Insulins Flashcards
Which cells secrete insulin?
Pancreatic beta cells
What is the natural insulin secretion profile?
Basal insulin - slow and steady secretion of background insulin that controls glucose continuously; released from liver
Bolus insulin - secreted in response to glucose absorbed from food and drink
What are the three types of insulins available in the UK?
- Human insulin
- Human insulin analogue
- Animal insulin (bovine or porcine)
What inactives Insulin?
G.I enzymes inactivates it, therefore it cannot be taken orally. Therefore given by injection.
Best route is S.C route
Where do patients inject themselves?
In areas with most subcutaneous fat.
- Abdomen (fastest absorption rate)
- Inner thigh
- Outer thigh/buttock (slower absorption compared to abdomen or inner thigh)
What must be done to avoid lipohypertrophy? And why?
Rotate sites to minimise risk.
Injection in the same place can cause area to be infected, bruised, swollen.
What are the three insulin preparations?
- Short acting insulins (soluble & rapid acting)
- Intermediate-acting insulins
- Long acting insulins
When are short rapid acting insulin used?
Injected immediately before meals
Examples of short, rapid insulin?
LAG
- Lispro (Humalog)
- Aspart (Novorapid, fiasp)
- Glulisine (apidra)
What is the onset time and duration for short, rapid acting insulin?
Onset - 15 mins
Duration - 2-5hrs
When is short soluble acting insulin used?
Used in diabetic emergencies like ketoacidosis & perioperatively
What are some examples of short soluble acting inuslin?
Actrapid - Humulin S, Insuman
What is the onset and duration for short soluble acting inuslin?
Onset - 30-60 mins (SC admin)
Duration - 9 hours
What is intermediate insulin? What are the different types? And when is it used?
Different types of insulins mixed together - biphasic - to mimic basal insulin
- Isophane = insulin & protamine
- Mix/pre-mix = has to be mixed up
Injected before meals
What are some examples of Intermediate acting inuslin?
Isophane/NPH - Humulin I
Biphasic - Novomix, Humalogmix, Humulin M3
What is the onset and duration of Intermediate acting insulin?
Onset - 1-2hrs
Duration - 11-24hrs
What are some examples of long acting insulin?
DGD
Detemir - Levemir, added unto to Liraglutide (OD-BD)
Glargine - Lantus, Toujeo (OD)
Degludec - Tresiba (OD)
Which insulins are given to type 2 diabetes?
Determir & lantus
What are the 4 types of insulin regimens?
- Basal-bolus
- Mixed/biphasic regimen
- Once daily regimen
- Continuous subcutaneous insulin infusion (insulin pump)
What is first line recommendation for newly diagnosed type 1 diabetes?
- Basal Bolus regimen
What are the advantages and disadvantages of basal-bolus regimens?
Advantages:
- Very flexible regimen, as you can eat when you like and what you like as doses can be adjusted based on carbohydrate content
- Close to natural secretion profile
- Can be used in type 2 diabetes
Disadvantages:
- Multiple injections needed each day
Example of the basal bolus reigmen?
Includes both basal and bolus insulin, so resembles natural insulin profile.
Basal - Long acting or intermediate insulin is used. Taken OD or BD (usually bed time)
Bolu - Short, rapid acting insulin is used
What is the basal bolus regimen for type 1 n type 2 diabetes?
Type 1 - Short acting at meal times and Long acting (OD or BD) at bed time
Type 2 - Short acting & intermediate acting
What is the once daily regimen?
When a single dose of insulin is taken
Who normally uses the once daily regimen?
Type 2 diabetic patients
Taken alongside oral tablets
Which insulins are given for once daily regimen?
- Long acting
OR - Intermediate Isophane/NPH
Long acting - for people who experience hyperglycaemia throughout the day & night
Intermediate - for people who experience hyperglycaemia at night or morning but fine in the day. So taken before bed.
Explain the Mixed/biphasic regimen?
Injected once, twice or three times a day before meals - for those who have a consistent daily routine that includes 3 meals a day
Biphasic = short acting & intermediate insulin
Usually pre-mixed / mixed with syringe
Which diabetic patients use mixed/biphasic regimen?
Type 1 n type 2
Recommended for new type 2 diabetes (NOT NEWLY TYPE 1)
What is continuous insulin pump? Who’s this normally given to?
When a pump gives a regular / continuous amount of insulin.
This is only for adults who suffer disabling hypoglycaemia or high HbA1c (60mmol/mol +)
Only initiated by specialist
Which factors can affect insulin requirements and cause poor glucose control?
- Adherence
- Injection technique
- Injection site problems
- Blood glucose monitoring skills
- Lifestyle issues (diet, alcohol, exercise)
- Psychological issues
- Renal disease
- Thyroid disorders
Which activities increase and decrease insulin requirements?
Increases:
- Infection
- Stress
- Accidental or surgical trauma
- Pregnancy (2n & 3rd trimester)
Decreases:
- Physical activity
- Vomiting
- Reduced food intake
- Impaired renal function
- Certain endocrine disorders (e.g. Addisons disease)
- Fasting
What must be advised and given with hypodermic equipement?
- Advise on safe disposal of lancets, single use syringes and needles and provide suitable disposable containers
- Advise on disposal of these containers
Explain the sick day rules of diabetic patients?
SICK
Sugar - you’ll have to measure your blood glucose levels more, because they tend to rise when sick, even if the person is not eating. And medications may need to be increased temporarily during illness to manage these glucose levels.
Insulin - Never stop insulin or oral diabetes medications; these may need to be increased, especially if ketones are present.
Carbohydrate - ensure patient maintains carbs intake and hydration. If vomiting, replace meals with sugary fluids.
If glucose levels are high, maintain fluid intake with sugar-free fluids.
If low, have regular intake of sugary fluids.
Ketones - Type 1 diabetes must check for ketones every 2-4 hours.
Give extra rapid-acting insulin doses (in addition to regular doses) based on total daily insulin dose, if ketones are present.
Advise to drink plenty of water to flush ketones and remain hydrated.
What are SADMAN rules?
The medications that must be stopped when a diabetic patient is sick.
S - SGLT2
A - ACE inhibitors
D - Diuretics
M - Metformin
A - ARBs
N - NSAIDs
What medications must be stopped temporarily when sick, and why?
- SGLT2 = Can cause dehydration, and increase risk of developing euglycaemic DKA
- ACE inhibitors = Can cause dehydration, and increase risk of developing AKI due to reduced renal efferent vasoconstriction.
- Diuretics = Can cause dehydration, and increase risk of developing AKI
- Metformin = Can cause dehydration, and increase risk of developing lactic acidosis
- ARBs = Can cause dehydration, and increase risk of developing AKI
- NSAIDs = Can cause dehydration, and increase risk of developing AKI due to reduced renal afferent vasodilation.
When can a person start taking the SADMAN medications again?
Once the person is feeling better and able to eat n drink for 24-48 hours.
Which SADMAN medications can increase risk of developing AKI?
ACE inhibitors
Diuretics
ARBS
NSAIDs
What should be done to reduce errors with insulin?
- Provide them with more adequate information
- Explain difference in appearance of different insulin
- Training programmes for health care staff
- Always check insulin container, pen, and needle size.
What are some important safety information for insulin?
- MHRA advice = risk of cutaneous amyloidosis at injection site. Injection can lead to deposits of amyloid proteins under the skin, which interferes with insulin absorption and affects glycaemic control.
So advise, if a lump is present at injection site, avoid injecting there; frequently rotate sites. - Advise patients to not withdraw insulin pens or cartridges devices, with a syringe. You use the pens n cartridges devices as they are.
- On prescriptions, words like ‘units’ or ‘international units’ should not be abbreviated.
What are the insulin monitoring levels?
For most time = 4-9mmol/litre
Before meals = 4-7mmolL
After meals = <9mmol/L
Stop levels falling before 4mmol/l. Keep it around 5mmol/l.
What are some further advice given to patients n carers for all insulin?
- Instruct on how to avoid hypoglycaemia
- Offer insulin passports and PILs to all patients receiving insulin.
- Drivers told to avoid hypoglycaemia
What is bovine insulin?
Cow insulin
What is Porcine insulin?
Pig insulin
What is the dose change when changing from animal insulin to human insulin?
Bovine to human - reduce dose by 10% to avoid hypoglycaemia
Porcine to human - no dose change
