insulin treatment pg 1-12

Question 1

what insulins are approved for IV use?

Answer 1

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

Question 2

what site of injection is the fastest?

Answer 2

abdomen
then buttocks then thigh as the slowest

Question 3

what does heat do to insulin?

Answer 3

increases absorption and action

Question 4

what does exercise/massage do to insulin?

Answer 4

increases absorption and action
effect may depend on inject site

Question 5

how does renal function affect insulin action?

Answer 5

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

Question 6

what does stress do to insulin action?

Answer 6

increases insulin clearance

Question 7

when mixing insulins, which one should you draw up first?

Answer 7

short-acting
stable in fridge for 7 days if regular/NPH
give immediately if aspart, glulisine, or lispro is mixed with NPH

Question 8

what are some causes of hypoglycemia?

Answer 8

increased insulin dosage
decreased caloric intake
increased muscle utilization
excessive alcohol

Question 9

how do b-blockers affect hypoglycemia?

Answer 9

they block the sympathetic warning symptoms
decreases responsiveness to hypoglycemia event

Question 10

how would you treat a hypoglycemia episode?

Answer 10

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

Question 11

what is the rule of 15?

Answer 11

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

Question 12

what are some examples of 15 grams of fast-acting carbohydrates?

Answer 12

4-5oz of OJ
4-6oz of cola
5-6 lifesavers
4tsp of sugar
1 tbsp of honey
4 glucose tablets

Question 13

what are some side effects of insulin therapy?

Answer 13

hypoglycemia
weight gain
lipohypertrophy
lipoatrophy

Question 14

what is lipohypertrophy?

Answer 14

accumulation of fatty tissue caused by repeated injects into the same size

Question 15

what is lipoatrophy?

Answer 15

concavities caused by destruction of fat from antibodies or allergic reactions

Question 16

what are insulin analogs?

Answer 16

glulisine, lispro, or aspart insulin
more closely stimulates physiologic insulin secretion relative to meals

Question 17

what are some advantages of using insulin analogs?

Answer 17

decreases post-prandial hypoglycemia and superior postprandial lowering of blood sugars
fewer overall occurrences of hypoglycemia (and less at night)
greater flexibility

Question 18

what are some disadvantages of insulin analogs?

Answer 18

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

Question 19

what are some long-acting or ultra-long acting insulins?

Answer 19

glargine, degludec

Question 20

what are the advantages of using glargine/degludec?

Answer 20

provides 24+ hours coverage with a constant absorption patter (no pronounced peak)
may be beneficial in patients suffering from nocturnal hypoglycemia due to stabalization

Question 21

what are some disadvantages of glargine/degludec?

Answer 21

some european studies suggest risk of malignancy
cannot be mixed with any other insulins

Question 22

what is the DEVOTE trial?

Answer 22

studied CV risk in long-acting insulins used in patients with T2DM and either CVD or risk of CVD

Question 23

how would dose change when switching from daily NPH to glargine/degludec?

Answer 23

it wouldn’t
keep it the same

Question 24

how would dose change when switching from BID NPH to glargine/degludec?

Answer 24

it would decrease by 20%

Question 25

how would dose change when switching from BID NPH to U-300 glargine?

Answer 25

it would decrease by 20%

Question 26

what would have a conversion factor of 1:1?

Answer 26

daily glargine (lantus/basaglar) to daily glargine (toujeo) basal insulin and u-200 degludec (tresiba) lispro u-100 to u-200

Question 27

how would you determine what dose to change to when switching u-100 to u-500?

Answer 27

assess A1c U-500 replaces both basal and bolus insulin types so depends on TDD

Question 28

how would dose change if the A1c is <8% when switching to U-500?

Answer 28

decrease TDD by 10-20%

Question 29

how would dose change if the A1c is between 8-10% when switching to U-500?

Answer 29

it would not change

Question 30

how would dose change if the A1c is >10% when switching to U-500?

Answer 30

increase TDD by 10-20%

Question 31

how would the dose schedule look for U-500 conversion when TDD is 150-300 units?

Answer 31

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

Question 32

how would the dose schedule look for U-500 conversion when TDD is 300-600 units?

Answer 32

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

Question 33

how would the dose schedule look for U-500 conversion when TDD is >600 units?

Answer 33

30% breakfast 30% lunch 30% dinner 10% bedtime

Question 34

what is the average TDD of T1DM patients?

Answer 34

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)

Question 35

when should T1DM pts check their blood glucose levels?

Answer 35

4 times a day before meals and at bedtime occasionally at 3am to assess insulin dosages

Question 36

what is typical T1DM basal dosing?

Answer 36

1-2 doses of glargine or degludec 1-2+ doses of NPH

Question 37

what is typical T1DM bolus (prandial) dosing?

Answer 37

provided by meal-time short acting or ultra shorting acting insulines (regular, lispro, glulisine, or aspart)

Question 38

what is the typical T1DM basal-bolus dosing?

Answer 38

50-70% is basal 30-50% is bolus it's all variable!

Question 39

how would a mixture of NPH and short-acting be utilized in T1DM?

Answer 39

two daily injections of mixture only breakfast and dinner AM dose --> 40% NPH + 15% short acting PM dose --> 30% NPH + 15% short acting

Question 40

what is the typical starting insulin type in T2DM?

Answer 40

long-acting (glargine/degludec) OR NPH in combination with non-insulin agents (some orals can be d/c when basal/bolus insulin is initiated)

Question 41

what is the ADA recommendation for T2DM starting basal insulin dose?

Answer 41

0.1-0.2 units/kg/day OR 10 units/day

Question 42

what is the AACE recommendation for T2DM starting basal insulin dose?

Answer 42

if A1c is <8%, start 0.1-0.2 units/kg/day if A1c is >8%, start 0.2-0.3 units/kg/day

Question 43

what is the ADA recommendation for T2DM adjusting basal dose?

Answer 43

increase the dose by 2 units every 3 days to reach FBS goal

Question 44

what is the AACE recommendation for T2DM adjusting basal dose?

Answer 44

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

Question 45

when should bolus be added in T2DM?

Answer 45

usually needs it eventually, but especially in pts who are on equal to or greater than 0.5 units/kg/day

Question 46

what is the procedure for adding bolus in T2DM?

Answer 46

- 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

Question 47

what is the average insulin dose for T2DM pts?

Answer 47

over 1 unit per kg