Endocrine - Online MedEd - Insulin management

Question 1

Always basal insulin… as you eat 3 meals… what happens to glucose

Answer 1

Glucose levels rise with meals
Will have post-prandial insulin spikes!
Causes glucose to be controlled

Question 2

Type 2 diabetes pancreas burns out… called

Answer 2

insulin insensitivity

Question 3

If to replace insulin… the same physiology would occur

what is the best strategy?

Answer 3

Basal bolus

• Basal - long acting insulin given at night
• Bolus - a rapid acting insulin given in the day with meals

Question 4

What are the different insulin types? Will be using trade names and generic names

Answer 4

1) Long acting insulins: lantus, lever (L’s)
2) Rapid acting (bolus): novo, huma - novolog and humalog
3) Mixed (70-30, 50-50), these are a mix of long acting and short acting insulin: novolin, humalin
4) NPH

Question 5

Long-acting insulins

Answer 5

Basal coverage

Lantemir, lantus

Question 6

Rapid-acting insulins

Answer 6

Novolog, humalog

Question 7

Mixed insulins

Answer 7

Novolin, humalin - mix of NPH and regular insulin
NPH - long acting, BID
Regular insulin - rapid, really long half life

Question 8

When to pick NPH and regular

Answer 8

Cheap

Question 9

Pick novolin and humalin mixes?

Answer 9

Easy to use

But not great

Question 10

Best regimen of insulin is basal-bolus

Answer 10

Lantus/lentemir once a day and novolog/humalog with meals

Question 11

So when you have decided to go with insulin what is the first drug/dose? This is in the clinic setting.

Answer 11

Long-acting insulin 0.1 unit/kg –> start once daily ingestion –> check sugar before breakfast –> titrate based on fasting glucose in morning –> continue to increase basal until AM sugar is normal
Up to 15 units
*Eventually will get to a basal bolus strategy

Question 12

Let’s say you have started insulin and a long-acting insulin titration… what to do next?

Answer 12

Measure A1C goal

Not at goal… start a second insulin at the biggest meal time

Question 13

What does the basal-bolus regimen look like?

Answer 13

Breakfast - bolus –> steps are: check glucose, give insulin, then eat (If do not eat, then don’t give insulin –> will cause hypoglycaemia)
Lunch - bolus - same steps repeat for each meal time
Dinner - bolus
Bedtime - long-acting
*Glucose at current meal time is dependent on how much glucose eaten in previous meal and how much insulin given in previous meal (so always remember PREVIOUS!)
Ex. AM check titrates the long-acting bedtime glucose/insulin
If glucose at lunch is high, adjust insulin at breakfast
*4 glucose checks; use 2 types of insulins

Question 14

Other options of insulin regimens are:

Answer 14

Easy way:
Give a combination of long and short BID
- BID mixed
- Ideal for patients who are unwilling to check sugars frequently
- But glucose control not as great! Not as physiologic

Question 15

Sliding scale insulin in hospital is considered the wrong way

Answer 15

Check sugar and give insulin based on sugar right now!
But this is wrong… but sugar now is based on insulin previously!
What happens is that you get swings of up and down… you are being reactive not proactive

Question 16

Hospital want to do what regimen…

Answer 16

Basal bolus + supplemental sliding scale

-Supplemental: at am, at bedtime, and q4h if npo

Question 17

In the hospital… how would you pick the insulin…

Answer 17

Basal bolus regimen –> Total daily insulin: Either 0.5 units/kg or 0.3 units/kg
Total daily insulin will be divided up:
50% into basal, 50% into bolus, bolus is divided into 3 meals

Mixed bolus regimen –> Total daily insulin will be 2/3 AM and 1/3 PM

So at the end of the day* tally up how much extra insulin needed on insulin sliding scale
Then add it to the total daily insulin the same ratio –> 50/50 for example**That way you increase insulin control until glucose is under control

Question 18

Types of insulin management regimens

Answer 18

1) Basal bolus - best
2) Mixed - okay
3) Sliding scale - on its own - do not use
4) Okay to use sliding scale in addition to other regimens in the hospital. Allows you to identify how much insulin they need and add it to current regimen