Exam 3 "Diabetes" Flashcards by Natalie Dziadosz

What insulin is used in IV formulation?

regular insulin

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Can you use NPH in IV? Why or why not?

No, NPH is a suspension

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Can you give glargine IV? Why or why not?

No, precipitates at physiologic pH

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Can you give detemir IV? Why or why not?

No, binds to albumin

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Can you give degludec IV? Why or why not?

No, can cause severe hypoglycemia if IV

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What are the ultra-short acting insulins that we need to know?

aspart, lispro, glulisine (novolog, humalog, apidra)

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What are the short acting insulins we need to know?

regular

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What are the intermediate insulins that we need to know?

NPH

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What are the long acting insulins that we need to know?

glargine, detemir

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What are the ultra-long acting insulins that we need to know?

degludec

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Give the routes of administration of insulin action from fastest to slowest.

(Intranasal) > IV > IM > SQ

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Give the sites of injection of insulin action from the fastest to the slowest.

Stomach > buttock > thigh

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Does heat cause insulin to act faster or slower?

FASTER

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Does exercise/massage cause insulin to act faster or slower?

FASTER but may depend on injection site

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Short-acting effect of insulins may be ___ if mixed incorrectly.

lost

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Renal failure ___ insulin clearance, thereby ___ insulin action/

decrease, increase

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Stress __ insulin clearance.

increases

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How long do most insulin formulations stay stable for?

28 days

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How long does levemir stay good for?

42 days

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How long is Regular/NPH good for in what conditions?

stable for 7 days in the refrigerator ALWAYS DRAW UP SHORT-ACTING FIRST

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How long is Aspart, Glulisine, or Lispro with NPH good for?

not long at all, give immediately

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How long is Degludec, Detemir, and Glargine with any other insulin good for?

NOT GOOD AT ALL - NOT COMPATIBLE

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What are the 4 causes of hypoglycemia?

increased insulin dosage
decreased caloric intake
increased muscle utilization
excessive alcohol

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What are the 3 levels of hypoglycemia?

Level 1: Glucose < 70 mg/dL
Level 2: Glucose < 54 mg/dL
Level 3: Severe event with altered mental and/or physical functioning needing another person for recovery

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What are the signs and symptoms are hypoglycemia?

Tremors, tachycardia, diaphoresis, irritability, confusion, hunger, slurred speech, drowsiness, weakness, headache and irritability

What class of blood pressure drugs decrease responsiveness to hypoglycemia due to blocking sympathetic warning symptoms?

Beta-blockers

How do you treat level 1 hypoglycemia?

15-30 gm carbohydrate

How do you treat hypoglycemia level 2 and level 3?

glucagon

What do insulin analogs more closely represent?

physiologic insulin secretion relative to meals

What are the advantages of insulin analogs?

1. decreases in post-prandial hypoglycemia and superior postprandial lowering of BS 2. fewer overall occurences of hypoglycemia, less nocturnal hypoglycemia 3. greater flexibility

What are the disadvantages of insulin analogs?

1. risk of hypoglycemia if no meal within 15 mins of dose 2. will need to combine with longer acting insulin for optimal BS control 3. if mixed with another insulin, give immediately after mixing 4. hyperglycemia/ketosis may occur more rapidly if insulin delivery is interuppted

What are the advantages of long acting and ultra long acting insulins?

1. provides 24+ hour coverage with a constant absorption pattern and no pronounced peak 2. may be beneficial in patients suffering from nocturnal hypoglycemic episodes

What are the disadvantages of long acting and ultra long insulins?

1. Risk of malignancy? - associations seen for increased cancer risk among patients taking glargine insulin vs. other types - other trials have not demonstrated this risk 2. Can NOT be mixed with any other insulin 3. COST

How do you change from daily NPH to glargine/detemir/degludec?

keep dose the same

How do you change from BID NPH to glargine/detemir/degludec?

decrease dose by 20%

What is the average daily dose for Type 1 patients?

0.5-0.6 U/kg/day (actual body weight)

How would you dose a newly diagnosed patient?

Use lower dosages -- honeymoon phase 0.1-0.4 U/kg/day

IDEALLY how many times should patients test in one day to assess insulin dosages?

4 times daily before meals and at bedtime, and occasionally at 3 am

___ of the insulin requirements are usually given as basal insulin while the other ___ is divided among the meals as bolus insulin?

50-70%, 30-50%

How do you treat type 2 patients with insulin?

Usually long-acting or intermediate insulin

What is the ADA type 2 starting dose?

0.1-0.2 units/kg/day OR 10 units/day

What is the AACE type 2 starting dose?

- if A1C < 8%, start 0.1-0.2 units/kg/day | - if A1C > 8%, start 0.2-0.3 units/kg/day

What is the ADA guidelines on adjusting insulin dose?

Increase the dose by 2 units every 3 days to reach FBS goal

What is the AACE guidelines for adjusting insulin dose?

titrate every 2 to 3 days based on blood glucose level - >180 mg/dL: add 20% of TDD - 140-180 mg/dL: add 10% of TDD - 110-139 mg/dL: decrease by 10-20% of TDD - <70 mg/dL: decrease by 10-20% of TDD - <40 mg/dL: decrease by 20-40% of TDD

Basal insulin is provided by either 1-2 doses of ___, ___ or ___ or 1-2 doses of ___

glargine, detemir, degludec. NPH

Eventually many type 2 patients will need what similar to a type 1 patient?

bolus insulin

What is the average insulin dose for patients with T2DM?

>1 U/kg

For all diabetic patients on insulin, increase/decrease dose every ___ days until goals are met

2-4

If A1C > 10%, 70% of the problem involves what?

FBS

If A1C < 7.5%, 70% of the problem involves what?

PPG

What is the rule of 500?

Individualizing carbohydrate to insulin ratios

How do you use the rule of 500?

take 500/total daily insulin dose (basal and bolus) and this will equal # of gm of CHO for 1 unit of insulin

1 unit of short acting insulin will decrease BS by how much?

20 mg/dL

Are type 1s or type 2s more sensitive to insulin changes?

type 1s

If the patient is having low BG readings, you can decrease insulin dose by how much?

10%, 2-4 units

What is the somogyi effect?

nocturnal hypoglycemia with rebound hyperglycemia

How would you handle the somogyi effect?

add a bedtime snack if BS at 3 AM is low and have S/Sx

If patient gets sick would they have to check BS more or less?

When would you consider changing a patient to concentrated insulins?

if patient is injecting large doses of insulin

What is the insulin naive Afrezza dose?

start 4 units at each meal

What is the insulin experience Afrezza dose?

if on x-y units/meal, start on y units per meal

Explain the MOA of metformin.

decreases hepatic production of glucose, increased instestinal glucose utilization and decreased glucose uptake into circulation

What are the ADA recommendations for metformin?

use for ALL T2DM, if tolerated and not contraindicated

What are some drawbacks of metformin?

- may cause lactic acidosis (rare)

What are some cautions and contraindications of metformin?

- renal dysfunction (use eGFR) - contraindicated in HF patients - alcoholics - avoid in pts at risk for lactic acidosis (post MI, COPD, shock)

What are the side effects of metformin?

- GI effects: diarrhea, flatulence, n/v | - Vitamin B12 malabsorption and/or deficiency

What is the initial metformin dose?

500 mg - 850 mg PO daily with meals

What is the maximum metformin dose?

2 g per day!

If eGFR is < 30 would you start metformin?

NO, d/c if currently taking

If eGFR < 45 but >= 30 could you start metformin?

Not recommended to start, decrease by 1/2 if already taking

If eGFR is >= 45 can you start metformin?

Safe to start therapy and continue therapy

What is the MOA of SGLT2s?

Inhibit SGLT2 in kidneys, leads to increased glucose excretion in urine

What are the 5 FDA warnings for SGLT2s?

DKA, AKI (canagliflozin and dapagliflozin), bone fractures (canagliflozin), increased risk of leg and foot amputations (canagliflozin), serious genital infections

What is the usual dose for canagliflozin?

100 mg PO daily

If eGFR > 60 what's the max daily dose of canagliflozin?

300mg/day

If eGFR is 45-60 what's the max daily dose of canagliflozin?

100mg/day IF no albuminuria

If eGFR > 45 what's the usual dose for dapagliflozin? Is there a max?

usual: 5 mg PO daily max: 10 mg PO daily

If eGFR > 45 what's the usual dose of empagliflozin? Is there a max?

usual: 10 mg PO daily max: 25 mg PO daily

If eGFR > 60 what's the usual dose of ertugliflozin? Is there a max?

usual: 5 mg PO daily max: 15 mg PO daily