Insulin Treatment Flashcards
What is the insulin used as the IV formulation?
Regular insulin
Do not give the following as IV:
NPH - is a suspension
Glargine - precipitates at physiologic pH
Detemir - binds to albumin through it FA chain
Degludec - may cause severe hypoglycemia if given IV
Uses of insulin
Type 1 and 2 diabetes: high fasting glucose levels > 280-300 mg/dL; patients with ketoacidosis; gestational diabetes; when deemed appropriate by clinician + patient
Hyperkalemia
Type 2 diabetes in combo with various non-insulin agents
Describe the onset, peak, duration of action, and adverse effects of each of the insulin preparations available.
Ultra Short-Acting
Short-Acting
Intermediate
Long-Acting
Ultra Long-Acting
Ultra-Short Acting
Aspart (Novolog)
Lispro (Humalog)
Glulisine (Apidra)
Aspart (Novolog)
Onset: 10-20 min
Peak: 30-90 min
Duration: 3-5 hours
Compatible when mixed with: NPH
Lispro (Humalog)
Onset: 10-20 min
Peak: 30-90 min
Duration: 3-5 hours
Compatible when mixed with: NPH
Glulisine (Apidra)
Onset: 10-20 min
Peak: 30-90 min
Duration: 3-5 hours
Compatible when mixed with: NPH
Short-Acting
Regular (Humulin)
Regular (Humulin)
Onset: 30-60 min
Peak: 2-4 hours
Duration: 5-8 hours
Compatible when mixed with: NPH
Intermediate
NPH (Humulin N, Novolin N)
NPH (Humulin N, Novolin N)
Onset: 2-4 hours
Peak: 4-10 hours
Duration: 8-12 hours
Compatible when mixed with Regular, Lispro, Aspart, Glulisine
Long-Acting
Glargine (Lantus, Basaglar, Semglee)
Detemir (Levemir)
Glargine (Lantus, Basaglar, Semglee)
Onset: 2-4 hours
Peak: no peak
Duration: 20-24 hours
Not compatible when mixed with others
Detemir (Levemir)
Onset: 1.5-4 hours
Peak: 6-14 hours
Duration: 16-20 hours
Not compatible when mixed with others
Ultra Long-Acting
Degludec (Tresiba)
Degludec (Tresiba)
Onset: 1 hour
Peak: no peak
Duration: over 24 hours (~ 42)
Not compatible when mixed with others
Insulin Pre-mixtures
Reduce the # of injections
Problem: can’t individually adjust them
NPH/Regular mixture 70/30
75% neutral protamine lispro/25% lispro
50% neutral protamine lispro/50% lispro
70% aspart protamine suspension/30% aspart
Degludec U-100/aspart U-100
Concentrated insulins
Humulin-R U500
Degludec U200 (Tresiba)
Glargine U300 (Toujeo)
Glargine U 300 (Toujeo Max)
Lispro U200 (Humalog Kwikpen)
Humulin-R U500
DOA: 6-10 hours
Greatest A1C reduction T2DM
Most weight gain
Most expensive
Degludec U200 (Tresiba)
DOA: 42 hours
Second greatest A1C reduction T2DM
Least weight gain
2nd most expensive
Glargine U300 (Toujeo)
DOA: > 30 hours
3rd greatest A1C reduction
3rd most weight gain
2nd to least expensive
Glargine U 300 (Toujeo Max)
DOA: > 30 hours
3rd greatest A1C reduction
3rd most weight gain
3rd most expensive
Lispro U200 (Humalog Kwikpen)
only bolus insulin that is concentrated
DOA: 3-5 hours
Least amount of A1C reduction
2nd most weight gain
Cheapest
Factors altering insulin action
Route of administration
Site of injection
Temperature
Exercise/massage
Preparation/mixtures
Dose
Patient compliance
Patient errors
Irregular diet/exercise
Renal function
Stress
Drugs
Route of administration of insulin
IV > IM > SQ
intranasal may even be faster
Site of injection
Stomach is fastest
Butt and thigh slowest
Want to keep same site for same time of day
Temperature
heat increases absorption and action
Exercise and massage
increase absorption and action
Preparations/mixtures
always draw short-acting insulins 1st
short-acting effect of insulins may be lost if mixed incorrectly
smaller volume (more concentrated) allows for overall increased absorption
Dose
lower dose is absorbed more rapidly (less volume)
Renal function
renal failure decreases insulin clearance, thereby increasing insulin action (risk of hypoglycemia)
Stress
increases insulin clearance (increases BS)
Insulin vials stable at room temp for
28 days
42 days with levemir
refrigerate vials/pens not in use , do not freeze
Insulin you prefill in syringes is stable for
28 days with refrigeration, as long as not mixed
10-28 days at room temp
Mixture stability
Regular/NPH: stable for 7 days in fridge
Aspart, Glulisine, or Lispro with NPH: give immediately
Degludec, Detemir, and Glargine with any other insulin: ??
Hypoglycemia Causes
increased insulin dosage
decreased caloric intake
increased muscle utilization
excessive alcohol
Hypoglycemia Classification
level 1: glucose < 70 mg/dL
level 2: glucose < 54 mg/dL
level 3: severe event with altered mental state
Hypoglycemia Signs/Symptoms
tremore, diaphoresis, anxiety, dizziness, hunger, tachycardia, blurred vision, weakness/drowsiness, headache, irritability, confusion, slurred speech
beta-blockers can decrease responsiveness to hypoglycemia due to blocking sympathetic warning symptoms
Hypoglycemia Treatment
rule of 15’s: start with 15 gm of FAST-ACTING carb unless BS < 50 mg/dl (then use 30 gm) - 4 oz OJ, 6 oz cola, 5-6 lifesavers, 2 tsp sugar, 1 T honey, 4-5 glucose tabs/gel
wait for 15 min, check BS again, if not > 79 mg/dL, repeat iwth another 15 gm
follow with complex carb - eat your meal if within the hour, eat 30 gm CHO snack if meal > 1 hour away
glucagon for level 2/3 patients: 3 mg intranasal Baqsimi, 1 mg SQ, IV, IM glucagon, 0.6 mg SQ dasiglucaogon
Complications of insulin therapy
hypoglycemia
weight gain
lipohypertrophy - repeated injections into same site, tumerous like fat pads
lipoatrophy - concavities caused by destruction of fat from antibodies or allergic reactions
allergic reactions
Glulisine, Lispro, or Aspart Insulin Advantages
decreases post-prandial hypoglycemia and superior post-prandial lowering of BS
fewer overall occurrences of hypoglycemia, less noctural hypoglycemia
greater flexibility (can take right after eating)
Glulisine, Lispro, or Aspart Insulin Disadvantages
risk of hypoglycemia if no meal within 15 min of dose
need to combine with longer acting insulin for optimal BS control
if mixed with another insulin, give immediately after mixing
hyperglycemia/ketosis may occur more rapidly if insulin delivery is interrupted
Glargine, Detemir, or Degludec Advantages
provides 24+ hour coverage with a constant absorption pattern and no pronounced peak (detemir may require BID dosing in order to acheive 24 hr coverage)
may be beneficial in pts suffering from nocturnal hypoglycemic episodes
Glargine, Detemir, or Degludec Disadvantages
risk of malignancy
can NOT be mixed with any other insulin
DEVOTE trial
glargine vs degludec
T2DM with either CVD or risk factors for CVD
CVD risk was basically the same for each
degludec has much less hypoglycemia
Changing between U-100 therapies
pts change from daily NPH to glargine/detemir/degludec, keep dose the same
pts change from BID NPH to glargine/detemir/degludec, decrease dose by 20%
Changing U-100 to a concentrated insulin therapy
pts change from BID NPH to U-300 glargine, decrease dose by 20%
1:1 conversion between daily glargine (lantus, basaglar, semglee) or daily detemir (levemir) to daily glargine (toujeo or toujeo max) but pts may need an increased dose of toujeo or toujeo max
1:1 conversion between basal insulin and U-200 insulin degludec
1:1 conversion between lispro U-100 to U-200
U-100 basal-bolus regimen to U-500 regimen
U-500 replaces both basal and bolus insulin types
if A1C > 8%, consider 1:1 conversion
if A1C </= 8%, use a 20% dosage reduction
Type 1 pts average daily dose
0.5-0.6 U/kg/day
use lower dosages in newly diagnosed pt: 0.1-0.4 U/kg/day
Basal is provided by
either 1-2 doses of glargine, detemir, or degludec or 1-2 doses of NPH
Bolus dosing is provided by
meal-time short-acting or ultra-short acting insulins (regular, lispro, glulisine, aspart)
50-70% of the insulin requirements are given as
basal insulin
other 30-50% is divided among the meal as bolus insulin
Prandial doses can be adjusted based on
carbohydrate content of meals
1 unit for every 15 gm of CHO (1:15 insulin: CHO ratio)
Insulin pumps
rapid acting insulin used to cover both basal and prandial insulin needs
basal rate throughout the day
bolus dose calculator to determine bolus doses bases on glucose levels, carb intake, and insulin on board
Type 2 patients start insulin if
A1C >/= 10%
usually long-acting or intermediate insulin is started in combo with non-insulin agents
bedtime insulin usually added to previous non-insulin therapies
Starting dose of insulin in T2DM
0.1-0.2 U/kg/day or 10 U/day
Adjusting dose in T2DM
increase dose by 2 units every 3 days to reach FBS goal
Basal in T2DM
basal provided by either 1-2 doses of glargine, detemir, or degludec or 1-2 doses of NPH
Eventually, many T2D pts will need
bolus insulin
consider addition of bolus, especially for pts on >/= 0.5 U/kg/day
usually can start with 10% of basal dose or 4-5 units of ultra-short or short-acting insulin with largest meal
General dosing principles
for all diabetic pts on insulin, increase/decrease dose every 2-4 days until goals are met
target FBS, then PPG - with A1C > 10%, 70% of the problem involves FBS, with A1C < 7.5%, 70% of the problem involves PPG
Insulin to Carb ratio
1 unit:10-15 gm CHO for adults
1 unit:20-30 gm for children
calculating insulin:carb ratio - divide # of grams of CHO for a meal by amount of bolus insulin given
rule of 500: take 500/total daily insulin dose and this will equal the # gm of CHO for 1 unit of insulin
Correction factor
guidance for fixing high BS
rule of 1800: 1800/total daily dose of insulin = # of mg/dL blood glucose will drop for every 1 unit of insulin
If you use a CF dose before bedtime
consider only giving 50% of the dose
Use 1500 if the pt is
on regular insulin
For many T1 pts, an increased insulin dose by ~2 units decreases the BS by
~50 mg/dL
For many T2 pts, an increased insulin dose by ~4 units decreases the BS by
~50 mg/dL
Somogyi effect
nocturnal hypoglycemia with rebound hyperglycemia
signs/sx: wake up sweaty, serious/scary dreams
add a bedtime snack; move NPH from dinner to bedtime or decrease long-acting dose at bedtime
Concentrated insulins were developed in order to
provide sustained glucose-lowering effect with less risk of hypoglycemia, lower intra-individual variability, fewer injections, better adherence, less pain, less frequent pen changes
consider when TDD = 200-300 U/day
Afrezza
inhaled insulin
adverse rxs: hypoglycemia, cough, acute bronchospasm, URI, decline in pulmonary function, lung cancer, throat/irritation, hypersensitivity rxns
