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PHRM 844 > Lecture 11: Insulin (exam 3) > Flashcards

Lecture 11: Insulin (exam 3) Flashcards

1
Q

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

A

E. coli
S. cerevisiae

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2
Q

Physical and CHemical Properties

T or F: NPH is a solution

A

F; suspension

not IV

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3
Q

Physical and CHemical Properties

Glargine is a ___ solution, but do not give ___
- ___ at physiological pH

A

clear
IV
precipitates

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4
Q

Physical and CHemical Properties

T or F: aspart, glulisine, lispro, and regular insulin are all approved for IV use

A

T; But there’s no advantage in using aspart, glulisine, or lispro in comparision in regular. Regular is cheaper, so use that one

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5
Q

Physical and CHemical Properties

Detemir and Degludec are ___ solutions but do not give ___

A

clear
IV

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6
Q

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

A
  • 280-300
  • ketoacidosis
  • gestational
  • hyperkalemia
  • II
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7
Q

Difference between Toujeo and Toujeo Max
Max: single dose ___ units vs ___ units

A
  • 80
  • 160
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8
Q

factors altering insulin action

  • route of administration: ___ > ___ > ___
  • site of injection: ___ fastest, ___ and ___ slowest
  • temperature: heat ___ absorption and action
  • exercise/massage ____ absorption and action
A

IV > IM > SQ
- stomach, buttocks, thigh
- increases
- increases

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9
Q

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

A
  • lost
  • onset, duration, absorption
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10
Q

factors altering insulin action

Renal function
- renal failure ___ insulin clearance, thereby ____ insulin action
- 15-20% of insulin metabolism occurs in the ___

A
  • decreases, increasing
  • kidneys
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11
Q

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)
A
  • 28
  • 42
  • 7-56
  • 28
  • 28, mixed
  • 10-28
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12
Q

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: ___
A
  • 7, short acting
  • immediately
  • NEVER
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13
Q

complications of insulin therapy - hypoglycemia

Causes
- increased ___ doses
- decreased ___ intake
- increased ___ utilization
- excessive ___

A
  • insulin
  • caloric
  • muscle
  • alcohol
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14
Q

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

A
  • 70
  • 54
  • mental, physical
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15
Q

hypoglycemia signs and symptoms

A
  • tremors
  • diaphoresis
  • anxiety
  • dizziness
  • hunger
  • tachycardia
  • blurred vision
  • weakness/drowsiness
  • headache
  • irritability
  • confusion
  • slurred speech
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16
Q

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
A
  • 15, 50, 30
  • 15, 79, 15
  • 30
  • glucagon
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17
Q

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

A
  • OJ
  • cola
  • 5-6
  • 2
  • 1
  • 4, (4-5)
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18
Q

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 ___ %
A

same
20%

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19
Q

T or F: you cannot mix other insulins with long acting insulin

A

T; available in premixtures

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20
Q

hypoglycemia treatment - rule of 15s

Glucagon for level ___ and ___ pts
- 3 mg intranasal ___
- 1 mg SQ, ___ , or IV glucagon
- 0.6 mg SQ ___

A

2, 3
- Baqsimi
- IM
- dasiglucagon

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21
Q

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)
A
  • gain
  • lipohypertrophy
  • lipoatrophy
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22
Q

review of agents

which analogs closely simulates physiologic insulin secretion relative to meals? (3)

A

glulisine, lispro, or aspart

23
Q

Advantages of Short acting insulin

  • decrease ____ hypoglycemia
  • superior ___ lowering of BG
  • fewer overall occurances of ___
  • less ___ hypoglycemia
  • greater flexibility
A
  • post prandial
  • post prandial
  • hypoglycemia
  • nocternal

made to take befor you eat, but you can also give after (good for kids)

24
Q

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
A
  • 15 min
  • long
  • immediatley
  • ketosis
25
Q

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
A
  • 24+ hr
  • pronounced
  • nocternal
26
Q

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

A

T

27
Q

Disadvantages of Long acting insulins

  • risk of malignancy for ___ (potentially?)
  • can not be ___ with other insulins
A
  • glargine
  • mixed

one trial showed increased cancer risk with glargine vs other types

28
Q

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)

A
  • hypoglycemia
  • glargine
29
Q

Changing between U-100 therapies

if pt change from daily NPH to glargine/detemir/degludec…

A

keep dose the same

30
Q

Changing between U-100 therapies

if pts change from BID NPH to glargine/detemir/degludec…

A

decrease dose by 20%

31
Q

Changing from U-100 to concentrated insulin therapy

if pt changes from BID NPH to U-300 glargine…

A

decrease dose by 20%

32
Q

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

A
  • 1:1
  • glargine
  • detemir
  • glargine
  • increase
33
Q

Changing from U-100 to concentrated insulin therapy

___ conversion between basal insulin and U-200 insulin ____ (Tresiba)

A
  • 1:1
  • degludec
34
Q

Changing from U-100 to concentrated insulin therapy

1:1 conversion between ___ U-100 to U-200

A

lispro

35
Q

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

A

20%
- TDD (total daily dose)
- 1:1
- 20%

36
Q

T or F: U-500 replaces both basal and bolus insulin

A

True

has both a peak and long tail

37
Q

BID U-500 dosing example

A

Breakfast: 60%
Dinner: 40%

38
Q

TID U-500 Dosing example

A

Breakfast: 40%
Lunch: 30%
Dinner: 30%

OR

Breakfast: 40%
Lunch: 40%
Dinner: 20%

39
Q

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

A
  • 0.5-0.6
  • actual
  • 0.4
  • 4

test before meals, at bedtime, and occasionally at 3 am

40
Q

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

A

0.1-0.4

41
Q

Insulin dosing - T1DM

Basal: provided by either ___ doses of ___ , ___ , or ___. Or ___ +doses of ___

A
  • 1-2
  • glargine
  • detemir
  • degludec
  • 1-2+
  • NPH
42
Q

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

A
  • meal, short
  • regular, lispro, glulisine, aspart
  • 50-70%
  • 30-50%
43
Q

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

A

30
5-5-5-0
0-0-0-15

adds to 30, will adjust according to each pt

44
Q

prandial doses can be adjusted based on carb content of meals; a good starting point is 1 unit for every ___ gm of CHO

Ratio: ___

A

15
1:15 insulin:CHO

45
Q

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

A

Two, NPH
- 40%, 15%
- 30%, 15%

70/30 - 0 - 70/30 - 0
75/25 - 0 - 75/25 - 0

46
Q

Insulin dosing - T1DM example 2

for a 60 kg pt
total insulin requirement = ___ units
Regular: (????)
NPH: (????)

A

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

47
Q

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

A

long, glargine, deludec, detemir, NPH, non-insulin
- bedtime, non-insulin
- hepatic, night
- SU

48
Q

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

A
  • 0.1-0.2, 10
  • 0.1-0.2, 0.2-0.3
  • 10-15
49
Q

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

A

2 units, 80-130 mg/dL
2-3 days
- 20%
- 10%
- 1 unit
- 10-20%
- 20-40%

50
Q

Insulin dosing - T2DM adjusting the dose

Basal is provided by either ___ doses of ___ , ___ , or ___

Or 1-2 doses of ___

A

1-2, glargine, detemir, degludec
NPH

51
Q

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

A

bolus
- 0.5
- 10%, 4-5
- 1, 3
- 10-15%, 3-4
- hypoglycemia
- 1-2, 15 gm

52
Q

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

A

Ls, A, G

53
Q

T or F: the average insulin dose for patients with T1DM is ofter greater than 1 unit/kg

A

F; T2DM

PHRM 844 (52 decks)

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