttocks

*All insulin are given SC (regular may be given IV/IM/SC)

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6
Q

[INSULIN]
What is the distribution profile of insulin?

A

Insulin enters the bloodstream after SC administration

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7
Q

[INSULIN]
What is the metabolism/elimination profile of insulin?
*Contrast endogenous and exogenous insulin

A

Endogenous insulin is metabolized mainly by the liver, while exogenous insulin is metabolized mainly via the kidney

=> Thus, exogenous insulin requires renal adjustment

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8
Q

[INSULIN ADMINISTRATION]

What is the range of needle length available for insulin pens and syringes (vials) respectively?

Explain why one is longer than the other?

A

Pen: 4mm to 12.7mm

Syringe: 6mm to 12.7mm

Syringe need to be longer to pierce through the stopper

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9
Q

[INSULIN ADMINISTRATION]

What are some considerations when choosing needle length?

A

Average skin thickness at insulin injection site is 2.4mm, with no significance difference b/w BMI, race, age.

Hence, should not recommend needles >8mm, prevent injection into IM which has faster absorption, can cause hypogycemia

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10
Q

[INSULIN ADMINISTRATION]

What is meant by the gauge size of a needle

A

Gauge is the thickness of the needle

28, 29, 30, 21, 32 gauges

Higher the gauge, the finer the needle (32 gauge is the finest)

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11
Q

[INSULIN ADMINISTRATION]

Explain the advantages and disadvantages of a higher gauge

A

Advantage:
- Finer needle => less painful injection

Disadvantage:
- Weaker needle, may break easily
- Slower speed of injection (need to hold for longer duration)

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12
Q

[INSULIN ADMINISTRATION]

What are the available syringe sizes?

A

100IU/ml

  • 1cc (ml), 100 units, 2 units scale increment
  • 1/2cc, 50 units, 1 unit scale increment
  • 3/10cc, 30 units, 1 unit scale increment
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13
Q

[INSULIN ADMINISTRATION]

Common insulin vial size is U-100, what does this contain?

A

100 units / 1ml of insulin
Typically, vials are 10ml, thus contain 1000 units

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14
Q

[INSULIN ADMINISTRATION]

What is the general stability of an unopened insulin vial?

A

If stored in refrigerator: can store till expiration date

If stored in room temperature: can store for 28 days

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15
Q

[INSULIN ADMINISTRATION]

What is the general stability of an opened insulin vial?

What is the exception?

A

Once open, good for 28 days regardless of whether stored in refrigerator or not

Except Detemir - good for 42 days

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16
Q

[INSULIN ADMINISTRATION]

Briefly describe the steps involved in insulin dose preparation

A
  1. Check insulin type and expiration date
  2. Visually inspect for contamination/degradation (e.g., white clumps, color change)
  3. For cloudy insulin (e.g., NPH), roll the vial gently back and forth b/w hands
  4. Wipe top of vial and injection site with alcohol swab
  5. Remove protective covering over the plunger and needle
  6. Draw up air equal to the insulin dose to be administered into the syringe
  7. Inject air into the vial
  8. With the syringe inserted, invert the vial and withdraw the insulin dose
  9. Tap syringe to remove bubbles, and remove syringe from the vial
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17
Q

[INSULIN ADMINISTRATION]

Why do we roll the cloudy insulin vial instead of shaking?

A

Insulin is a protein, do not want to denature it

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18
Q

[INSULIN ADMINISTRATION]

Why must we inject air into the vial before drawing up the dose of insulin?

A

Without this step, would be unable to draw out the insulin due to vacuum created

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19
Q

[INSULIN ADMINISTRATION]

Describe the insulin injection technique
*Also state the degree angle of needle insertion in diff patient populations

A
  1. Pinch the area to be injected
  2. Insert the needle at a 90 degree angle (45 if small children or thin adult or frail elderly)
  3. Release the pinch
  4. Press plunger to inject
  5. Hold syringe in area for 5-10s to ensure full delivery (prevent leaking out)
  6. Remove syringe
20
Q

[INSULIN ADMINISTRATION]

Patients using ___mm needles do not need to pinch a skinfold for injection

A

4-5mm - NO NEED TO PINCH (no risk of reaching IM layer)
- Unless pt has lesser SC fat, and use arms/thighs (may still need to pinch)

6mm, 8mm, 12.7mm, still need to punch to ensure insulin is injected into the intended absorption site in the SC tissue

21
Q

[INSULIN ADMINISTRATION]

Why should patients rotate insulin injection site?

A

Prevent lipohypertrophy (lump of thickened, hard fatty/adipose tissue)
=> Affects insulin absorption

22
Q

[INSULIN ADMINISTRATION]

What are some factors affecting insulin absorption?

A
  1. Temperature - heat increases absorption
  2. Massage - increase absorption
  3. Exercise - increase absorption
  4. Jet injectors - increase absorption
  5. Lipodystrophy - lipoatrophy incr absorption, lipohypertrophy dcr absorption

Other factors: needle size/gauge, administration technique, insulin preparations, mixtures, concentrations, dose, insulin stability

23
Q

[INSULIN TYPES]

List examples of rapid-acting insulin, and comment on their onset, peak effect, and duration of action

A

Aspart, Lispro, Glulisine

  • Onset: 5-15min (*inject 15min before meal)
  • Peak effect: 1-2h
  • Duration of action: 3-5h

*Target PPG

24
Q

[INSULIN TYPES]

List examples of short-acting insulin, and comment on their onset, peak effect, and duration of action

A

Regular insulin

  • Onset: 30-60min (*inject 30min before meal)
  • Peak effect: 2-4h
  • Duration of action: 6-8h

*Target PPG

25
Q

[INSULIN TYPES]

List examples of intermediate insulin, and comment on their onset, peak effect, and duration of action

A

NPH (neutral protamine hagedorn) => cloudy, crystalline insulin suspension

  • Onset: 1-2h
  • Peak effect: 6-12h
  • Duration of action: 10-16h (*2 injections for 24h coverage)

*Target FPG

26
Q

[INSULIN TYPES]

List examples of long-acting insulin, and comment on their onset, peak effect, and duration of action

A

Detemir [C-14 fatty acid]
- Onset: 0.8-2h
- Peak effect: hill
- Duration of action: 12h for 0.2units/kg, 20-24h for 0.4units/kg (*2 injections for better coverage)

Glargine (U-100) [lower pI, less soluble, formulated at pH4]
- Onset: 1.5h
- Peak effect: peakless
- Duration of action: 24h (*1 injection for 24h coverage)

*Target FPG

27
Q

[INSULIN TYPES]

While rapid and short acting insulin are injected before meals, intermediate and long acting insulins are injected ______ of meal _____________.

A

Regardless of meal, at the same time everyday

28
Q

[INSULIN TYPES]

Name two ultra-short acting insulin
- When are they administered wrt meal timings?

*Both contain 2 additional excipients
*Not yet available in Sg

A
  1. Insulin aspart
    - Vit B3 - incr speed of initial absorption
    - L-arginine - stabilizes formulation
  2. Insulin lispro-aabc
    - Treprostinil - enhance absorption via vasodilation
    - Citrate - enhance vascular permeability

They can be administered at the start of the meal or within 20min after starting the meal

29
Q

[INSULIN TYPES]

Name two ultra-long acting insulins
- State their peak effect, duration of action, and administration timing each day

A
  1. Insulin Degludec
    - Duration of action: 42h
    - Peak: peakless
    - Inject at any time of the day
  2. Insulin Glargine (U-300) / Concentrated glargine
    - Duration of action: 36h
    - Peak: peakless
    - Inject at the same time everyday

*Note that ultra-long acting have lower rates of hypoglycemia than Glargine (U-100)

30
Q

[INSULIN MIXING]

What insulins are compatible to form stable mixes?

A
  • Regular + NPH
  • Rapid-acting + NPH
  • Rapid-acting (aspart) + Degludec - mix just prior to administration
31
Q

[INSULIN MIXING]

What insulin are incompatible, form unstable mixes?

A

Glargine - due to incompatible pH

Detemir

Glulisine and insulins other than NPH

32
Q

[INSULIN MIXING]

Which insulin should be drawn first when self-mixing insulin?

A

Draw the clear insulin first, before the cloudy one

33
Q

[INSULIN PRE-MIXED]

What are some examples of pre-mixed insulin products?

A
  1. Novomix 30 (30% aspart, 70% aspart protamine)
  2. Humalog 75/25 (25% lispro, 75% lispro protamine)
  3. Mixtard 70/30 (70% NPH, 30% regular)
  4. Mixtard 50/50 (50% NPH, 50% regular)

*Given twice a day (due to NPH), either given 15min or 30min before meal (depending on whether rapid-acting or regular)

34
Q

[INSULIN PRE-MIXED]

What are some advantages and disadvantages or pre-mixed insulin products?

A

Advantages:

  • Has both FPG and PPG coverage
  • Beneficial for pt with difficulty measuring and mixing insulin
  • Retain indiv PD profile
  • Less injections
  • Expect multiple peaks

Disadvantages:

  • Challenging to titrate and adjust dose (both basal and prandial coverage adjusted tgt)
  • Would be easier to adjust if pt performs SMBG, and HCP is aware of pt lifestyle
35
Q

[INSULIN COMBI CONSIDERATIONS]

A patient on Metformin is newly started on Insulin. What must be done?

A

Nothing, Metformin can be continued with insulin

36
Q

[INSULIN COMBI CONSIDERATIONS]

A patient on Thiazolinediones is newly started on Insulin. What must be done?

A

TZDs are insulin sensitizer, hence need to reduce dose/discontinue TZD, to prevent risk of hypoglycemia

*Only Pioglitazone is approved for use with insulin

37
Q

[INSULIN COMBI CONSIDERATIONS]

A patient on Sulfonylurea is newly started on Insulin. What must be done?

A

Sulfonylurea secretes insulin, and works mainly on reducing PPG

If BASAL insulin started, discontinue/reduce dose of SU by 50%

If MEALTIME/PRE-MIXED insulin started, discontinue SU

*Also recall that SU effectiveness wears out overtime, hence pt will eventually have to switch to insulin

38
Q

[INSULIN COMBI CONSIDERATIONS]

A patient on SGLT2i is newly started on Insulin. What must be done?

A

Nothing

39
Q

[INSULIN COMBI CONSIDERATIONS]

A patient on DPP-4i is newly started on Insulin. What must be done?

What if pt on DPP-4i is started on SC Liraglutide?

A

DPP-4i can be continued with insulin

Liraglutide is a GLP-1 agonist, due to similar MOA (incr incretin hormones), should discontinue DPP-4i

40
Q

[INSULIN CONVERSION]

Explain general rule of insulin dose conversion

A

Most insulin conversions are 1:1

E.g., Mixtard 30 (regular + NPH) to Novomix 30 (aspart + NPH) can be converted same units

41
Q

[INSULIN CONVERSION]

If pt is at high risk of hypoglycemia, insulin dose should generally be reduced by ____

A

10-20%

42
Q

[INSULIN CONVERSION]

Explain the exceptions in insulin dose conversion

A

Switching from twice daily NPH to once daily glargine/detemir (long-acting) requires a reduction in dose by 20%
E.g., 20 units twice daily NPH = 32 units Glargine

FYI: Glargine U-300 to other alternative basal insulin requires 20% dose reduction

43
Q

[INSULIN ADVERSE EFFECTS]

Define hypoglycemia < ____, and its signs and symptoms

A

Hypoglycemia: BG =< 4.0mmol/L

S&S:
- Shaking, tremor
- Fast heartbeat
- Sweating
- Dizziness
- Anxious
- Hunger
- Impaired (blurry) vision
- Weakness, fatigue
- Headache
- Irritable
- Confusion

44
Q

[INSULIN ADVERSE EFFECTS]

How to manage an episode of hypoglycemia?

A

15-15-15 rule

  • 15g fast acting carbohydrates
  • Wait 15min
  • Check BG, if still <4.0mmol/L, take another 15g fast acting carbohydrates

E.g., 1/2 cup / 4oz fruit juice/soft drink, 1tbsp sugar/honey, 3 cubes of sugar, 2tbsp raisins, 5-6 hard candies, commercially available fast-acting CHO pdts such as glucose tablets/gels

45
Q

[INSULIN ADVERSE EFFECTS]

Apart from hypoglycemia, what are some other adverse effects of insulin?

A
  1. Weight gain
    - More than SUs
    - Remind pt on diet, exercise, weight loss
  2. Lipoatrophy
    - Concavity or pitting of adipose tissue, localised loss of fats, due to animal insulin (immune response)
  3. Lipohypertrophy
    - Bulging adipose tissue due to not rotating injection site
  4. Local allergic rxn (swelling, redness, itching at injection site)
    - Was more common with animal insulin
  5. Systemic allergic rxn
    - RARE
  6. Insulin resistance
    - RARE (immune phenomenon)
46
Q

[INSULIN ADVERSE EFFECTS]

(from Doreen eL)

Insulin in T2DM is a/w increase in __________________

A

Insulin in T2DM is alw increase in all cause mortality and increase in hospitalization for HF

3152 Endocrine (DM + Thyroid) (11 decks)

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