Glycaemic Control Flashcards
List the rapid acting analogues
Humalog
Apidra
Novorapid
List the short acting analogues
Acts Hastily
Actrapid
Humulin S (short)
List Intermediate analogues
Intermediate Hyperglycaemic Intervention
Insulatard
Humulin I
Insuman basal
Long acting analogues
Long Long Time
Lantus
Levemir
Tresiba
Difference between pre-mixed regular and analogue?
Regular: Comb OR M3
analogue: Mix
How often do you review insulin for adjustment?
Every 48 hours
DONT OMIT IT
For basal-bolus, how do you manage…
Recurrent hyperglycaemia
Unexplained hypoglycaemia
Increase/Reduce dose prior to episode by 2-4 units (eg morning reading, alter nightime) for hyper/hypo respectively
How do you alter the following regimens in recurrent hyperglycaemia/hypoglycaemia
Basal bolus
Twice daily mixed analogues
Long-acting analogues +/- oral hypoglycaemics
General:
Increase/reduce the dose prior to the reading* time by 2-4 units (breakfast reading –> alter nightime dose)*
Long acting:
Fasting hyperglycaemia: Increase 2-4 units
Non-fasting hyperglycaemia: Consider short acting at mealtimes
In T2DM, what is the typical first line?
Metformin
What should be checked prior to metformin prescription?
Baseline eGFR
<45: Reduce dose
<30: Contraindicated
What are the common side effects of metformin and how are they managed?
GI upset: trial MR form
Lactic acidosis: stop and seek advice
What are the alternatives to metformin?
DPP-4Is (gliptins)
Sulfonylureas (gliciazide)
SGLT-2Is (flozins)
Pioglitazone (can be problematic tho)
What is step up treatment following first line
2nd line: + another agent
3rd line: + 3rd agent OR commence insulin
What is a basal-bolus regimen
Long acting insulin + Rapid/Short acting insulin
When is VRIII considered?
For basal-bolus, how do you manage…
Recurrent hyperglycaemia
Unexplained hypoglycaemia
Increase/Reduce dose prior to episode by 2-4 units (eg morning reading, alter nightime) for hyper/hypo respectively
When is VRIII considered?
Hyperglycaemic emergencies
Surgical procedures/diabetic patients
Major vascular events (eg MI): use DIGAMI
Post-CVA
Refractory/fluctuating hyperglycaemia
How do you know what dose of VRIII to give?
Measure glucose
Check against local protocol
How often does a new VRIII need to be made?
Every 24 hours
What electrolyte is particularly important in VRIII administration?
Potassium
Insulin drives potassium IN to cells
How do you switch a T2DM patient from VRIII to oral?
Commence oral at next meal
Stop VRIII 30 mins after admin and patient finished eating
How do you recommence SC GLP-1s after VRIII
Same as oral meds (Give at meal, stop VRIII after 30 mins + patient has eaten)
What are the particular considerations for the following when switching from VRIII:
Metformin
Sulfonylureas
Thiazolinediones
DPPP4s
SGLT-2I
Metformin: eGFR >45 + no sepsis, liver/cardiac failure
Sulfonylureas: reduced dose if less oral intake
Thiazolinediones: As per SU + check HF
DPP4s + SGLT-2I: Senior advice
When to restart SC insulin?
Eating and drinking without N+V
Give background before stopping VRIII
Seek diabetic input if poor optimisation
Outline VRIII to basal bolus switch
Fast-acting: inject at meal time, discontinue VRIII 30-60 mins later
If long acting stopped in error: continue VRIII until background given
Converting basal to SC: half dose in morning, overlap fasting and VRIII at next mealtime, continue insulin regmien as normal
VRIII to twice daily
Re-commence SC before breakfast or evening meal ONLY
Overlap the switch over 30-60 mins
VRIII to SC infusion
Basal rate continued: Keep VRIII for 30 min mealtime overlap
Stopped: start basal rate once eating and drinking. Stop VRIII after mealtime bolus.
Dont recommence CSII at what time?
BEDTIME
How can you calculate the SC insulin dose for a naive patient
Weight based: kgs x 0.5 (0.3 if frail, 4-5CKD, HPB failure)
VRIII stable phase: Avg hrly dose over last 6 hours x 20
What are the uses of the…
GIK regimen
DIGAMI
Reduce perioperative hypokalaemia as part of insulin regime
Giving insulin-glucose infusion + SC insulin to MI patients to improve survival
