Lecture 11: Insulin (exam 3) Flashcards
Insulin therapy
biosynthesis: recombinant DNA origin
- genetic code for humin proinsulin is inserted into plasmid of ___ or ___ or yeast
- end product is indentical to human insulin after purification
E. coli
S. cerevisiae
Physical and CHemical Properties
T or F: NPH is a solution
F; suspension
not IV
Physical and CHemical Properties
Glargine is a ___ solution, but do not give ___
- ___ at physiological pH
clear
IV
precipitates
Physical and CHemical Properties
T or F: aspart, glulisine, lispro, and regular insulin are all approved for IV use
T; But there’s no advantage in using aspart, glulisine, or lispro in comparision in regular. Regular is cheaper, so use that one
Physical and CHemical Properties
Detemir and Degludec are ___ solutions but do not give ___
clear
IV
Insulin Uses
type I and II
- high fasting glucose levels: > ___ - ___ mg/dL
- pts with ___
- ___ diabetes
- hyper___
- type ___ diabetes in combination with various non-insulin agents
- 280-300
- ketoacidosis
- gestational
- hyperkalemia
- II
Difference between Toujeo and Toujeo Max
Max: single dose ___ units vs ___ units
- 80
- 160
factors altering insulin action
- route of administration: ___ > ___ > ___
- site of injection: ___ fastest, ___ and ___ slowest
- temperature: heat ___ absorption and action
- exercise/massage ____ absorption and action
IV > IM > SQ
- stomach, buttocks, thigh
- increases
- increases
factors altering insulin action
preparation/mixtures
- short acting effects of insulins may be ___ if mixed incorrectly
- U-500 regular insulin has a delayed ___ , peak, and longer ___ than U-100, but smaller volume allows for more ___
dont want to introduce cloudy NPH into clear, short acting insulin
- lost
- onset, duration, absorption
factors altering insulin action
Renal function
- renal failure ___ insulin clearance, thereby ____ insulin action
- 15-20% of insulin metabolism occurs in the ___
- decreases, increasing
- kidneys
Insulin Stability
- insulin vials are stable at room temp for ___ days
- ___ days with levemir
- insulin pens are variable ____ - ___ days
- open pens/vials should be discarded after ___ days
- insulin in prefilled syringes are stable for ___ days with refigeration as long as not ___
- insulin in prefilled syringes is stable for ___ - ___ days at room temp (highly variable)
- 28
- 42
- 7-56
- 28
- 28, mixed
- 10-28
Mixture stability
- regular/NPH: stable for ___ days in refrigerator; draw up ___ first
- aspart, glulisine, or lispro with NPH: must be given ___
- degludec, detemir, and glargine with any other insulin: ___
- 7, short acting
- immediately
- NEVER
complications of insulin therapy - hypoglycemia
Causes
- increased ___ doses
- decreased ___ intake
- increased ___ utilization
- excessive ___
- insulin
- caloric
- muscle
- alcohol
complications of insulin therapy - hypoglycemia classification
level 1) glucose < ___ mg/dL
level 2) glucose < ___ mg/dL
level 3) severe event with altered ___ and/or ___ functioning needing another person for recovery
- 70
- 54
- mental, physical
hypoglycemia signs and symptoms
- tremors
- diaphoresis
- anxiety
- dizziness
- hunger
- tachycardia
- blurred vision
- weakness/drowsiness
- headache
- irritability
- confusion
- slurred speech
hypoglycemia treatment - rule of 15s
- start with ___ gm of fast acting carbohydrate unless BS < ___ mg/dL (then they can use ___ gm)
- wait ___ min, check BS again. if BS is not > ___ mg/dL, repeat with another ___ gms
- eat your meal if it is in within the hour
- eat ___ gm snack if meal is over an hour away
- ___ for level 2 or 3 patients
- 15, 50, 30
- 15, 79, 15
- 30
- glucagon
hypoglycemia treatment - rule of 15s
examples of glucose sources:
- 4 oz ___
- 6 oz ___
- ___ lifesavers
- ___ tsp sugar
- ___ T honey
- ___ glucose tabs ( ___ gm CHO/tab) or gel
- OJ
- cola
- 5-6
- 2
- 1
- 4, (4-5)
changing between U-100 therapies
- pts switching from daily NPH to glargine/detemir/degludec, keep dose the same
- pts switching from BID NPH to glargine/detemir/degludec, decrease dose by ___ %
same
20%
T or F: you cannot mix other insulins with long acting insulin
T; available in premixtures
hypoglycemia treatment - rule of 15s
Glucagon for level ___ and ___ pts
- 3 mg intranasal ___
- 1 mg SQ, ___ , or IV glucagon
- 0.6 mg SQ ___
2, 3
- Baqsimi
- IM
- dasiglucagon
complications of insulin therapy
- weight ___
- lipo___ - repeated injections into the same site
- lipo___ - concavities caused by destruction of fat from antibodies or allergic reactions (rare with human insulin)
- gain
- lipohypertrophy
- lipoatrophy
review of agents
which analogs closely simulates physiologic insulin secretion relative to meals? (3)
glulisine, lispro, or aspart
Advantages of Short acting insulin
- decrease ____ hypoglycemia
- superior ___ lowering of BG
- fewer overall occurances of ___
- less ___ hypoglycemia
- greater flexibility
- post prandial
- post prandial
- hypoglycemia
- nocternal
made to take befor you eat, but you can also give after (good for kids)
Disadvantages to short acting insulin
- risk of hypoglycemia if no meal within ___ min of dose
- will need to combine with ___ acting insulin for optimal BS control
- if mixed with another insulin, give ___ after mixing
- hyperglycemia and ___ may occur more rapidly if insulin delivery in interupted
- 15 min
- long
- immediatley
- ketosis
Advantages of Long acting insulins
- provides ___ + hr coverage with a constant absorption pattern and no ___ peak
- may be beneficial in pts suffering from ___ hypoglycemic episodes
- 24+ hr
- pronounced
- nocternal
T or F: detemir may be the shortest acting of the 3 long acting insulins and can require BID dosing in order to achieve 24 hr coverage
T
Disadvantages of Long acting insulins
- risk of malignancy for ___ (potentially?)
- can not be ___ with other insulins
- glargine
- mixed
one trial showed increased cancer risk with glargine vs other types
Glargine vs Degludec
DEVOTE trial
- T2DM with either CVD or risk factors
- Primary: not a statistically signifant difference in CV death, non fatal MI, or stroke
- Secondary: severe ___ moreso in ___ (p < 0.001)
- hypoglycemia
- glargine
Changing between U-100 therapies
if pt change from daily NPH to glargine/detemir/degludec…
keep dose the same
Changing between U-100 therapies
if pts change from BID NPH to glargine/detemir/degludec…
decrease dose by 20%
Changing from U-100 to concentrated insulin therapy
if pt changes from BID NPH to U-300 glargine…
decrease dose by 20%
Changing from U-100 to concentrated insulin therapy
___ conversion between daily ___ (Lantus, Basaglar, or Semglee) or daily ___ (Levemir) to daily ___ (Toujeo ot Toujeo Max) but pt may need to ___ dose for Toujeo or Toujeo Max
- 1:1
- glargine
- detemir
- glargine
- increase
Changing from U-100 to concentrated insulin therapy
___ conversion between basal insulin and U-200 insulin ____ (Tresiba)
- 1:1
- degludec
Changing from U-100 to concentrated insulin therapy
1:1 conversion between ___ U-100 to U-200
lispro
Changing from U-100 to concentrated insulin therapy
U-100 basal-bolus regimen to U-500 regimen may require ___ % dosage reduction depending on BS readings/A1C
- calculate pts ___
- if A1C is > 8% consider ___ conversion
- if A1C less than or equal to 8% , use ___ % reduction
20%
- TDD (total daily dose)
- 1:1
- 20%
T or F: U-500 replaces both basal and bolus insulin
True
has both a peak and long tail
BID U-500 dosing example
Breakfast: 60%
Dinner: 40%
TID U-500 Dosing example
Breakfast: 40%
Lunch: 30%
Dinner: 30%
OR
Breakfast: 40%
Lunch: 40%
Dinner: 20%
Insulin dosing - T1DM
avg daily dose: ___ units/kg/day
- use ___ body weight
Newly diagnosed pt dose: ___ units/kg/day
ideally, pts should test BG ___ times daily
- 0.5-0.6
- actual
- 0.4
- 4
test before meals, at bedtime, and occasionally at 3 am
Insulin dosing - T1DM
honeymoon phase - pancreas will remember how to do its job and will make insulin. Might need to adjust how much insulin is given ___-___ units/kg/day
0.1-0.4
Insulin dosing - T1DM
Basal: provided by either ___ doses of ___ , ___ , or ___. Or ___ +doses of ___
- 1-2
- glargine
- detemir
- degludec
- 1-2+
- NPH
Insulin dosing - T1DM
Bolus: ___ time ___ acting insulins like ___ , ___ , ___ , and ___
- ___ - ___ % of the insulin requirements are usually given as basal insulin while the other ___ - ___% is divided among meals as bolus insulin
- meal, short
- regular, lispro, glulisine, aspart
- 50-70%
- 30-50%
Insulin dosing - T1DM example 1
for a 60 kg pt
total insulin requirement = ___ units
Bolus: (????)
Basal: (????)
use 0.5 units/kg/day for easy math
30
5-5-5-0
0-0-0-15
adds to 30, will adjust according to each pt
prandial doses can be adjusted based on carb content of meals; a good starting point is 1 unit for every ___ gm of CHO
Ratio: ___
15
1:15 insulin:CHO
Insulin dosing - T1DM
___ daily injections of a mixture of ___ and short acting
Split daily dosing:
- AM: ___ % ___ + ___ % short acting
- PM: ___ % ___ + ___ % short acting
- R/N - 0 - R/N - 0
- R/N - 0 - R - N
less common now with ultra short acting
Two, NPH
- 40%, 15%
- 30%, 15%
70/30 - 0 - 70/30 - 0
75/25 - 0 - 75/25 - 0
Insulin dosing - T1DM example 2
for a 60 kg pt
total insulin requirement = ___ units
Regular: (????)
NPH: (????)
30
4-0-4-0
12-0-9-0
R: 0.15 x 30 = 4 ish
N: 0.3 x 30 = 9
0.4 x 30 = 12
Insulin dosing - T2DM
usually ___ acting ( ___ , ___ , or ___ ) or intermediate ___ is started in combo with ___ agents
- ___ insulin added to previous ___ therapies
- helps supress ___ glucose production at ___
- orals like ___ may be discontinued especially when basal/bolus insulin is initiated
long, glargine, deludec, detemir, NPH, non-insulin
- bedtime, non-insulin
- hepatic, night
- SU
Insulin dosing - T2DM starting dose
ADA: ___ units/kg/day or ____ units/day
AACE: A1C < 8%, start ___ units/kg/day
A1C > 8% start ___ units/kg/day
___ ish units/day
- 0.1-0.2, 10
- 0.1-0.2, 0.2-0.3
- 10-15
Insulin dosing - T2DM adjusting the dose
ADA: increase the dose by ___ units every 3 days to reach FBG goal ( ___ mg/dL )
AACE: titrate every ___ days based on BG level
- > 180 mg/dL: add ___ % of TDD
- 140-180 mg/dL: add ___% of TDD
- 110-139 mg/dL: add ___ unit
- < 70 mg/dL: decrease by ___% of TDD
- < 40 mg/dL: decrease by ___% of TDD
2 units, 80-130 mg/dL
2-3 days
- 20%
- 10%
- 1 unit
- 10-20%
- 20-40%
Insulin dosing - T2DM adjusting the dose
Basal is provided by either ___ doses of ___ , ___ , or ___
Or 1-2 doses of ___
1-2, glargine, detemir, degludec
NPH
Insulin dosing - T2DM adjusting the dose
eventually, many T2DM pts will need ___ insulin similar to T1DM
- consider addition when greater than or equal to ___ units/kg/day
- usually can start with ___% basal dose or ___ units of ultra-short/short acting insulin with largest meal
- may start with ___ meal at a time or all ____ based on severity
- adjust dose by ___ % every ___ days
- can pull some from the basal dose to prevent ___
- may also provide carb ratio of ___ units for every ___ gm CHO
bolus
- 0.5
- 10%, 4-5
- 1, 3
- 10-15%, 3-4
- hypoglycemia
- 1-2, 15 gm
Insulin dosing - T2DM
mixed can also be used
N/R - 0 - N/R - 0
N/R - 0 - R - N
R can be replaced by ___ , ___ , or ___
Available pre-mixes can be used
Ls, A, G
T or F: the average insulin dose for patients with T1DM is ofter greater than 1 unit/kg
F; T2DM
