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PR3152 > IC13 Diabetes II > Flashcards

IC13 Diabetes II Flashcards

1
Q

Insulin reduce HbA1c by up to _____%.

A

2.5

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2
Q

Who can insulin be prescribed to?

A

All DM patients including pregnant patient

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3
Q

How does insulin works?

A

Regulate

  1. carbohydrates - increasing uptake of glucose in muscles and adipose tissues and inhibit hepatic glucose output
  2. fats - increase fat storage via lipogenesis and inhibit fts mobilization for energy in adipose tissues via lipolysis and free fatty acid oxidation
  3. protein - increase protein synthesis and inhibit proteolysis in muscle tissue
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4
Q

What is the rate limiting step for SQ injection?

A

Movement from fats to tissues

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5
Q

How is exogenous and endogenous insulin metabolised?

A

Exogenous: Kidney
Endogenous: Liver

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6
Q

When should insulin be started?

A

If patient is symptomatic (can consider in patients with HbA1c > 9%)

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7
Q

For asymptomatic patients, when and what treatment should be given?

A

HbA1c < 9%: oral glucose loweing agent

HbA1c > 9%: 2 or 3 oral glucose lowering agent OR insulin

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8
Q

How is insulin stored?

A

Unopened: refrigerate at 2 to 8 degree celcius till expiry OR 28 days at room temperature

Opened: 28 days

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9
Q

Insulin should be injected subcutaneously at ____ for adults and ____ for children or thin adults.

A

90 degree
45 degree

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10
Q

Why is frequent rotation around abodmen needed when injecting insulin?

A

To prevent lipohypertrophy

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11
Q

What are some factors affecting insulin absoprtion?

A
  1. Temperature (hot increase, cold decrease)
  2. massage (increase)
  3. exercise (increase)
  4. jet injectors (increase due to pressure)
  5. Lipodystrophy (Lipoatrophy increase, Lipohypertrophy decrease)
  6. Others: Needle size/ guage, adminstration techinques, insulin preparation, mixtures, concentration, dose, stability
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12
Q

Which insulin targets post-prandial glucose?

A

Rapid (aspart, lispro, glusiline) and short acting (actrapid)

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13
Q

Which insulin targets fasting prandial glucose?

A

Intermediate (NPH) and long acting (detemir, glargine)

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14
Q

What are the two classses of insulin?

A

Bolus and basal

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15
Q

List the time of onset, peak effect and duration of rapid insulin.

A

Time of onset: 5 to 15 mins
Peak Effect: 1 to 2 hours
Duration: 3 to 5 hours

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16
Q

List the time of onset, peak effect and duration of short acting insulin.

A

Time of onset: 30 to 60 mins
Peak Effect: 2 to 4 hours
Duration: 6 to 8 hours

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17
Q

List the time of onset, peak effect and duration of intermediate acting insulin.

A

Time of onset: 1 to 2 hours
Peak Effect: 6 to 12 hours
Duration: 10 to 16 hours

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18
Q

List the time of onset, peak effect and duration of long acting insulin (detemir, galrgine).

A

Time of onset: 0.8 to 2 hours (detemir); 1.5H (galrgine)
Peak Effect: hill (detemir) and peakless (glargine)
Duration: 20 to 24 hours

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19
Q

What are some stable mixture of insulin?

A
  1. Regualr + NPH
  2. Rapid acting + NPH
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20
Q

What are some unstable mixture of insulin?

A
  1. Glargine + other insulin (pH cannot)
  2. Glulisine and insulins other than NPH
  3. Detemir and other insulin
21
Q

Why are pre-mixed insulin useful?

A
  1. Cover meals/snacks and basal
  2. Good for PT with difficulty measuring and self-mixing insulin
    3.Retains individual PD profiles
  3. Less injections
  4. Multiple peaks
22
Q

What are some considerations for oral glucose lowering agent when patient is prescribed with insulin/ GLP-1?

A
  1. Metformin and SGLT2i can be continued.
  2. If on DPP4i, discontiune GLP-1 agonist
  3. If on TZDs, discontiune or reduce dose
  4. If no sulfonylurea, discontinue or reduce dose by 50% when basal insulin is started or discontiune if premixed or meal time insulin is started
23
Q

How is dose for various insulin converted?

A

Based on 1:1

Exceptions:
1. decrease dose by 10 to 20% if high risk of hypoglycemia
2. BD NPH to OD glargine/ detemir (reduce by 20%)
3. U-300 glargine to other alterantive basal insulin analog (decrease by 20%)

24
Q

What is the adverse effect associated with insulin?

A
  1. Hypoglycemia if blood glucose less than ≤ 4.0mmol/L
  2. weight gain
  3. Lipodystrophy
  4. Local allergic reaction
  5. Systemic allergic reaction
  6. insulin resistance
25
Q

Explain the 15-15-15 rule for hypoglycemia.

A

15g of fast acting carbohydrates, wait 15 mins. If blood glucose <4.0 mmol/L, take another 15g of fast acting carbohydrates

26
Q

How dose GLP-1 receptor agonists work?

A

Mimics GLP-1 in body and binds to receptors on β cells

27
Q

List the four GLP-1 receptor agonists.

A

Litaglutide, Dulaglutide, Semaglutide (ozempic), Semaglutide (rubelsus)

28
Q

GLP-1 do not require ____ dosing adjustment.

A

renal

29
Q

How is litaglutide, dulaglutide and semaglutide (ozempic) given?

A

SQ injection OD regardless of meals

30
Q

How is litaglutide tirated?

A

0.6 to 1.2mg after 1 week
1.2 to 1.8mg

31
Q

What is the starting dose of litaglutide?

A

0.6mg

32
Q

What is the starting dose of dulaglutide?

A

0.75mg

33
Q

How is dulaglutide titrated?

A

0.75 to 1.5 mg after 4 weeks
1.5 to 3/4.5 mg

34
Q

How is semaglutide (ozempic) titrated?

A

0.25 to 0.5mg after 4 weeks
0.5mg to 1mg

35
Q

What is the starting dose of semaglutide?

A

0.25mg

36
Q

How is semaglutide (rubeisus) given?

A

PO OD 30 mins before meals

37
Q

What is the starting dose for semaglutide (rubeisus)?

A

3mg

38
Q

How is semaglutide titrated?

A

3 to 7mg after 1 month
7 to 14mg

39
Q

List at least 3 adverse effects of GLP-1 receptor agonist.

A

Thyroid C cell tumor (black box)
N/V (common)
Acute pancreatitis or Cholecystitis

40
Q

What advice will you tell patients in order to get adequate absorption of the oral semaglutide?

A
  1. Dosed in morning on empty stomach
  2. At least30 mins before other medications, food or drinks
  3. ≤ 120mL water
41
Q

Oral semglutide can be taken with _____ to increase ____ as _____ environment increases absorption.

A
  1. PPI (e.g. omperazole)
  2. absorption
  3. alkaline
42
Q

GLP-1 receptor agonist decreases HbA1c by ____ to _____%.

A

1, 2 %

43
Q

GLP-1 receptor agonist is contraindicated in patients with ___________ or __________.

A

History of pancreatitis
Family history of thyroid cancer

44
Q

What are some additional benefits of GLP-1 receptor agonist?

A

ASCVD: Liraglutide, Dulaglutide, SC semaglutide

CKD: SC GLP-1 receptor agonist reduces macroalbuminuria

45
Q

Insulin dosing is initiated with ___ control.

A

basal

46
Q

Which basal insulin can be given for glucose control? State the dose

A

NPH 10 units at bedtime or 0.1 to 0.2 units/kg per day

47
Q

If HbA1c is uncontrolled, contiune to act on FPG by increasing insulin
a. _____ every ___ days
b. _____ every __ days if consistently above 10mmol/L

OR

decreasing insulin
c. ___ to ___% if no clear reason for hypolycemia.

A

a. 2 units, 3
b. 4 units, 3
c. 10, 20

48
Q

What should be done if HbA1c is above goal despite basal dose > 0.5 units/kg OR FPG at goal?

A
  1. Add prandial coverage (rapid or regular)
    a. 1dose with largest meal or 4 units or 10% of basal.
    b. if HbA1c < 8%, to also decrease basal dose by 4 units or 10%
  2. If on bedtime NPH, consider splitting into 2 doses, 2/3 in morning and 1/3 in evening
49
Q

What is the rule of thumb for basal insulin?

A

50% or more of total daily dose

PR3152 (2 decks)

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