EXAM 4 Bolus Insulin Dr. Hess

Question 1

Which Insulin is considered Ultra-rapid and what makes it faster?

Answer 1

-Fiasp
F: faster
i: Insulin
Asp: Aspart

-Lispro - aabc (Lyumjev):

-minutes faster
-the faster onset is due to the excipients in the formulation

Question 2

What makes Lispro - aabc (Lyumjev) ultra-rapid?

Answer 2

Treprostinil (prostaglandin analog):
-increases blood flow to the area of injection
-increases the permeability of the monomers to cross into the blood

Question 3

What makes Aspart Fiasp ultra-rapid?

Answer 3

Niacinamide (Vitamin B3)
-localized vasodilation on the injection site, more blood flow -> better absorption of injected insulin)

Question 4

Which of the insulin has the option to be administered 20 mins after eating?

FDA indication

Answer 4

Ultra-rapid:
-Lispro - aabc (Lyumjev)
-Aspart Fiasp

Rapid-acting:
-Glulisine Apidra

Question 5

When is it too late after a meal to administer Insulin?

Answer 5

more than 1 hour from the meal

-risk for hypoglycemia

Question 6

When do T2DM patients be treated with bolus insulin?

Answer 6

after they tried oral antidiabetic drugs and basal insulin and their A1c is still not at goal

Question 7

How is bolus insulin dosed?

Answer 7

start with:
empirically 4U or 10% of basal insulin with the largest meal: only 1 bolus

-if A1c gets <8% reduce the basal insulin by 4U or 10%
-> to reduce risk of nocturnal hypoglycemia

Question 8

How should the dose of bolus insulin be increased if needed?

Answer 8

increase by 1-2U or 10-15% twice weekly
-if hypoglycemia occurs investigate the cause or reduce it by 10-20%

Question 9

What is the sliding scale approach?

Answer 9

used to correct hyperglycemia within 4 hours after injection

-not used to cover glucose meals after meals

Question 10

How often should a correction by sliding scale be performed?

Answer 10

not more than every 4 hours

Question 11

Disadvantages of the sliding scale

Answer 11

-it is reactive, not proactive (sometimes kind of proactive when the patient’s glucose is high before a meal and given before the meal to account for the high glucose)

-no improved clinical outcomes
-risk of hypoglycemia

Question 12

When would a patient need a high dose of sliding scale insulin?

Answer 12

-Overweight
-infection
-when on steroids (increases glucose)

-> use lower dose when underweight or elderly

Question 13

Which units are available for regular Insulin?

Answer 13

U-100

Question 14

When should regular Insulin be discarded?

Answer 14

Humulin R:
-Vial: 40 days

Novolin R:
-Vial: 42 days
-Pen: 28 days

Question 15

Which units are available for Insulin Lispro?

Answer 15

U-100
U-200 (pen only)

discard the pen after 28 days (room temperature)

Question 16

Which units are available for Insulin Aspart (Novolog)?

Answer 16

U-100

discard the pen after 28 days

Question 17

Which units are available for Insulin Glulisine?

Answer 17

U-100

discard the pen after 28 days

Question 18

When should a T2DM patient on bolus insulin measure their blood glucose?

Answer 18

post-prandial - 2h after the mea!!
should be <180 mg/dl

Question 19

Can bolus insulin be given IV?

Answer 19

Yes, usually they use regular insulin inpatient (rapid-acting is not faster, since it is IV and it goes into the blood immediately)

-basal insulin is not used for IV

Question 20

If a patient used a long-acting and short-acting insulin and was started on a pump, what should be changed?

Answer 20

discontinue the long-acting insulin

Question 21

How are bolus insulin converted within each other?

Answer 21

1:1 dosing conversion (except for inhaled insulin)
-in case the patients need to change their bolus insulin (insurance issues fe)

-they all work equally

Question 22

How fast do insulin inhalers work?

Answer 22

Ultra-rapid

(ex: Afreeza)

Question 23

How often do insulin inhalers need to be replaced?

Answer 23

every 15 days
-so for a month’s supply they need 2 inhalers

Question 24

What is the conversion from insulin inhalers to injectables?

Answer 24

1 injection = 1.5 inhaler

Question 25

Side effects of inhaled insulin

Answer 25

-Hypoglycemia
-Cough
-Throat pain
-acute bronchospasm in patients with chronic lung disease (BBW)

-decline in pulmonary function (FEV1 goes down)
-> needs spirometry test before use and 6 months after !!!
-may cause lung cancer

Question 26

Which patient population is contraindicated for insulin inhaler use?

Answer 26

-chronic lung disease: COPD, asthma

-not in patients who have smoked in the past 6 months

Question 27

Basal insulin + Bolus insulin = …

Answer 27

MDI (multiple dose insulin)

Question 28

What is the TDD?

Answer 28

total daily dose of insulin = consists of 50% basal and 50% bolus insulin

-0.3U/kg/day
-0.3U/kg/day
->divided across the meals

Question 29

How to calculate the bolus dose based on the carb intake with rapid-acting or ultra-rapid insulin?

Answer 29

ICR: 500 rule

500/TDD = g of carbs that 1U will cover

Question 30

How to calculate the bolus dose based on the carb intake with short-acting insulin?

Answer 30

ICR: 450 rule

450/TDD

Question 31

Which factor is used for hyperglycemia correction in T1DM patients?

Answer 31

Insulin sensitivity factor ISF:
how much 1U of insulin lowers their blood sugar

Question 32

ISF for different insulins

Answer 32

ultra-rapid and rapid-acting: 1800/TDD

short-acting: 1500/TDD

Question 33

Calculation

Answer 33

1. calculate their TDD: 0.6U/kg/day
2. divide TDD into basal and bolus (50/50)
3. ICR = 500/TDD (for rapid-acting)
   ex: 500/40 = 13g of carbs that 1U of insulin will cover
4. ISF = 1800/TDD
   ex: 1800/40 = 45 mg/dl reduction with 1U of insulin

If the patient is eating 60g of carbs for a meal, how many units of insulin does the patient need?

60/13 = 4.6 or 5 units of bolus insulin for the meal (PENS can give 4.6, round up for syringes)

If a patient’s fasting blood glucose is 214 mg/dl, what would be the unit of insulin to correct it? (goal: 120 mg/dl)

214 - 120 = 94 mg/dl
94/45 = 2 units of insulin

5 + 2 = 7 Units (for the meal and the correction)

Question 34

Which type of insulin is used in insulin pumps?

Answer 34

bolus insulin (no basal insulin needed!)

it continuously pumps bolus insulin at specific rate that resembles the basal insulin in addition to the calculated bolus dose for meals