Lecture 25: Insulin Therapy Flashcards by Brooke Thornburg

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

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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

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IV insulin

-REGULAR
-can use LAG but more expensive not worth it

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insulin suspension

NPH

-cloudy solutions
-DO NOT give as IV

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insulin solutions

-glargine
-degludec

-clear solutions
-do NOT give as IV

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Insulin uses

-type 1 and 2 diabetes
-hyperkalemia
-type 2 diabetes in combo w noninsulin agents

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insulin use in type 1 and 2 diabetes

-high fasting glucose levels > 280-300
-pt w ketoacidosis
-gestational diabetes
-whatever clinician says

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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

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Short acting insulin

-Regular (Humulin R)

-take 30 min before meals

-30-60 min onset
-5-8h duration
-compatible w NPH

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-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

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Long acting insulin

-Glargine (Lantus)
-2-4h onset
-20-24h duration
-no peak
-no combo

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Ultra long acting insulin

-Degludec (Tresiba)
-onset 1h
-24-48h duration
-no peak
-no combo

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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

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Concentrated insulins

-Regular U500 (weight gain)
-Degludec U200
-Toujeo U300
-Lispro U200

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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

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Site of injection

-stomach fastest
-butt and thighs slowest

-dont change the site for same meals

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Temp effect

-heat increases absortpion and action

-outside heat
-heat from exercise

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Exercise effect

-inc absorption and action
-less insulin on exercise days
-impacts injection site

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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