Exam 3: Diabetes pt 2: Insulin Tx Flashcards

Question

Complications of insulin therapy: Hypoglycemia - causes

Answer 1

Increased insulin dosage - overshot, be conservative initially (sometimes patients do it themselves) Decreased caloric intake - patient goes on a diet and didn't tell us Increased muscle utilization - increased exercise Excessive alcohol - can cause hypoglycemia

Answer 2

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

Answer 3

Tremors, diaphoresis, anxiety, dizziness, hunger, tachycardia, blurred vision, weakness/drowsiness, headache, irritability, confusion, slurred speech Beta blockers can decrease responsiveness to hypoglycemia due to blocking sympathetic warning symptoms **Some signs and symptoms will be mased by B blockers** **Does not mean we should not use B blockers in diabetic patient**

Answer 4

**First thing to do - check blood sugar** Start with 15 gm of fast-acting carb (unless BS < 50mg/dL then use 30 gm)-> level 2 Wait 15 minutes, check BS again; if BS is not >70 mg/dL, repeat with another 15 gm Examples of what to eat: *4-5 oz OJ, 4-6 oz cola (half a can), 5-6 lifesavers, 4tsp sugar(white or brown), 1 T honey, *Glucose tabs 4-5 gm CHO/tabs) or gel Follow with complex carb (30 gram) Glucagon for level 2 or 3 patients: -- 3 mg intranasal Baqsimi -- 1 mg SQ, IM, or IV glucagon (Gvoke Hypopen, GlucaGen®) -- 0.6 mg SQ dasiglucagon (Zegalogue®)

Answer 5

Decreases post-prandial and superior **postprandial lowering of BS** Fewer overall occurrences of hypoglycemia, less nocturnal hypoglycemia Greater flexibility

Answer 6

Risk of hypoglycemia if no meal within 15 minutes of dose - **IF YOU DO NOT EAT FAST ENOUGH** Will need to combine w/a longer acting insulin for optimal BS control If mixed with another insulin, give immediately after mixing Hyperglycemia/ketosis may occur more rapidly if insulin delivery is interrupted

Answer 7

Provide s24+ hour coverage with a constant absorption pattern and no pronounced peak May be beneficial in patients suffering from **nocturnal hypoglycemic episodes**

Answer 8

Risk of malignancy Associations seen for an increased cancer risk (breast cancer and possibly colon and pancreatic cancer) among patients taking glargine insulin vs. other types Other trials have not demonstrated this risk Can NOT be mixed with any other insulin

Answer 9

i.T2DM w/ either CVD or risk factors for CVD ii.Cardiovascular risk 1.CV death: 3.6% vs. 3.7%, degludec & glargine, respectively (p = 0.71) 2.Nonfatal MI: 3.8% vs. 4.4% (p = 0.15) 3.Stroke: 1.9% vs. 2.1% (p = 0.50) iii.Secondary outcome of hypoglycemia 1.Severe hypoglycemia: 4.9% degludec vs. 6.6% glargine (p<0.001) *If patient can afford to switch to degludec, want to suggest – less risk of hypoglycemia

Answer 10

If patients change from **daily** NPH to glargine/degludec, keep dose the same If patients change from **BID** NPH to glargine/degludec, **Lower dose by 20%** -**32 U/day for twice daily**

Answer 11

If patients change from **BID NPH to U-300 glargine, lower dose by 20%** 1:1 conversion between daily glargine to daily glargine (Toujeo) but patients may need an increased dose of the Toujeo or Toujeo Max 1:1 conversion btw basal insulin and U-200 insulin degludec 1:1 conversion btw lispro U-100 to U-200 U-100 basal-bolus regimen to U-500 regimen, may require 20% dosage reduction depending on BS readings/A1C

Answer 12

If A1C is <8%: -Lower TDD by 10-20% If A1C is 8-10% -Keep same TDD If A1C is >10% -Increase TTD by 10-20%

Answer 13

Change to BID or TID dosing **BID: 60% before breakfast and 40% before dinner** **TID: 40% before breakfast, 30% before lunch, 30% before dinner (0r 45-35-20)**

Answer 14

Change to TID dosing May consider 10% dose at bedtime for 4th injection

Answer 15

30% breakfast, 30% lunch 30% dinner - 10% bedtime

Answer 16

**Average total daily dose is 0.4-1 units/kg/day (actual body weight)** -Higher amounts during puberty, menses, and medical illness

Answer 17

**Honeymoon phase 0.2-0.6 units/kg/day** Pancreas suddenly remembers it can make insulin again - does not last The younger they are the more pronounced it is

Answer 18

4 times daily (before meals and bedtime) Occasionally at 3AM to assess insulin dosages

Answer 19

Basal is provided by either 1-2 doses of **Glargine** or **Degludec** or 1-2+ doses of **NPH** Basal will prevent **DKA** 50-70% of the insulin requirements are usually given as basal insulin while the other 30-50% is divided among the meals as bolus insulin (VARIABLE)

Answer 20

Carbohydrate content of meals; a good starting point is 1 unit for every 15 grams of CHO (1:15 insulin: CHO ratio)

Answer 21

Split daily dosing: AM: 40% NPH + 15% short-acting PM: 30% NPH + 15% short-acting

Answer 22

Provide increased flexibility in dosing and may improve quality of life. Initiation of pump therapy depends on the patient's preference lifestyle and self-care capabilities -Rapid acting insulin used to cover both basal and prandial insulin needs -Basal rate throughout the day -Use bolus dose calculator to determine bolus doses based on glucose levels, carb intake, and insulin on board

Answer 23

Usually LA (glargine or degludec) or intermediate (NPH) is started in combination with non-insulin agents -Bedtime insulin helps suppress hepatic glucose production at night -Eventually some orals (esp sulfonylurea) may be D/C if bolus is added

Answer 24

ADA: **0.1-0.2 units/kg/day OR 10 unirs/day** AACE: If A1C <8%, start 0.1-0.2 units/kg/day If A1C >8%, start 0.2-0.3 units/kg/day 10-15 units

Answer 25

ADA: **increase the dose by 2 units every 3 days to reach FBS goal** AACE: Titrate every 2-3 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: add 1 unit <70 mg/dL: decrease by 10-20% of TDD <40 mg/dL: decrease by 20-40% of TDD

Answer 26

Bolus, **especially for patients on >0.5 units/kg/day** **Usually can start with 10% of basal dose or 4 units of ultra-short/short acting insulin w/largest meal** **Start with biggest meal** Adjust dose by 10-15% every 3-4 days **Can pull someone from the basal dose** if needed to prevent hypoglycemia

Answer 27

For ALL diabetic patients on insulin: Increase/decrease dose every 2-4 days until goals are met Target FBS initially, then PPG -With A1C > 10%, 70% of the problem involves FBS -With A1C <7.5%, 70% of the problem involves PPG Once the basic insulin dose is established and the patient understands how to adjust insulin, the patient can be taught how to adjust their own insulin dose

Answer 28

Amount of short acting insulin needed to cover a patient's meal (or snack) **Average may be 1 unit: 10-15 gm CHO for adults, and 1 unit: 20-30 gm for school-aged children** **NOT ONE SIZE FITS ALL**

Answer 29

500 divided by total daily insulin dose (basal and bolus) this will equal the amount of grams of CHO for 1 unit of insulin EX: 500/40 = 12.5 This means, **1 unit of insulin will be needed for every 12.5 gm CHO -> round** Round up to be conservative

Answer 30

For patients taking **Short acting insulin** 1800/TTD of insul = # of mg/dL blood glucose will drop for every 1 unit of insulin

Answer 31

**Nocturnal hypoglycemia with Rebound hyperglycemia** -Check BS at 3 am and ask about signs and symptoms -Add a bedtime snack -If applicable, move NPH from dinner to bedtime or decrease LA dose at HS

Answer 32

Let friend/relative know that you are sick so they may periodically check in -Continue insulin even if food intake is decrease -Stress of illness often increases insulin requirements -Maintain fluid intake (drink 12 8 oz glasses/day esp if fever present) Test BG every 4 hours at minimum Test urine ketones with each urination -Supplemental doses of insulin **1-2 units for every 30-50 mg/dL over 120mg/dL**

Answer 33

Urine ketones are present and BG is > 250 mg/dL -breathing becomes difficult -fruity odor on breath -excessive thirst and frequent urination -mental status changes -vomiting, repeatedly