insulin treatment

Question 1

· Describe physiologic insulin secretion in the fasting and postprandial states

Answer 1

pancreas secretes insulin in response to glucose and to maintain basal concentration.

Question 2

phases of insulin secretion

Answer 2

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

Question 3

List rapid acting insulins

Answer 3

humalog (Lispro), novolog (Aspart), glulisine (Apidra)

Question 4

rapid acting insulins pharmacokinetics

Answer 4

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

Question 5

List short acting( regular) insulins

Answer 5

Humulin R; Novolin R

Question 6

Short acting insulins pharmacokinetics

Answer 6

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

Question 7

List intermediate acting insulins/NPH

Answer 7

neutral protamine hagedorn, Humulin N; Novolin N

Question 8

Intermediate acting insulins pharmacokinetics

Answer 8

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

Question 9

List long acting insulins

Answer 9

glargine (Lantus) and detemir (Levemir)

Question 10

long acting insulins pharmacokinetics

Answer 10

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)

Question 11

list pre mixed insulins

Answer 11

Human: (%NPH/%regular): 70/30, 50/50. Analogs: Humalog 75/25, Humalog 50/50, Novolog 70/30

Question 12

function of mixed insulins

Answer 12

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.

Question 13

pharmacokinetics of injected insulin may vary based on…

Answer 13

Volume, Concentration, Body site (thigh vs. abdomen), Presence of lipodystrophy, Intradermal vs. subcutaneous vs. intramuscular (If site is warm, rubbed or exercised)

Question 14

three purposes for insulin therapy

Answer 14

basal, prandial, and correctional needs

Question 15

what is basal insulin

Answer 15

Insulin taken to suppress hepatic glucose production and to maintain normal fasting blood glucose levels

Question 16

list agents used for basal insulin

Answer 16

glargine (Lantus) and detemir (Levemir)- long acting, and NPH

Question 17

what happens if diabetic doesn’t inject basal insulin

Answer 17

type 1” DKA. Type 2: severe hyperglycemia but not DKA

Question 18

What is bolus/prandial insulin

Answer 18

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.

Question 19

List agents used for prandial insulin

Answer 19

Humalog OR novolog OR glulisine (rapid acting) before each meal

Question 20

how is prandial insulin dose calculated

Answer 20

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

Question 21

what are correctional doses of insulin

Answer 21

used to “correct” a high blood glucose level

Question 22

List correctional insulin agents

Answer 22

rapid-acting insulin Humalog, Novolg and Apidra

Question 23

how do you calculate correction factor

Answer 23

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

Question 24

list agents used for type 1 diabetes

Answer 24

glargine given once daily for basal bolus OR detemir twice daily for basal bolus and lispro/ aspart/ glulisine before each meal for prandial.

Question 25

how are pre-mixed insulins given?

Answer 25

NPH + regular injected 30 min before meals. Insulin analog premixes are injected 15 minutes before meals.

Question 26

possibl causes of early morning hyperglycemia

Answer 26

(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

Question 27

what is the Continuous subcutaneous insulin infusion (CSII) therapy (insulin pump)

Answer 27

a pump that injects insulin into body in calculated, controlled manner

Question 28

insulin pump advantages

Answer 28

Eliminates multiple daily injections. Different basal rates- “Dawn phenomenon” or workweek/weekend. Small increment boluses are possible. Different bolus types (square vs. dual wave)

Question 29

insulin pump caveats

Answer 29

cost, training, motivation, ability to troubleshoot, interruption of infusion or bad site can lead to major problems within hours (ie. DKA)

Question 30

When is insulin used in type 2 diabetes

Answer 30

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)

Question 31

what are signs of insulin deficiency that warrant insulin in type 2 diabetes

Answer 31

weight loss, fasting blood glucose >250mg/dl, random blood glucose >300mg/dl, or A1C >10%

Question 32

strategy for instituting insulin in T2D patients

Answer 32

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

Question 33

ways to monitor blood glucose

Answer 33

glucometers (at least 2x per day but 4x is optimal- fasting, pre-lung, pre-dinner, bedtime), continous glucose monitors (useful if lots of lows)

Question 34

management of inpatient hyperglycemia

Answer 34

IV insulin if critically ill, or scheduled insulin if not critical