Managing Insulin Therapy

Question 1

Insulin peaks

Answer 1

around meal time

Question 2

Mixed Insulin

Answer 2

Combination of SA with longer-acting NPH-like insulin in one injection

Question 3

Mixed advantage

Answer 3

Advantage: decreases number of shots potentially while providing both types of insulin coverage

Question 4

Mixed disadvantage

Answer 4

Disadvantage: Harder to fine-tune

Question 5

Types of mix

Answer 5

70/30: Aspart (Novalog) Mix: 70% insulin aspart protamine (likeNPH), 30% aspart (like Novalog)
50/50 Humalog Mix: 50% insulin lispro protamine (like NPH), 50% lispro (Humalog)
70/30 Regular Mix: 70% NPH, 30% Regular

Question 6

clinical indications for insulin type 1

Answer 6

Diabetes Mellitus
Evidence of ongoing catabolism (weight loss)
Symptoms of hyperglycemia are present

Question 7

Clincial indications for insulin type 2

Answer 7

◦ A1c>10%
◦ Blood glucose levels (≥300 mg/dL)

◦ Consider:
◦ Effect of treatment on cardiovascular and renal comorbidities, efficacy, hypoglycemia risk, impact on weight, cost, risk for
side effects, and patient preferences
◦ GLP-1 Agonist or SGLT-2 Cotransporter may be preferable

Question 8

Administer 50% of daily insulin as ___ and 50% as ____*.

Answer 8

basal (throughout the day)

prandail (meail time

Question 9

Total daily insulin requirements can be estimated based on weight give details amounts regardin this

Answer 9

◦ Typical doses range from 0.3* to 1.0 units/kg/day

Question 10

higher doses are requried during

Answer 10

puberty, pregnancy, and medical illness.

Question 11

The American Diabetes Association/JDRF Type 1 Diabetes Sourcebook notes

Answer 11

0.5 units/kg/day as a typical starting dose in patients with type 1 diabetes who
are metabolically stable
◦ half administered as prandial insulin given to control blood glucose after meals and the other half as basal insulin to control glycemia in the periods between meal absorption

Question 12

Multidose regimens for patients with type 1 diabetes combine

Answer 12

emeal use of shorter-acting insulins with a longer-acting formulation,
usually at night

Question 13

Patient should have

Answer 13

regimen closest to physiologic insulin pattern
Patient needs to have emergency plan for hypoglycemia
Patient needs to have “sick day” plan when oral intake is compromised

Question 14

Each 15 gm CHO serving raises BG approximately

Answer 14

50 mg/dL.

Question 15

1 unit bolus of insulin lowers glucose approximately

Answer 15

20 to 60

mg/dL.

Question 16

The rule of 1,500 enables the provider to find

Answer 16

the CF or how much 1 unit of insulin will lower
blood glucose for high blood glucose levels (usually >140 to 150 mg/dL). First, calculate the
total daily dose (TDD) of insulin as basal + bolus—about 50% of each. Then divide 1,500 by
the TDD. For example, 1,500 divided by 30 units per day of insulin equals 50. One unit of
short-acting insulin will drop glucose 50 mg/dL. For rapid-acting insulin, use 1,800 as the
basis for calculation.

Question 17

The rule of 500 enables the provider to find the

Answer 17

I:C ratio. Divide 500 by the TDD. For
example, 500 divided by 30 units per day of insulin equals 16.7 One unit of insulin will
manage 16 to 17 g of CHO. For ease of use, round to 1 unit equals 15 g (Scheiner, 2017)

Question 18

• The correction factor (CF) and insulin to

Answer 18

carbohydrate (CHO) ratio (I:C) for patients with

either type 1 or 2 DM taking insulin.

Question 19

Dosing: 50% bolus, 50% basal needs

◦ Depends on

Answer 19

blood gas (BG) levels, diet, exercise, weight
◦ Based on type of DM, type of insulin, calories, exercise
◦ Average insulin doses: 0.3 to 0.8 units/kg/24 hours

Question 20

◦ Example: 60 kg adult type 1 DM (using 0.5 units/ kg/24
hours)
◦ Requires

Answer 20

30 units
◦ Insulin glargine (Lantus): 15 units at bedtime
◦ Insulin Lispro: 15 units total divided over meals
◦ Before breakfast: 5 units
◦ Before lunch: 5 units
◦ Before dinner: 5 units

Question 21

Must understand:

Answer 21

◦ Insulin regimen: onset, peak, duration of action of insulins uses
◦ Glucose level goals
◦ Process of titration
◦ Patient’s lifestyles and eating habits

Question 22

Three Basic Regimens

Answer 22

◦ Once daily intermediate-acting or long-acting; usually given at HS
◦ Twice daily pre-mixed: am and at evening or HS (pre-mixed fixed ration SA and LA)
◦ Basal-bolus: 3 daily injections of rapid or SA with meals and 1-2 injections intermediate or LA
(basal) insulin

Question 23

Review BG log: 3-4 days worth of data minimum

Answer 23

◦ Typically am glucose, before lunch and evening meal, before bed
◦ If post-prandial readings added: do 2 h after meals
◦ Identify individual patient glycemic goals
◦ Look for patterns
◦ Note levels that fall outside of target range
◦ Attend to hypoglycemia first

Question 24

◦ Short- and rapid-acting insulin — adjust by no more

Answer 24

than two units (or 10 per cent of the current dose) daily

Question 25

intermediate-acting, long-acting and pre-mixed insulin — adjust by no more

Answer 25

than two units, or 10 per cent

(whichever is greater), every three to four days

Question 26

If patient takes more than 1

Answer 26

type of insulin, adjust one type at a time

Question 27

Clinical signals that may prompt evaluation of overbasalization include

Answer 27

◦ Basal dose more than ∼0.5 IU/kg
◦ High bedtime-morning or post-preprandial glucose differential
◦ Hypoglycemia (aware or unaware)
◦ High variability in BS
◦ Indication of overbasalization should prompt reevaluation to further individualize therapy

Question 28

V GO: Basal-bolus disposable insulin delivery device (type 2) Basal and bolus information

Answer 28

◦ Basal: 20,30,40 units/d

◦ Bolus: each push 2 Units

Question 29

Pramlintide is based on the naturally occurring β-cell peptide amylin
◦ Studies show

Answer 29

variable reductions of A1C (0–0.3%) and body weight (1–2 kg) with addition of
pramlintide to insulin

Question 30

Metformin

◦ small reductions

Answer 30

in body weight and lipid levels but did not improve A1C (

Question 31

GLP-1 agonists

◦ small (0.2%) reductions in

Answer 31

n A1C compared with insulin alone in people with type 1 diabetes and also
reduced body weight by ∼3 kg

Question 32

Sodium–glucose cotransporter 2 (SGLT2)

◦ improvements in

Answer 32

A1C and body weight

◦ two- to fourfold increase in ketoacidosis

Question 33

•14.16 Insulin should be used for management of type 1 diabetes in

Answer 33

A Insulin

is the preferred agent for the management of type 2 diabetes in pregnancy. E

Question 34

Either multiple daily injections or insulin pump technology can be used in

Answer 34

pregnancy complicated by type 1 diabetes. C

Question 35

Insulin resistance decreases dramatically immediately

Answer 35

postpartum, and insulin
requirements need to be evaluated and adjusted as they are often roughly half the
prepregnancy requirements for the initial few

Question 36

Level 1 hypoglycemia is defined as a

Answer 36

a measurable glucose concentration <70 mg/dL (3.9

mmol/L) but ≥54 mg/dL (3.0 mmol/L).

Question 37

Level 2 hypoglycemia (defined as a blood glucose concentration

Answer 37

<54 mg/dL [3.0 mmol/L]) is
the threshold at which neuroglycopenic symptoms begin to occur and requires immediate
action to resolve the hypoglycemic event

Question 38

Level 3 hypoglycemia is defined as a severe

Answer 38

event characterized by altered mental and/or

physical functioning that requires assistance from another person for recovery.

Question 39

treatment ffor hypoglycemia

Answer 39

◦ Tablets, gel tube, injectable (sc), nasal puff
◦ 15-15 rule—15 grams of carbohydrate to raise blood sugar and check it after 15 minutes. If it’s still
below 70 mg/dL, repeat.

Question 40

Hypoglycemia unawareness occurs more frequently in those who:

Answer 40

• Frequently have low blood sugar episodes (which can cause individual to stop sensing the early
warning signs of hypoglycemia).
• Have had diabetes for a long time.
• Tightly control their diabetes (which increases chances of having low blood sugar reactions).

Question 41

things that are helpful for hypoglycemia unawareness

Answer 41

• CMG with alarm is helpful
• Improved by avoiding hypoglycemia for several weeks
• Increase target blood sugar
• Accept higher A1c