Insulin prescribing

Question 1

Onset, peak and duration of rapid acting insulin analogues

Answer 1

Onset: 5 mins
Peak: 1 hour
Duration: 3-5 hours

Question 1

Onset, peak and duration of short-acting insulin analogues

Answer 1

Onset: 30 mins
Peak: 3 hours
Duration: 6-8 hours

Question 2

Onset, peak and duration of intermediate-acting acting insulin analogues

Answer 2

Onset: 2 hours
Peak: 5-8 hours
Duration: 12-18 hours

Question 3

Onset, peak and duration of long-acting acting insulin analogues

Answer 3

Onset: 1-2 hours
Peak: Flat profile
Duration: Up to 24 hours

Question 4

Examples of rapid acting insulin analogues

Answer 4

Novorapid (Aspart) Humalog (Lispro)
Apidra (Glulisine)

Question 5

Examples of short acting insulin analogues

Answer 5

Actrapid
Humulin S

FRIl (only short-acting)

Given 15-30 minutes before meal

Question 6

Examples of intermediate acting insulin analogues

Answer 6

Insulatard
Humulin I
Insuman basal

Given OD/BD or as part of a mix

Question 7

Examples of long acting insulin analogues

Answer 7

Lantus (Glargine)
Levemir (Determir)
Tresiba (Degludec)

Given OD

Question 8

Pre-mixed preparations: Novomix 30

Answer 8

Intermediate + Rapid (at start of breakfast and dinner)

30% insulin aspart (rapid-acting), 70% insulin aspart protamine

Question 9

Pre-mixed preparations: Humalog Mix25/50

Answer 9

25%/50% rapid-acting (insulin lispro)

Question 10

How to administer insulin

Answer 10

rotate injection sites to prevent lipodystrophy

Question 11

What regimens of insulin exist?

Answer 11

Basal bolus regimen
BD pre-mixed regimen

OD intermediate morning/evening regimen

Question 12

How many units of insulin in 1mL?

Answer 12

100 units

Question 13

Biphasic insulin dose

Answer 13

0.5 - 0.8 UNITS / kg

2/3rds in the morning, 1/3rd in the evening

Question 14

Rules for diabetics on insulin going for surgery

Answer 14

If glucose 4-12mmol/L = proceed with surgery

If glucose >12mmol/L, capillary blood ketones >3 or urine ketones +++ = delay surgery and give VRII

1 U = ~3mmol/L glucose drop

Question 15

If patient is NBM, how should insulin be adjusted?

Answer 15

Continue basal insulin

Omit bolus insulin

Question 16

In what situations should you increase insulin?

Answer 16

DKA/HHS, sepsis, steroids, missed doses, pancreatitis, dehydration

IE-asthma goes home with 5 days PO prednisolone → +10% to daily insulin

Question 17

In what situations should you decrease insulin?

Answer 17

ETOH, reduced renal function, reduced calonies

Question 18

How should you adjust basal/bolus regimens if high/low before breakfast/at night?

Answer 18

Increase/decrease evening long acting

Question 19

How should you adjust basal/bolus regimens if high/low before lunch/dinner/bed?

Answer 19

Increase/decrease rapid acting in meal before

Question 20

How should you adjust BD pre-mixed/intermediate regimens if high/low before bed AND before breakfast?

Answer 20

Increase/decrease evening insulin

Question 21

How should you adjust BD pre-mixed/intermediate regimens if high/low before lunch AND before evening meal?

Answer 21

Increase/decrease morning insulin

Question 22

VRII indications

Answer 22

NBM surgery patients, post FRII in DKA

Question 23

VRII mix

Answer 23

50 UNITS Actrapid insulin (or Humulin S) in 50mL of 0.9% sodium chloride

Question 24

IV glucose medical vs surgical

Answer 24

Medical: 1L 5% glucose + 0.30% K+ at 100mL/hour

Surgical: 1L 5% glucose + 0.30% K+ at 80mL/hour

Question 25

Stopping a VRII checklist

Answer 25

E+D normally

Taken long-acting insulin (≥1 hour before)

Taken mixed/rapid insulin at usual mealtime (and wait 30 minutes before stopping VRII)

Monitor CBG QDS for ≥24 hours

Question 26

BM <4
Conscious / able to swallow

Answer 26

Glucotabs (47) OR 150-200mL fruit juice OR 4 teaspoons sugar dissolved in water

2nd choice: IM glucagon OR glucose 20% 100mL IV over 10 mins

Question 27

BM <4
Unconscious / no swallow

Answer 27

IM glucagon (community, no IV) OR Glucose 20%, 100mL, IV, over 10 mins

Question 28

BM > 4
Conscious / able to swallow

Answer 28

Long-acting CHO
(two biscuits, one slice of bread, 200-300 mL of milk