Insulin and Diabetic Emergencies Flashcards
What are the broad types of insulin?
Rapid Acting
Short Acting
Intermediate Acting
Long Acting
Ultra long acting insulin
What are the factors affecting insulin absorption?
Temperature
Massage
Exercise
Jet injectors
Lipodystrophy
Name the Rapid Acting insulin and what is the target blood glucose
Aspart
Lispro
Glulisine
Targets PPG; inject 15 mins before meal
Name the Short Acting insulin and what is the target blood glucose. When should it be injected?
Regular insulin
Targets PPG; inject 30mins before meal
Name the Intermediate acting insulin and what is the target blood glucose. When should it be injected?
NPH
Targets FPG; Inject at same time everyday.
Name the Long Acting insulin and what is the target blood glucose. When should it be injected?
Detemir
Glargine (U-100)
Target FPG. Inject regardless of meal at same time everyday
Name the Ultra Long Acting Insulin
Insulin Degludec
Insulin Glargine (U-300)
What insulin regimens are safe to be mixed?
Regular + NPH
Rapid acting + NPH
Rapid Acting + Degludec (ultra long acting)
What insulin regimens are unstable to be mixed? Why is that so?
Glargine/ Detemir with other insulin
- Not compatible
Name the premixed Rapid Acting + Intermediate Acting and their proportion.
Novomix: 30% insulin aspart; 70% insulin aspart protamine
Humalog: 25% insulin lispro + 75% insulin lispro protamine
Name the premixed regular + NPH insulin and their proportion
Mixtard 70/30: 70% NPH + 30% regular
Mixtard 50/50 : 50% NPH + 50% regular
How often should premixed insulin be given?
Twice a day
What is the place in therapy for the use of premixed insulin?
Provides meal / snack and basal coverage
Beneficial for patients who have difficulty measuring and mixing
Retains individual pharmacodynamic profiles
Lesser injections needed
What is a potential challenge upon using premixed insulin?
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
What are some considerations about oral therapies upon starting patient on insulin?
Metformin
SGLT2i
TZD
SU
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
What is the general rule of thumb for insulin dose conversion?
1:1
(e.g. regular + NPH –> rapid acting + NPH)
What should you do if patient is at risk of hypoglycemic while conducting the insulin dose conversion?
Reduce dose by 10-20%
What are some exceptions in terms of insulin conversion and what should be done?
Switching from twice daily NPH to once daily glargine/ detemir
- Decrease dose by 20% (NOTE: Need to consider one full day’s dose)
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?
34 units of glargine once daily
6 units of aspart three times daily before meals
What are the adverse effects of insulin?
Hypoglycemia
Weight gain
Lipodystrophy (more common lipohypertrophy)
Rare: Local allergic reaction, systemic allergic reaction and insulin resistance
What are the hypoglycemia symptoms and how should a patient manage them?
Blurry vision, sweating, tremor, hunger, confusion, shaking, irregular HR
What is the first line of therapy for T2DM?
Metformin
Should patient’s Hba1c be uncontrolled and patient is suffering from other comorbidities such as ASCVD, CKD and HF, what can be added?
ASCVD: GLP-1 agonist and SGLT2i
CKD and HF: SGLT2i
What can we consider prioritizing if patient’s A1C level is above goal after using 2 agents?
Weight loss
Financial difficulties
What BG is prioritized if we start patient on insulin and how should insulin be started ?
FPG
NPH < 10 units at bedtime
Insulin: If A1c level of patient remains uncontrolled, what must we consider first and what can we consider doing?
FPG high for 3 consecutive days
Increase insulin by 2 units every 3 days until FPG is at goal
If A1c level of patient remains uncontrolled at >10mmol/L, what can we consider doing?
Increase insulin by 4 units every 3 days until goal
What should we consider next once FPG is at goal while A1c remains high?
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
If prandial coverage was added to cover PPG, what dose should be initiated?
4 IU OR 10% of basal with largest meal
If prandial coverage was added, however patient’s A1c level < 8%, what should be done?
Decrease by 4 IU OR 10% of basal with largest meal
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?
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)
What is the usual final regimen for those on insulin?
Full basal bolus: injection of basal insulin + rapid acting/ regular for each meal
Twice daily pre mix: NPH + regular/ rapid
Why do diabetic emergencies occur more in Type 1 than in Type 2?
T1DM have absolute insulin deficiency while T2DM have residual insulin production and therefore are protected against excessive lipolysis and ketone production
Why do diabetic emergencies occur?
Happens when ketones are formed as a by-product of fat metabolism
What is the difference between DKA and Hyperglycemic hyperosmolar state?
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
Why does HSS have no ketones or acidic pH?
Residual insulin still present and hence no ketones form
How can DM complications be prevented and managed?
Aspirin administration (debatable)
Smoking cessation
BP
Lipid profile
Why is Aspirin considered?
Acts as a secondary prevention strategy for DM and ASCVD patients
Who are suitable candidates for aspirin initiation?
Young patients with > 1 risk factor
Old patients with no risk factors
Who are unsuitable candidates for aspirin management?
Olde patients > 70 y
Low risk ASCVD diabetic patients
Define the somogyi effect
Happens when blood glucose drops sharply
Body then responds by increasing glucagon and hence causing blood glucose to increase
Define the dawn phenomenon
Release of cortisol (due to stress) in waking hours cause blood glucose to rise sharply
