Injectable and Inhaled Insulins

Question 1

What is the expected clinical effect of the GLP-1 agonists on blood glucose control

Answer 1

about 1%

Question 2

Contraindications to GLP-1 agonists

Answer 2

• Type 1 DM
• Ketoacidosis
• Severe GI dz
• Hx of pancreatitis

Question 3

MoA of GLP-1 Agonist

Answer 3

• Activate GLP receptors on the cell surface of beta cells → insulin release in the presence of elevated BG
• Decreases glucagon secretion in a glucose-dependent manner
• Lowers blood glucose by delaying gastric emptying

Question 4

Additional contraindication to Byetta (GLP-1)

Answer 4

ESRD or severe renal impairment (CrCl <30 ml/min)

Question 5

Additional contraindication to Victoza (GLP-1)

Answer 5

Hx or fam hx of medullary thyroid cancer (MTC) or hx of multiple endocrine neoplasia syndrome type 2 (MEN 2)

Question 6

ADRs of GLP-1 Agonist

Answer 6

• MC: dose-dependent nausea
• nausea, HA, diarrhea
• hemorrhagic and necrotizing pancreatitis
• serious hypoglycemia (when used in combo w/ SU or meglitinide)

Question 7

What are the rapid acting insulin preps?

Answer 7

• Novolog
• Humalog
• Apidra

Question 8

What are the long acting insulin preps?

Answer 8

• Lantus

- Levamir

Question 9

short acting insulin prep

Answer 9

Regular (Humalin R and Novalin R)

Question 10

intermediate acting insulin prep

Answer 10

NPH (Humalin N and Novalin N)

Question 11

Bolus insulin

Answer 11

• Novolog
• Humalog
• Apidra
• Regular

Question 12

Basal insulin

Answer 12

• Lantus
• Levamir
• NPH

Question 13

Given a regimen of bolus insulins, select the appropriate administration time.

Answer 13

• rapid acting: 15 min. before meal

- short acting: 30 min. before meal

Question 14

Given a regimen of basal insulins, select the appropriate administration time.

Answer 14

• basal are injected once or twice daily (12 hrs apart) without regard to meals
• the injections should be at the same time daily

Question 15

What is the purpose of rotating insulin injection sties?

Answer 15

to avoid or decrease the development of lipodystrophy (hypotrophy or atrophy)

Question 16

Define U-100, U-200, U-300

Answer 16

• U = number of units of insulin per milliliter of fluid
• Ex: U-100 means there are 100 units of insulin per mL of fluid (same for 200 and 300)
• All vials are 10 mL (1,000 units of insulin per vial)

Question 17

Insulin storage

Answer 17

• unopened vials should be kept in the fridge not freezer
• open vials can be kept at room temp (60-75 degrees) **except Lantus which has to be refrigerated
• discard after 28-30 days
• pens have expiration dates (10-14 days once used)
• keep out of sun and humidity
• avoid excess agitation (don’t shake)

Question 18

which insulins should be clear vs. cloudy?

Answer 18

• clear: lantus, regular, humalog, nocolog

- cloudy: NPH

Question 19

clinical indications for the use of insulin in T2D

Answer 19

• severe hyperglycemia (glucose toxicity) BG > 300 mg/dl
• temporary situations like pregnancy
• when co-morbid chronic conditions such as CHF, renal insufficiency or liver dz exists that makes it hard to use oral agents safely
• for tx of acute hyperglycemia complications such as hyperosmotic syndrome

Question 20

Choose the appropriate starting dose and monitoring parameters for a patient with T2DM starting insulin

Answer 20

1. start w/ bedtime basal insulin - 10U or 0.1-0.2 u/kg
2. check fasting BG daily and increase dose 2U q 3 days until fasting levels are in target range
3. if hypoglycemia occurs then decrease dose by 10%

Question 21

titration options

Answer 21

• 2U every 3 days

- per the chart: 10-15% or 2-4U once-twice weekly

Question 22

How to initiate a bolus insulin dose in a patient who is already using basal insulin

Answer 22

• Add a rapid acting insulin for post-prandial control
• Start with the time of day blood sugar is highest
• Start with 4 Units, 0.1 U/kg, or 10% of basal dose (Letassy says 5-10 units is fine)
• Adjust dose by 1-2 U or 10-15% once or twice weekly until reach target glucose levels
• Dosing is best based on CHO counting

Question 23

given a pt. on a basal bolus insulin regimen, convert to a split mixed insulin product

Answer 23

• divide current basal dose into 2/3 AM 1/3 PM or 1/2 and 1/2
• increase dose 1-2U or 10-15% once-twice weekly until target is reached