insulin treatment pg 15-21

Question 1

what is a carbohydrate ratio?

Answer 1

a guide for how much insulin one would need to cover the amount of carbohydrate in a meal or snack
average is 1 unit:10-15 grams for adults
1 unit:20-30 grams for school-aged children

Question 2

how would a carb ratio be established?

Answer 2

by dividing the number of grams of carbohydrate for a meal by the amount of bolus insulin given

Question 3

how should a carb ratio be checked to determine effectiveness?

Answer 3

check blood sugar pre and post (3 hours later) meal

Question 4

what is the rule of 500?

Answer 4

500 divided by TDD = number of grams of carbohydrates for 1 unit of insulin
example if pt is taking 40 units
500 / 40 –> 12.5gm of carbohydrate for 1 unit of insulin
so for a 60g meal divide by 12.5 and get roughly 5 units of insulin to cover

Question 5

what is the rule of 1800?

Answer 5

used for correction factor for patients taking ultra-short acting insulins
1800 divided by TDD = number of mg/dL blood glucose will drop for every 1 units of insulin

Question 6

if a patient is taking 90 units of insulin daily, how much will BS decrease with 1 unit of insulin?

Answer 6

20 mg/dL
1800 / 90 –> 20

Question 7

when is correction factor most likely added?

Answer 7

used to add to a dose of prandial insulin when BS are elevated BEFORE a meal
may be used to correct hyperglycemia, but use caution when discussing with pts to avoid stacking

Question 8

what is a good CF baseline?

Answer 8

for every 50 mg/dL over 150, add 1 unit of insulin

Question 9

if a patient is taking regular insulin, what should their baseline be instead of 1800?

Answer 9

1500

Question 10

how would you treat hyperglycemia during fasting?

Answer 10

find cause (bedtime eating, too small dose, somogyi effect)
if on qd long-acting or NPH –> increase dose or consider dividing into BID
if on BID –> increase pre-supper or bedtime dose
if on basal-bolus –> increase basal or PM bolus depending on night readings

Question 11

what should a patient do if hyperglycemia pre-lunch?

Answer 11

increase short acting morning dose/breakfast

Question 12

what should a pt do if hyperglycemia pre-dinner?

Answer 12

increase morning NPH or long insulin dose OR increase short-acting at pre-lunch

Question 13

what should a pt do if hyperglycemia at bedtime?

Answer 13

increase short-acting dose to pre-dinner dose

Question 14

what should a pt do if hypoglycemia during fasting?

Answer 14

decrease evening insulin dose (also check timing of morning test and dose)
if on basal-bolus regimen –> decrease basal

Question 15

what should a pt do if hypoglycemia pre-lunch?

Answer 15

decrease/omit short-acting insulin dose in the morning

Question 16

what should a pt do if hypoglycemia pre-dinner?

Answer 16

decrease lunch bolus dose or morning NPH/long-acting dose

Question 17

what should a pt do if hypoglycemia at bedtime?

Answer 17

add bedtime snack
decrease pre-dinner dose of short acting
decrease pre-dinner dose of NPH if given earlier in the afternoon

Question 18

what is the somogyi effect?

Answer 18

nocturnal hypoglycemia with rebound hyperglycemia (rollercoaster effect)
check BS at 3 am and ask about signs and symptoms
add a bedtime snack
if applicable, move NPH from dinner to bedtime or decrease long-acting dose at night

Question 19

how should a pts regimen be changed when sick?

Answer 19

if they’re sick, they’re likely not eating –> continue insulin but decrease dose
maintain fluid (12 8oz glasses/day)
test urine for ketones (could lead to DKA)

Question 20

when should a pt switch to a concentrated form of insulin?

Answer 20

on large dose (200-300 units/day)

Question 21

what are some side effects of large insulin doses?

Answer 21

unpredictable absorption
increased pain/discomfort
leakage

Question 22

what are some advantages of concentrated forms of insulin?

Answer 22

provide sustained glucose-lowering effect with less risk of hypoglycemia
lower intra-individual variability
potential for fewer injections, better adherence, less pain, and less frequent pen changes

Question 23

what is afrezza?

Answer 23

inhaled human insulin
AE –> hypoglycemia, cough, URTI, decline in pulmonary function

Question 24

what is icodec?

Answer 24

analogue of human insulin that is used once weekly
approved in other countries, but not really in practice in the US

Question 25

what is teplizumab?

Answer 25

tzield
humanized anti-CD3 monoclonal antibody
may delay T1DM from stage 2 to stage 3
daily IV infusion for 14 consecutive days