insulin Flashcards

Question

continue PO metformin?

Answer 1

discontinue when initiate insulin OR reduce TZD dose TZDL insulin sensitiser, incr risk of hypoglycemia

Answer 2

discontinue. reduce SU dose by 50% when BASAl insulin (pt risk of hypogly) discontinue is mealtime insulin (PPG added) - effectiveness of SU will wear off over time SU: targets PPG

Answer 3

Most insulin conversion 1: 1unit □ Reduce dose 10-20% if pt high risk of hypoglycemia Exceptions □ BD NPH --> OD glargine/ detemir * Reduce dose by 20% □ U300 glargine --> basal insulin (U-100 glargine/ detemir) * Decr dose by 20%

Answer 4

Mixtard (70% NPH, 30% regular) 30units BD = 60 units NPH = 0.70 x 60 = 42.0 ---- FBG 42 x 0.80 = 33.6 (34) decr dose Regular = 0.3 x 60 = 18.0 ---- PPG same = 34units of glargine OD + 18/3 =6units aspart TDS during meals

Answer 5

hypoglycemia (<4mmol/L) Weight gain Lipodystrophy (lipoatrophy, lipohypertrophy) local allergic rxn systemic allergic rxn (rare) insulin resistance (rate)

Answer 6

15g fast acting carb wait 15mins check BG, still <4.0mmol/L, add another 15f of fasting cards

Answer 7

1. First line = metformin a. Continued as long as possible, start early also b. Combi can be considered if HbA1c really quite elevated c. If history of: 1) ASCVD: GLP1 agonist/ SGLT2i 2) HF: SGLT2i 3) CKD: SGLT2i

Answer 8

a. Need minimise hypoglycemia (elderly) = AVOID: SU, Insulin b. Need promote weight loss = GLP1, SGLT2i c. Financial difficulties = SU > TZDs > DPP4

Answer 9

a. GLP1 agonist INJ b. Insulin □ Only first line INJ if: Catabolism (weight loss)/ symp of Hypergly, A1c > 10%, BGL > 16.7 mmol/L

Answer 10

a. Initiate with BASAL, FPG □ Contributes most to HbA1c readings □ 10 units or 0.1IU/Kg □BEDTIME NPH □ Or glargine/ determir/ degludec ($$$$$)

Answer 11

Act on FPG (TITRATION) - Incr insulin 2 units every 3 days (until FPG goal) - Incr 4 units every 3 days (if FPG consistently >10 mmol/L) ◊ Must be out of control for 3 days then u titrate *Decr insulin by 10-20% if hypogly with no reason Target FPG 5-7mmol/L - Higher end if pt needs

Answer 12

A1c still high, but 1) basal>0.5 IU/kg 2) FPG alr at goal - Change to pre-mixed insulin/ self-mixed to decr number of injections (Prandial + NPH)

Answer 13

- OVER-BASALISATION ◊ Basal insulin at ceiling effective dose ◊ Incr dose, less proportional decr FBG =Lead to weight gain, hypogly, Postpradial hypergly

Answer 14

1. Add Prandial coverage (rapid / regular insulin) - Initiate 1 dose with largest meal - 4IU/ 10% of basal dose ◊ STOP SU (glipizide) -Decr BASAL by 4IU/ 10% ◊ If A1c <8% 2. (or) Split dose of bedtime NPH - 2/3 for morning - 1/3 for evening

Answer 15

1) full basal-bolus regimen * 1 inj (basal, glargine) + 3 inj (regular/ rapid for each meal) =4inj 2) or twice daily pre-mix regimen *BD NPH+regular/ rapid insulin = 2inj (basal consist >50% of total daily dose) -- premix

Answer 16

Ketones are byproducts of fat metabolism Type1 > type2 * Absolute insulin deficiency Lipolysis + metabolism of FFA □ Form ketones (beta-hydroxybutyrate, acetoacetic acid, acetone) in liver * Stress Stimulates insulin counter regulatory hormones (glucagon, catecholamines, glucocorticoids, growth hormone) □ Excess glucagon: incr gluconeogenesis, decr peripheral ketone ultilisation

Answer 17

* Ketones formed ○ Found in blood, urine ○ Fruity breath odor ○ Acidosis * Still alert * BG > 14mmol/L

Answer 18

Glucose pH low Bicar low Acetoacetate (ketones) high Osmolarity (conc with blood) not too high Anion gap (acidosis) HIGH Sensorium = alert

Answer 19

* Still residual insulin, usually no ketones ○ No acidosis * Extremely dehydrated BGL >33 mmol/L * Stupor

Answer 20

Glucose HIGH pH neutral Bicar high Acetoacetate (ketones) ABSENT Osmolarity (conc with blood) HIGH Anion gap (acidosis) NO <12 Sensorium = COMA

Answer 21

* BG drop at night * Too much insulin/ no snack * Body respond by release glucagon * Incr BGL = SMBG at 3am at night is high or LOW

Answer 22

Release of cortisol in waking hrs causes BGL rise sharply =SMBG at 3am at night is normal

Answer 23

Aspirin admin// clopidogrel (if allergic to aspirin) 2nd prevention strategy if DM, ASCVD 1st prevention strategy if DM + incr risk of CV

Answer 24

□ LDL cholesterol >2.6mmol/L □ High BP □ Smoke □ CKD □ Albuminuria □ Fam hist/ premature ASCVD

Answer 25

Not needed --- Incr risk for bleeding events □ Low/ no risk of ASCVD □ Young <40 yrs □ Old > 70 yrs

Answer 26

- fail to correlate with macro complications - pop A1c diff among race, ethnic grps - fail to reflect harms of hypogly - fails tp reflect glycemic variability - represent a target without providing guidance as to how to achieve