Lecture 25: Insulin Therapy Flashcards
Insulin biosynthesis
-rDNA
-genetic code for human proinsulin inserted into plasmid of E. coli or bacteria/yeast to produce human proinsulin
-connecting peptide cleaved
-end product identical to human insulin
Physical and chemical properties fo insulin
-Lispro, Aspart, Glulisine, Regular insulin approved IV
-regular insulin used as IV formulation bc other ones are expensive and not even better
-NPH is suspension
-glargine and degludac are solutions
IV insulin
-REGULAR
-can use LAG but more expensive not worth it
insulin suspension
NPH
-cloudy solutions
-DO NOT give as IV
insulin solutions
-glargine
-degludec
-clear solutions
-do NOT give as IV
Insulin uses
-type 1 and 2 diabetes
-hyperkalemia
-type 2 diabetes in combo w noninsulin agents
insulin use in type 1 and 2 diabetes
-high fasting glucose levels > 280-300
-pt w ketoacidosis
-gestational diabetes
-whatever clinician says
Ultra short acting insulins
-Lispro (Humalog)
-Aspart (Novolog)
-Glulisine (Apidra)
-10-20 min onset
-dose after eating
-last 3-5 hours
-compatible when mixed w NPH
Short acting insulin
-Regular (Humulin R)
-take 30 min before meals
-30-60 min onset
-5-8h duration
-compatible w NPH
-intermediate acting insulin
-NPH (humulin N)
-2-4h onset
-8-12h duration
-peak 4-10 hours dont have to give lunch dose
-can combo w lispro, aspart, gluilisince, regular
Long acting insulin
-Glargine (Lantus)
-2-4h onset
-20-24h duration
-no peak
-no combo
Ultra long acting insulin
-Degludec (Tresiba)
-onset 1h
-24-48h duration
-no peak
-no combo
Insulin pre mixtures (short+long)
-NPH/regular mix 70/30 (Humulin 70/30 or Novolin 70/30)
-75% NPH (lispro instead of H) / 25% lispro (humalog 75/25) (or 50/50)
-70% aspart suspension / 30% aspart (Novolog 70/30)
-Degludec/aspart (Ryzodeg 70/30)
-add protamine to short acting to make last longer
Concentrated insulins
-Regular U500 (weight gain)
-Degludec U200
-Toujeo U300
-Lispro U200
Factors altering insulin action
-route of admin
-site of inj
-temp
-exercise/massage
-mixtures
-dose
-compliance
-pt errors
-irregular diet/exercise
-renal function
-stress
-drugs
Site of injection
-stomach fastest
-butt and thighs slowest
-dont change the site for same meals
Temp effect
-heat increases absortpion and action
-outside heat
-heat from exercise
Exercise effect
-inc absorption and action
-less insulin on exercise days
-impacts injection site
Prep/mixture effect
-short-acting effect may be LOST is mixed incorrectly or left too long
-U-500 vs U 100 regular
Dose effect
-smaller dose are absorbed more RAPIDLY
Renal function effect
-dec insulin clearance
=inc insulin action
-15-20% of insulin metabolized by kidneys
Stress effect
-inc insulin clearance
INsulin stability
-vials at room temp: 28 days
-refrigerate vials/pens not in use (NO FREEZE)
-opened: discard after 28 days max
-prefilled syringes (non-mixes): 28 days cold, 10-28 days room temp
Mixture stability: Regular/NPH
-stable 7 days in fridge
-always draw up short-acting fast
Mix stability: L/A/G + NPH
-give immediately
Mix stability: Degludec or Glargine with any other insulin
-NEVER
-NOT COMPATIBLE
Complications of insulin therapy
-HYPOglycemia
-weight gain
-lipohypertrophy
-lipoatrophy
-allergic reactions
Hypoglycemia causes
-inc insulin dosage
-dec caloric intake
-inc muscle utilization
-excess alcohol
Classification hypoglcemia
-Level 1: glucose <70
-2: <54
3: severe event w mental/physical impairment needing another peson for recovery
Low blood sugar symptoms
-shaking
-sweating
-anxious
-dizziness
-hunger
-inc HR
-vision
-fatigue
-HA
-irritable
-lots of sx gonna be masked by beta blockers
Hypoglycemia tx
-Rule of 15s
-15g carb (30g if BG<50)
-wait 15 min and check BG
-if not >70 mg/dL, repeat
-follow w complex carb (30g) if a meal is not planned within one hour
-glucagon for sever
15g fact acting sugars
-4-5oz OJ
-4-6oz cola (half can)
-5-6 lifesavers
-4 tsp sugar
-1 T honey
-glucose tabs/gel
Glucagon
-use for pt w severe hypoglycemia
-IN, SQ, IM, IV
-Baqsimi inhalation 3mg
-Glucagen injection 1mg
-Zegalogue injection 0.6mg
Lipohypertrophy
-repeated inj into same site
-tumerous-like fat pads
Lipoatrophy
-concavities caused by destruction of fat from immune response
Advantages of ultra short
-dec postprandial hypoglycemia
-better lowering of BG
-less risk of hypoglycemia
-better flexibility
Disadvantages of ultra-shorts
-risk of hypoglycemia if no meal right after dose
-need to use w long acting insulin
-must use immediately after mixing
-hyperglycemia may occur faster is insulin delivery interuppted
Advantages of long acting
-24+ hour coverage w constant absorption
-good for pt w nocturnal hyperglycemia
Disadvantages of long acting
-risk of cancer?
-can NOT be mixed w other insulin
Glargine vs degludec
-degludec less hypoglycemia risk
-more expensive maybe
Coverting U-100 insulins
-if pt changes from qd NPH to long acting, keep same dose
-if from BID NPH, dec dose by 20%
Coverting U-100 to concentrated insulins
-if pt change from BID NPH to U-300 glargine, dec dose by 20%
-1:1 conversion between daily glargine or detemir to daily glargine (Toujeo) may need an inc dose over time
-1:1 conversion between basal insulin and U-200 insulin degludec (Tresiba)
-1:1 between lispro U-100 to U-200
-U-100 to U-500 maybe 20% dec depending on A1c (replaces basal and bolus insulin types)
Conversion to U-500
A1c < 8%: dec daily dose 10-20%
A1c = 8-10%: same
A1c >10: inc dose 10-20%
-more at breakfast bc it hangs out longer
If daily dose 150-300 units conversion to U500
-BID 60% before breakfast, 40% dinner
-TID: 40/30/30
If TDD 300-600 units conversion to U500
-change to TID
-consider 10% dose at bedtime for 4th injection
If TDD>600 conversion to U500
30/30/30/10
