Intensifying Diabetes Flashcards
What is intensive therapy?
-A system of matching insulin doses to food, activity and life events using individualized adjustment guidelines based on glucose results
What kind of insulin therapy is intensive therapu
-Basal-Bolus Insulin Therapy (BBIT)
How is BBIT be administered?
- Multiple daily-injections (MDI)
- Continuous subcutaneous insulin infusion
Who can use intensive therapy?
-Type 1, Type 1.5, Type 2 and gestational
What is Type 1.5?
-LADE (Late-Autoimmune Diabetes of Adults) looks like Type II initially, but will require insulin earlier. They will also develop anti-bodies similar to type I
What is a key concept with diabetes and intensive insulin therapy?
Individualization of the diet is key
What are the medical benefits of IT?
- 45% reduction in microvascular complications (DCCT)
- 42% risk reduction in cardiovascular events (EDIC)
Other benefits of IT?
- Insulin therapy can be integrated into the individuals preferred lifestyle habits
- Quality of life is improved
- Overall better control
What are the disadvantages of intensive therapy?
- More injections
- Requires CHO counting
- Frequent monitoring(4x/week) is necessary
- Weight gain
3 reasons for weight gain in IT?
- Tighter control = less glycosuria (retaining more sugar)
- Extra insulin for extra food
- Over treating of hypoG
Discuss overtreating hypoG
We know the standard CHO amount to treat HypoG is 15 g, however many people will feel unwell during a hypo and immediately eat as much sugar as they can. This is linked to weight gain and counterintuitive to their goals.
When is a lower A1C target of = 6.5% recommended? Why?
- Adults w/ type II diabetes NOT on insulin secretagogues or insulin
- Likely newly diagnosed
- A1C at this level may increase risk of HypoG if on these drugs
A1C target for most adults with type I or II diabetes?
= 7.0%
A1C target for functionally dependant?
7.1-8.0%
A1C target for recurrent severe hypoglycemia and/or hypoglycemia unawareness, limited life expectancy or frail elderly w/ dementia?
7.1-8.5%
In palliative/comfort care how should A1C be addressed?
- No specific target
- Avoid higher A1C to minimize symptomatic hyperglycemia and acute/chronic complications
To achieve a target A1C of = 7%, what are the targets for preprandial PG and 2-h postprandial PG?
- 4.0-7.0 mmol/L
- 5.0-10.0 mmol/L
If A1C is not at target, what are the target preprandial PG and 2-h postprandial PG?
- 4.0-5.5 mmol/L
- 5.0-8.0 mmol/L
- -> More strict blood glucose targets
When A1C is not optimal, there are more strict BG targets. What should be considered?
Balance benefit against the risk of hypoglycemia
(T/F) we can always realistically normalize blood glucose
F
Diabetes is a combination of genetics and environment. What else can impact a patients management of diabetes?
- Work environment (i.e. busy shift and cannot do injection
- Family dynamics (i.e. working parents, is there support?)
- Education level(i.e for CHO counting)
- Cultural beliefs
- Finances, not all medication is covered
- Mental illness
2 key factors which lead to failure to normalize blood glucose in Type II patients?
- Myths regarding insulin therapy leading to the underutilization of insulin
- Inadequate understanding of the consequences of poor control
What are myths regarding insulin utilization?
- It is a death sentence
- They have failed
- They are extremely sick
- -> The truth is that insulin is simply another medication, which is extremely effective in delaying the onset of other complications
What is the mean time to inulin titration?What is the consequence?
- 9.2 yers
- This is currently TOO late, and is not aggressive enough
- We need earlier intervention
What are the two targets of therapy to achieve normal A1C? What is essential?
-Fasting PG
-2-hr PP PG
Monitoring is essential
Differentiate between monitoring BG values with a glucometer vs. continuous glucose monitoring
- Glucometer is only getting instantaneous screenshots or “frames” of BG during the day
- CGM will continously measure blood glucose, and we can have a “movie” of how BG changed throughout the day
(T/F) Flash glucose monitoring allows us to continually measure BG
F
Similar to glucometer, but easier to do
In people with type II diabetes, what is PPG and independant risk factor for? Has the same been demonstrated for type I diabetes?
Myocardial Infarction
-Not yet, but can be inferred as hyperglycemia ca acutely alter normal homeostasis.
What are 7 factors which can alter PPG?
- Pre-meal blood glucose and timing of injection
- GI of food
- Large volume, high fat/pro/fibre
- Time of day
- Stress, illness, exercise and hormones
- Gastroparesis
- Adequate basal insulin
Discuss PPG and time of of day
- Post-breakfast peaks are often the highest and “most difficult” to bring down - require more insulin.
- Upon waking up our GH and cortisol levels are the highest, therefore we have insulin resistance in the early AM
- We also tend to eat more refined CHOs for breakfast
Discuss PPG and gastroparesis
- Can offset the onset of insulin and expected digestion of the meal
- Can cause either hyper or hypoglycemia depending when insulin is taken
How can we asses if there is adequate basal insulin?
If they skip a meal, their basal insulin should keep BG steady.
-If BG creeps up, we may need to increase basal insulin.
_____ is the largest glycemic excursion of the day
Breakfast
Administration of rapid insulin analogs ____ mins before mealtime will result in lower post-prandial glucose excursions and more time spent in the ____ mmol/L range without increased risk of hypoglycemia.
- 15
- 3.5-10.0
The postprandial glucose has a mean peak time of _____
75 minutes
When do rapid-acting insulin analogs display a maximum effect after subcutaneous injection?
~100 mins
When will the height of the postprandial glucose excursion be minimized?
When the insulin peak action is synchronized with the glycemic excursions after a meal
What is key about giving bolus insulin?
The timing
Which type of insulin may be most effective for a synchronized peak with the glycemic excursion?
- Faster-acting
- Can inject right at time 0 (beginning of meal)
Why is it so hard for people to achieve their blood sugar targets?
The fear of hypoglycemia
What is common behaviours observed in patients with hypo fears?-
- Often very scared of night-time reactions and will keep BG high at bedtimes “just in case”
- Over-treat hypoG
“Morning-after” symptoms of hypoG?
- Wicked morning headache
- Foggy head
- Waking up w/ messed up blankets
- Nightmares or vivid dreams
Explain why having one hypo reaction will increase the risk for another
- During a hypo, there is a rapid utilization of counterregulatory hormones glucagon, cortisol and adrenaline
- These hormones are rapidly depleted, and take time for store to replenish
- Physiologically disadvantaged to increase BG after a hypo
What are important questions to aks someone after having a hypo?
- When did it happen?
- Did they check their BG when symptomatic?
- How are they treating?
- Why did it happen?
Explain how alcohol cause hypo
If we have low blood sugar, glucagon in the liver will function to increase BG. If there is alcohol, it will be detoxing in the liver, sparing the function of glucagon.
Why is A1C not always representative of good glucose control?
Because A1C is the AVERAGE
-We don’t know if this i the average between crazy highs and crazy lows
What is important to communicate about A1C to patients?
- That average blood glucose and A1C are NOT the same things
- A1C is an indicator of long-term glucose control over the pat 3 months
- Average blood glucose is the actual measure and average of Bg
What does Total Daily Dose (TDD) mean in Type I diabetes?
- Includes both basal and bolus insulin needs
- Ideally 50% of total dose given as basal insulin and 50% as rapid (bolus)
What is the typical Type I adult diabetic insulin dosage?
0.3-1.0 units/kg/day
When is 0.3 units/kg used?
New onset of type I
Why is such a low insulin dose used in new onsets of type I?
- They likely have some residual pancreatic function and insulin production
- “Honeymoon” period where in 1-2 year they will require more insulin
Average insulin dosage in Type I diabetes?
0.5-0.7 units/kg/day
Insulin dosage in young adults (age 18-21) Type I DM?
- 0.7-1.0
- Higher due to “still growing” higher GH causing insulin resistance
Recommended adult dosage of insulin if HBW?
0.5 units/kg
Recommended adult dosage of insulin if overweight?
0.7 units/kg
Recommended adult dosage of insulin if obese with A1C >9%?
1.0 units/kg
What does the Insulin to Carb ratio tell us?
How many grams of CHO are “covered” by 1 unit of
insulin
-The ratios vary at meals, and the strongest ratio is usually at breakfast (“tighter” carb ratio)
I:C when TDD > 40 units total?
500/TDD = 1 unit: ___ g CHO
I:C when TDD < 40 units total?
450/TDD = 1 unit: ___ g CHO
How should we compare I:C with?
With weight requirement formula
-Then use clinical judgement
What is the weight formula for I:C ratio?
(5.7 x wt) / TDD = 1 unit: ___ g CHO
What is the sensitivity/correction factor?
The drop in mmol/L that each unit of rapid insulin will provide
What is the sensitivity/correction factor useful for?
Correcting glucose once a target is set. allows for better control
How is ISF estimated?
100/TDD = ISF
How can ISF be used so patients can calculate their own correction insulin dosages?
(Actual BG - target BG) / Rounded off ISF
What are they 4 rules of good blood glucose control ?
- Check A1C and ensure it is a true value
- Consider hypo
- See if basal is adequate
- Bolus: look at mealtimes 2hr post to evaluate carb:ration
When may A1C be invalid?
- Anemia
- Blood loss
- High and lows providing an acceptable “average”
What should always be treated first/prioritized when monitoring patient BG?
-Hypoglycemia
When should their not be a difference of more than 2 mmol/L for BG?
- At night-time
- There is only basal insulin acting, therefore no other factors should affect blood glucose
- Adjust basal insulin if not at target
How can we ensure bolus insulin is titrated properly?
-Aim for no more of a 3 mmol/L elevation after meals
What is self-management education (SME)?
A systematic intervention that involve active patient participation in self-monitoring of health parameters and/or decision making
What does empowering patients through self-management education improve?
- A1C and quality of life
- Guides them towards making informed decisions
- Enables and enhances problem-solving skills
What are the basic knowledge skills that all patient should know?
- SMBG
- Medication adjustment
- Problem solving and identifying
What is lipohypertrophy?
A lump under the skin caused by the accumulation of extra fat at the site of many subcutaneous injections of insulin.
What are the consequences of lipohypertrophy? What should we recommend?
- Unsightly, mildly painful and may change the timing or completeness of insulin action
- Rotate injection sites often
What would be a concern about changing insulin injection sites due to lipohypertrophy?
- With lipohypertrophy, the insulin release is slow and incomplete
- Therefore, if we move to a new site, there will be more sensitivity
- May risk hypoglycemia
- May have to reduce insulin medication
A patient has an average CHO intake of 56 g at breakfast with an average insulin administration of 4 units. What is the CHO ratio?
56 g CHO/4 Units insulin = 14 g CHO per unit of insulin
When is it a good time to calculate CHO ratios?
- When the patients blood glucose is well controlled
- When the blood sugar is in target before a meal an doesn’t rise more than 3 mmol/L at 2hours post meal
