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PR3152 Study Deck - Pharmacotherapeutics > Insulin and Diabetic Emergencies > Flashcards

Insulin and Diabetic Emergencies Flashcards

1
Q

What are the broad types of insulin?

A

Rapid Acting
Short Acting
Intermediate Acting
Long Acting
Ultra long acting insulin

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2
Q

What are the factors affecting insulin absorption?

A

Temperature
Massage
Exercise
Jet injectors
Lipodystrophy

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3
Q

Name the Rapid Acting insulin and what is the target blood glucose

A

Aspart
Lispro
Glulisine

Targets PPG; inject 15 mins before meal

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4
Q

Name the Short Acting insulin and what is the target blood glucose. When should it be injected?

A

Regular insulin

Targets PPG; inject 30mins before meal

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5
Q

Name the Intermediate acting insulin and what is the target blood glucose. When should it be injected?

A

NPH

Targets FPG; Inject at same time everyday.

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6
Q

Name the Long Acting insulin and what is the target blood glucose. When should it be injected?

A

Detemir
Glargine (U-100)

Target FPG. Inject regardless of meal at same time everyday

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7
Q

Name the Ultra Long Acting Insulin

A

Insulin Degludec

Insulin Glargine (U-300)

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8
Q

What insulin regimens are safe to be mixed?

A

Regular + NPH
Rapid acting + NPH
Rapid Acting + Degludec (ultra long acting)

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9
Q

What insulin regimens are unstable to be mixed? Why is that so?

A

Glargine/ Detemir with other insulin
- Not compatible

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10
Q

Name the premixed Rapid Acting + Intermediate Acting and their proportion.

A

Novomix: 30% insulin aspart; 70% insulin aspart protamine

Humalog: 25% insulin lispro + 75% insulin lispro protamine

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11
Q

Name the premixed regular + NPH insulin and their proportion

A

Mixtard 70/30: 70% NPH + 30% regular

Mixtard 50/50 : 50% NPH + 50% regular

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12
Q

How often should premixed insulin be given?

A

Twice a day

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13
Q

What is the place in therapy for the use of premixed insulin?

A

Provides meal / snack and basal coverage

Beneficial for patients who have difficulty measuring and mixing

Retains individual pharmacodynamic profiles

Lesser injections needed

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14
Q

What is a potential challenge upon using premixed insulin?

A

Basal and prandial coverage must be adjusted together and is not possible without knowing patients and their lifestyle

Multiple peaks in glucose level may also make it tougher for it to adjust

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15
Q

What are some considerations about oral therapies upon starting patient on insulin?
Metformin
SGLT2i
TZD
SU

A

Metformin and SGLT2i: Continue
TZD: Discontinue when initiating insulin/ reduce dose
SU: Depends on type of insulin
- Basal insulin: discontinue / reduce dose by 50%
- Mealtime insulin: discontinue

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16
Q

What is the general rule of thumb for insulin dose conversion?

A

1:1
(e.g. regular + NPH –> rapid acting + NPH)

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17
Q

What should you do if patient is at risk of hypoglycemic while conducting the insulin dose conversion?

A

Reduce dose by 10-20%

18
Q

What are some exceptions in terms of insulin conversion and what should be done?

A

Switching from twice daily NPH to once daily glargine/ detemir
- Decrease dose by 20% (NOTE: Need to consider one full day’s dose)

19
Q

FG is a 65 year old female who has been on insulin Mixtard 30. She injects 30 units twice daily. As FG is getting older, her physician wants to switch her to Glargine and Aspart to reduce risk of hypoglycemia. Her current Hba1c hovers around 8% How do we do her new insulin regimen?

A

34 units of glargine once daily

6 units of aspart three times daily before meals

20
Q

What are the adverse effects of insulin?

A

Hypoglycemia
Weight gain
Lipodystrophy (more common lipohypertrophy)

Rare: Local allergic reaction, systemic allergic reaction and insulin resistance

21
Q

What are the hypoglycemia symptoms and how should a patient manage them?

A

Blurry vision, sweating, tremor, hunger, confusion, shaking, irregular HR

22
Q

What is the first line of therapy for T2DM?

A

Metformin

23
Q

Should patient’s Hba1c be uncontrolled and patient is suffering from other comorbidities such as ASCVD, CKD and HF, what can be added?

A

ASCVD: GLP-1 agonist and SGLT2i

CKD and HF: SGLT2i

24
Q

What can we consider prioritizing if patient’s A1C level is above goal after using 2 agents?

A

Weight loss
Financial difficulties

25
Q

What BG is prioritized if we start patient on insulin and how should insulin be started ?

A

FPG
NPH < 10 units at bedtime

26
Q

Insulin: If A1c level of patient remains uncontrolled, what must we consider first and what can we consider doing?

A

FPG high for 3 consecutive days
Increase insulin by 2 units every 3 days until FPG is at goal

27
Q

If A1c level of patient remains uncontrolled at >10mmol/L, what can we consider doing?

A

Increase insulin by 4 units every 3 days until goal

28
Q

What should we consider next once FPG is at goal while A1c remains high?

A

Addition of prandial coverage such as rapid/ regular acting insulin

Split the bedtime NPH dose in 2, 2/3 in the AM and 1/3 in the evening

29
Q

If prandial coverage was added to cover PPG, what dose should be initiated?

A

4 IU OR 10% of basal with largest meal

30
Q

If prandial coverage was added, however patient’s A1c level < 8%, what should be done?

A

Decrease by 4 IU OR 10% of basal with largest meal

31
Q

TSL is a 60 year old Chinese female who has been on insulin glargine 20 units ON for the past 3 months. Her average FPG is 5.7 mmol/L but her Hba1c level hovers around 8%. Her average PG for past 2 weeks is 13.2 mmol/L. Her largest meal is lunch. What should be done?

A

Add one rapid acting insulin for lunch.

Give rapid acting 2-4 units before lunch and give glargine 16-18 units ON (consider decreasing dose due to hypoglycemia)

32
Q

What is the usual final regimen for those on insulin?

A

Full basal bolus: injection of basal insulin + rapid acting/ regular for each meal

Twice daily pre mix: NPH + regular/ rapid

33
Q

Why do diabetic emergencies occur more in Type 1 than in Type 2?

A

T1DM have absolute insulin deficiency while T2DM have residual insulin production and therefore are protected against excessive lipolysis and ketone production

34
Q

Why do diabetic emergencies occur?

A

Happens when ketones are formed as a by-product of fat metabolism

35
Q

What is the difference between DKA and Hyperglycemic hyperosmolar state?

A

Presence of ketones
- DKA: yes, acidic pH, fruity breath and ketones in blood and urine
- HSS: no, neutral pH

Is patient awake?
- DKA: Yes in less severe cases
- HSS: Stupor/coma

Blood glucose
- DKA: Not as high, BG > 14 mmol/L
- HSS: High. BG > 33mmol/L

36
Q

Why does HSS have no ketones or acidic pH?

A

Residual insulin still present and hence no ketones form

37
Q

How can DM complications be prevented and managed?

A

Aspirin administration (debatable)
Smoking cessation
BP
Lipid profile

38
Q

Why is Aspirin considered?

A

Acts as a secondary prevention strategy for DM and ASCVD patients

39
Q

Who are suitable candidates for aspirin initiation?

A

Young patients with > 1 risk factor

Old patients with no risk factors

40
Q

Who are unsuitable candidates for aspirin management?

A

Olde patients > 70 y
Low risk ASCVD diabetic patients

41
Q

Define the somogyi effect

A

Happens when blood glucose drops sharply

Body then responds by increasing glucagon and hence causing blood glucose to increase

42
Q

Define the dawn phenomenon

A

Release of cortisol (due to stress) in waking hours cause blood glucose to rise sharply

PR3152 Study Deck - Pharmacotherapeutics (10 decks)

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