insulin treatment pg 1-12 Flashcards
kania pt 2
what insulins are approved for IV use?
aspart, glulisine, lispro, and regular are all approved but only regular insulin is used due to cost and no clear advantage of the other three
what site of injection is the fastest?
abdomen
then buttocks then thigh as the slowest
what does heat do to insulin?
increases absorption and action
what does exercise/massage do to insulin?
increases absorption and action
effect may depend on inject site
how does renal function affect insulin action?
renal failure decreases insulin clearance thus increasing insulin action
leads to a greater risk of hypoglycemia
15-20% of insulin metabolism occurs in the kidney
what does stress do to insulin action?
increases insulin clearance
when mixing insulins, which one should you draw up first?
short-acting
stable in fridge for 7 days if regular/NPH
give immediately if aspart, glulisine, or lispro is mixed with NPH
what are some causes of hypoglycemia?
increased insulin dosage
decreased caloric intake
increased muscle utilization
excessive alcohol
how do b-blockers affect hypoglycemia?
they block the sympathetic warning symptoms
decreases responsiveness to hypoglycemia event
how would you treat a hypoglycemia episode?
check blood glucose level to confirm
rule of 15
repeat if necessary
if eating meal within an hour, no follow up
if meal is over an hour away, eat a 30 gram carbohydrate snack
what is the rule of 15?
after confirming hypoglycemia episode (BS less than 70), eat 15 gm of fasting acting carbohydrate
wait 15 minutes
check BS again
if not above 70mg/dL, repeat another 15 grams
what are some examples of 15 grams of fast-acting carbohydrates?
4-5oz of OJ
4-6oz of cola
5-6 lifesavers
4tsp of sugar
1 tbsp of honey
4 glucose tablets
what are some side effects of insulin therapy?
hypoglycemia
weight gain
lipohypertrophy
lipoatrophy
what is lipohypertrophy?
accumulation of fatty tissue caused by repeated injects into the same size
what is lipoatrophy?
concavities caused by destruction of fat from antibodies or allergic reactions
what are insulin analogs?
glulisine, lispro, or aspart insulin
more closely stimulates physiologic insulin secretion relative to meals
what are some advantages of using insulin analogs?
decreases post-prandial hypoglycemia and superior postprandial lowering of blood sugars
fewer overall occurrences of hypoglycemia (and less at night)
greater flexibility
what are some disadvantages of insulin analogs?
risk of hypoglycemia if no meal within 15 minutes of dose
will need to combine with a longer acting insulin for optimal blood sugar control
if mixed with another insulin –> give immediately
hyperglycemia/ketosis may occur more rapidly if insulin delivery is interrupted
what are some long-acting or ultra-long acting insulins?
glargine, degludec
what are the advantages of using glargine/degludec?
provides 24+ hours coverage with a constant absorption patter (no pronounced peak)
may be beneficial in patients suffering from nocturnal hypoglycemia due to stabalization
what are some disadvantages of glargine/degludec?
some european studies suggest risk of malignancy
cannot be mixed with any other insulins
what is the DEVOTE trial?
studied CV risk in long-acting insulins used in patients with T2DM and either CVD or risk of CVD
how would dose change when switching from daily NPH to glargine/degludec?
it wouldn’t
keep it the same
how would dose change when switching from BID NPH to glargine/degludec?
it would decrease by 20%
how would dose change when switching from BID NPH to U-300 glargine?
it would decrease by 20%
what would have a conversion factor of 1:1?
daily glargine (lantus/basaglar) to daily glargine (toujeo)
basal insulin and u-200 degludec (tresiba)
lispro u-100 to u-200
how would you determine what dose to change to when switching u-100 to u-500?
assess A1c
U-500 replaces both basal and bolus insulin types so depends on TDD
how would dose change if the A1c is <8% when switching to U-500?
decrease TDD by 10-20%
how would dose change if the A1c is between 8-10% when switching to U-500?
it would not change
how would dose change if the A1c is >10% when switching to U-500?
increase TDD by 10-20%
how would the dose schedule look for U-500 conversion when TDD is 150-300 units?
change to BID or TID dosing
if BID –> 60% before breakfast and 40% before dinner
if TID –> 40% before breakfast, 30% before lunch, and 30% before dinner
how would the dose schedule look for U-500 conversion when TDD is 300-600 units?
TID dosing
40% before breakfast, 30% before lunch, and 30% before dinner
may consider a 10% dose at bedtime if concerned about nighttime spike and need 4th injection
how would the dose schedule look for U-500 conversion when TDD is >600 units?
30% breakfast
30% lunch
30% dinner
10% bedtime
what is the average TDD of T1DM patients?
0.4 to 1 units/kg/day (actual body weight)
use higher amounts during puberty, menses, and medical illness
use lower amounts in newly diagnosed pts (0.2-0.6)
when should T1DM pts check their blood glucose levels?
4 times a day before meals and at bedtime
occasionally at 3am to assess insulin dosages
what is typical T1DM basal dosing?
1-2 doses of glargine or degludec
1-2+ doses of NPH
what is typical T1DM bolus (prandial) dosing?
provided by meal-time short acting or ultra shorting acting insulines (regular, lispro, glulisine, or aspart)
what is the typical T1DM basal-bolus dosing?
50-70% is basal
30-50% is bolus
it’s all variable!
how would a mixture of NPH and short-acting be utilized in T1DM?
two daily injections of mixture only breakfast and dinner
AM dose –> 40% NPH + 15% short acting
PM dose –> 30% NPH + 15% short acting
what is the typical starting insulin type in T2DM?
long-acting (glargine/degludec) OR NPH in combination with non-insulin agents (some orals can be d/c when basal/bolus insulin is initiated)
what is the ADA recommendation for T2DM starting basal insulin dose?
0.1-0.2 units/kg/day OR 10 units/day
what is the AACE recommendation for T2DM starting basal insulin dose?
if A1c is <8%, start 0.1-0.2 units/kg/day
if A1c is >8%, start 0.2-0.3 units/kg/day
what is the ADA recommendation for T2DM adjusting basal dose?
increase the dose by 2 units every 3 days to reach FBS goal
what is the AACE recommendation for T2DM adjusting basal dose?
titrate every 2-3 days based on blood glucose levels
if over 180 –> add 20% of TDD
if 140-180 –> add 10% of TDD
if 110-139 –> add 1 unit
if under 70 –> decrease by 10-20% of TDD
when should bolus be added in T2DM?
usually needs it eventually, but especially in pts who are on equal to or greater than 0.5 units/kg/day
what is the procedure for adding bolus in T2DM?
- start with 10% of basal dose or 4 units with largest meal
-may start with one meal or all three based on pt preference
-adjust dose by 10-15% every 3/4 days
what is the average insulin dose for T2DM pts?
over 1 unit per kg
