Exam 3: Diabetes pt 2: Insulin Tx Flashcards
Solutions approved for IV use
Aspart, glulisine, lispro, and regular insulin
Regular insulin is the insulin used as the IV formulation
NPH as a suspension
Cloudy
-Top is clear - bottom is a white section
Shake it and it looks like milk
NOT AN IV SOLUTION
Clear solutions that you cannot give as IV
Glargine
Precipitates at high physiological pH
Makes a snowflake under the skin
Degludec
Can cause severe hypoglycemia
Ultra Short acting insulin
Aspart (Novolog, Novolog Flexpen, Fiasp)
Lispro (humalog, Humalog KwikPen U-100 and U-200)
Glulisine (Apidra, Apidra solostar)
Short acting Insulin
Regular (Humulin R, Humulin N - both U-100)
Intermediate acting Insulin
NPH (Humulin N, Novolin N)
Long-acting insulns
Glargine (Lantus, Lantus Solostar, Basaglar, Rezvoglar, Semglee®)
[all U-100]
Ultra long acting insulin
Degludec (Tresiba®U-100)
Important to remember with NPH
Delayed peak
-Take dose at breakfast - kicks in around lunch
-Helpful if someone cannot take a dose at lunch
Insulins compatibility
Shorts and intermediate - compatible
Long are not compatible with anything
Long acting/ultra long acting - no peak effect, cannot respond to meal time
Insulin premixes
NPH/Regular mixture 70/30 (Humulin 70/30, Humulin 70/30 Pen,
Novolin 70/30)
75% neutral protamine lispro (intermediate activity like NPH) / 25% lispro (Humalog Mix 75/25, Humalog Mix 75/25 KwikPen)
50% neutral protamine lispro / 50% lispro (Humalog Mix 50/50, Humalog Mix 50/50 KwikPen)
70% aspart protamine suspension / 30% aspart (Novolog Mix 70/30 Novolog Mix 70/30 FlexPen)
Degludec U-100 / aspart U-100 (Ryzodeg 70/30)
Route of admin
IV > IM > SubQ
Intranasal might be fastest - we do not usually use it
Site of injection for insulins
Stomach is the fastest
Butt and Thigh are the slowest
-Keep sites of injection consistent
-Might need to rotate injection sites
Preparation/mixtures
Short-acting effect of insulins may be lost if mixed incorrectly
U-500 regular insulin has a delayed onset, peak, and a long duration of action when compared to U-100 insulin, but its smaller volume often allows for overall increased absorption
If mixing insulins, always use short acting first
Insulin dosing property
Lower dose absorbed more rapidly
-When patient is using 100, then switch to 5000, 500 is going to be absorbed better (500 is more of a dose but in a smaller volume)
Patient compliance and insulin
Correct dose, timing, relation to meals, etc.
TIMING - purpose of insulin is to cover your meal glucose surge - smack sugar down and keeps it level
Patient errors and insulin
Dialing/drawing up insulin
Irregular diet and exercise
Will affect absorption and patient response
If they fast, can mess up insulin
Renal function
Renal failure decreases insulin clearance, thereby increasing insulin action
Greater risk of hypoglycemia
15-20% of insulin metabolism occurs in the kidneys
Stress
Increased insulin clearance
Stress - blood sugars increased; making more hormones: Also have less insulin
Drug interactions
Does not necessarily mean we will remove the medications - important to be aware
Insulin vials stable at room temp for
28 days (no exposure to extreme temps) - **90 day supply - keep in fridge
Insulin pens are variable
Refrigerate vials/pens nor in use and DO NOT FREEZE
discard opened insulin vials/pens after 28 days
Prefill insulin stability
Insulin your prefill in syringes is stable for 28 days with refrigeration as long as not mixed
Insulin you prefill in syringes is stable for 10-28 days at room temperature - highly variable
Mixed insulin stability
Regular/NPH: 7 days in fridge; DRAW UP SHORT FIRST
Aspart, Glulisine, or Lispro with NPH: GIVE IMMEDIATELY - cannot stay a long time
Degludec and Glargine with any other insulin: Never mix with other insulin
Complications of insulin therapy: Hypoglycemia - causes
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
Hypoglycemia classification
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
Signs/symptoms of hypoglycemia
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
Hypoglycemia treatment: Rule of 15’s
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®)
Insulin analogs; ultra-short: Glulisine, Lispro or Aspart Advantages
Decreases post-prandial and superior postprandial lowering of BS
Fewer overall occurrences of hypoglycemia, less nocturnal hypoglycemia
Greater flexibility
Insulin analogs; ultra-short: Glulisine, Lispro or Aspart Disadvantages
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
Long-Acting/Ultra Long-Acting Insulins: Glargine or degludec insulin: Advantages:
Provide s24+ hour coverage with a constant absorption pattern and no pronounced peak
May be beneficial in patients suffering from nocturnal hypoglycemic episodes
Long-Acting/Ultra Long-Acting Insulins: Glargine or degludec insulin: Disadvantages
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
Glargine vs Degludec
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
Changing between U-100 therapies
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
Changing U-100 to a concentrated insulin therapy
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
Assessing A1C (8%, 8-10%, >10%)
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%
If TDD 150-300 units
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)
IF TDD 300-600
Change to TID dosing
May consider 10% dose at bedtime for 4th injection
If TDD > 600 units
30% breakfast, 30% lunch 30% dinner - 10% bedtime
Insulin dosing in T1DM
Average total daily dose is 0.4-1 units/kg/day (actual body weight)
-Higher amounts during puberty, menses, and medical illness
Why do we use lower doses in newly diagnosed patients
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
How often should T1DM patients check blood sugars
4 times daily (before meals and bedtime)
Occasionally at 3AM to assess insulin dosages
Basal Bolus dosing T1DM
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)
T1DM: Prandial doses can be adjusted based on
Carbohydrate content of meals; a good starting point is 1 unit for every 15 grams of CHO (1:15 insulin: CHO ratio)
Two daily injections of a mix of intermediate insulin (NPH) and short-acting (less common now with ultra-short acting insulins) (only two shots)
Split daily dosing:
AM: 40% NPH + 15% short-acting
PM: 30% NPH + 15% short-acting
Insulin pumps Type 1 diabetes
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
T2DM patients insulin
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
Starting basal insulin dose for T2Dm
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
Adjusting insulin dose in T2Dm
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
For type 2 patients, consider addition of
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
General dosing principles for insulin
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
Insulin to carb ratio
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
Rule of 500
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
Correction factor: Rule of 1800
For patients taking Short acting insulin
1800/TTD of insul = # of mg/dL blood glucose will drop for every 1 unit of insulin
What number do we use for patients on Regular insulin
1500
Somogyi effect
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
Special situations: Sick day management
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
Seek medical attention if:
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
