insulin treatment Flashcards
· Describe physiologic insulin secretion in the fasting and postprandial states
pancreas secretes insulin in response to glucose and to maintain basal concentration.
phases of insulin secretion
first phase: initial release, peaks and drops down over 5 minutes. Second phase: sustained elevation tht occurs with sustaind hyperglycemia and peaks 30-45 min after starting meal
List rapid acting insulins
humalog (Lispro), novolog (Aspart), glulisine (Apidra)
rapid acting insulins pharmacokinetics
Insulin analog. Onset of action 5-15 min. Peak 1-1.5 hr. Duration 3-5 hr. SQ injection or in insulin pump. Given just prior to a meal. Dissociates rapidly into monomers
after injectionInsulin analog. Onset of action 5-15 min. Peak 1-1.5 hr. Duration 3-5 hr. SQ injection or in insulin pump. Given just prior to a meal. Dissociates rapidly into monomers
after injectionInsulin analog. Onset of action 5-15 min. Peak 1-1.5 hr. Duration 3-5 hr. SQ injection or in insulin pump. Given just prior to a meal. Dissociates rapidly into monomers
after injection
List short acting( regular) insulins
Humulin R; Novolin R
Short acting insulins pharmacokinetics
recombinant human insulin. Onset of action 30-60 min. Peak 2 hr. Duration 6-8 hr. SQ injection, IV infusion. Inject 30 minutes before eating
List intermediate acting insulins/NPH
neutral protamine hagedorn, Humulin N; Novolin N
Intermediate acting insulins pharmacokinetics
Onset of action 2-4 hr. Peak 6-7 hr. Duration 10-20 hr. SQ injection only. >2x/d for basal coverage. Cloudy solution. Can be given simultaneously with other insulin
List long acting insulins
glargine (Lantus) and detemir (Levemir)
long acting insulins pharmacokinetics
Forms precipitates that slowly release insulin into circulation. Onset of action 1-3 hr. No pronounced peak. Duration 24 hr (glargine) or ~17 hr (detemir). SQ injection only. Cannot be mixed in the same syringe with any other insulins (b/c acidic pH)
list pre mixed insulins
Human: (%NPH/%regular): 70/30, 50/50. Analogs: Humalog 75/25, Humalog 50/50, Novolog 70/30
function of mixed insulins
Patients may take intermediate-acting and short-acting insulins at the same time to achieve both short-term insulin coverage for meals and basal insulin effect.
pharmacokinetics of injected insulin may vary based on…
Volume, Concentration, Body site (thigh vs. abdomen), Presence of lipodystrophy, Intradermal vs. subcutaneous vs. intramuscular (If site is warm, rubbed or exercised)
three purposes for insulin therapy
basal, prandial, and correctional needs
what is basal insulin
Insulin taken to suppress hepatic glucose production and to maintain normal fasting blood glucose levels
list agents used for basal insulin
glargine (Lantus) and detemir (Levemir)- long acting, and NPH
what happens if diabetic doesn’t inject basal insulin
type 1” DKA. Type 2: severe hyperglycemia but not DKA
What is bolus/prandial insulin
Insulin taken to cover the rise in glucose from a meal. Can be fixed dose or according to carb content of meal. Additional insulin can be taken to correct pre-meal hyperglycemia.
List agents used for prandial insulin
Humalog OR novolog OR glulisine (rapid acting) before each meal
how is prandial insulin dose calculated
Estimated carb to insulin ration: number of grams of carbohydrates that 1 unit of insulin is anticipated to “cover” for that individual. Insulin sensitive individuals may require a C:I ratio of 15:1 or 20:1, while insulin resistant individuals may use a ratio of 10:1, 8:1
what are correctional doses of insulin
used to “correct” a high blood glucose level
List correctional insulin agents
rapid-acting insulin Humalog, Novolg and Apidra
how do you calculate correction factor
1600/ total daily dose of insulin= number of mg/dl that blood glucose is expected to drop with each unit of insulin given as correction dose
list agents used for type 1 diabetes
glargine given once daily for basal bolus OR detemir twice daily for basal bolus and lispro/ aspart/ glulisine before each meal for prandial.
how are pre-mixed insulins given?
NPH + regular injected 30 min before meals. Insulin analog premixes are injected 15 minutes before meals.
possibl causes of early morning hyperglycemia
(1) inadequate basal insulin dosing, (2) bedtime hyperglycemia, (3) waning effect of basal insulin, or (4) the Somogyi effect, which is nocturnal hypoglycemia causing a surge of counter-regulatory hormones resulting in morning hyperglycemia
what is the Continuous subcutaneous insulin infusion (CSII) therapy (insulin pump)
a pump that injects insulin into body in calculated, controlled manner
insulin pump advantages
Eliminates multiple daily injections. Different basal rates- “Dawn phenomenon” or workweek/weekend. Small increment boluses are possible. Different bolus types (square vs. dual wave)
insulin pump caveats
cost, training, motivation, ability to troubleshoot, interruption of infusion or bad site can lead to major problems within hours (ie. DKA)
When is insulin used in type 2 diabetes
If lifestyle modifications and non-insulin combinations don’t achieve target A1c OR contraindications to other meds (renal/hepatic dysfunction, CHF) OR if signs of insulin deficiency on presentation/ hospital admission for diabetic emergency (DKA or hyperglycemic hyperosmolar state)
what are signs of insulin deficiency that warrant insulin in type 2 diabetes
weight loss, fasting blood glucose >250mg/dl, random blood glucose >300mg/dl, or A1C >10%
strategy for instituting insulin in T2D patients
basal insulin alone +/- oral agents > basal insulin + 1-3 mealtime injections OR pre-mixed insulin twice daily > basal insulin + >2 meal time rapid acting injections
ways to monitor blood glucose
glucometers (at least 2x per day but 4x is optimal- fasting, pre-lung, pre-dinner, bedtime), continous glucose monitors (useful if lots of lows)
management of inpatient hyperglycemia
IV insulin if critically ill, or scheduled insulin if not critical
