Managing Insulin Therapy Flashcards
Insulin peaks
around meal time
Mixed Insulin
Combination of SA with longer-acting NPH-like insulin in one injection
Mixed advantage
Advantage: decreases number of shots potentially while providing both types of insulin coverage
Mixed disadvantage
Disadvantage: Harder to fine-tune
Types of mix
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
clinical indications for insulin type 1
Diabetes Mellitus
Evidence of ongoing catabolism (weight loss)
Symptoms of hyperglycemia are present
Clincial indications for insulin type 2
◦ 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
Administer 50% of daily insulin as ___ and 50% as ____*.
basal (throughout the day)
prandail (meail time
Total daily insulin requirements can be estimated based on weight give details amounts regardin this
◦ Typical doses range from 0.3* to 1.0 units/kg/day
higher doses are requried during
puberty, pregnancy, and medical illness.
The American Diabetes Association/JDRF Type 1 Diabetes Sourcebook notes
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
Multidose regimens for patients with type 1 diabetes combine
emeal use of shorter-acting insulins with a longer-acting formulation,
usually at night
Patient should have
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
Each 15 gm CHO serving raises BG approximately
50 mg/dL.
1 unit bolus of insulin lowers glucose approximately
20 to 60
mg/dL.
The rule of 1,500 enables the provider to find
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.
The rule of 500 enables the provider to find the
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)
• The correction factor (CF) and insulin to
carbohydrate (CHO) ratio (I:C) for patients with
either type 1 or 2 DM taking insulin.
Dosing: 50% bolus, 50% basal needs
◦ Depends on
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
◦ Example: 60 kg adult type 1 DM (using 0.5 units/ kg/24
hours)
◦ Requires
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
Must understand:
◦ Insulin regimen: onset, peak, duration of action of insulins uses
◦ Glucose level goals
◦ Process of titration
◦ Patient’s lifestyles and eating habits
Three Basic Regimens
◦ 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
Review BG log: 3-4 days worth of data minimum
◦ 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
◦ Short- and rapid-acting insulin — adjust by no more
than two units (or 10 per cent of the current dose) daily
intermediate-acting, long-acting and pre-mixed insulin — adjust by no more
than two units, or 10 per cent
(whichever is greater), every three to four days
If patient takes more than 1
type of insulin, adjust one type at a time
Clinical signals that may prompt evaluation of overbasalization include
◦ 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
V GO: Basal-bolus disposable insulin delivery device (type 2) Basal and bolus information
◦ Basal: 20,30,40 units/d
◦ Bolus: each push 2 Units
Pramlintide is based on the naturally occurring β-cell peptide amylin
◦ Studies show
variable reductions of A1C (0–0.3%) and body weight (1–2 kg) with addition of
pramlintide to insulin
Metformin
◦ small reductions
in body weight and lipid levels but did not improve A1C (
GLP-1 agonists
◦ small (0.2%) reductions in
n A1C compared with insulin alone in people with type 1 diabetes and also
reduced body weight by ∼3 kg
Sodium–glucose cotransporter 2 (SGLT2)
◦ improvements in
A1C and body weight
◦ two- to fourfold increase in ketoacidosis
•14.16 Insulin should be used for management of type 1 diabetes in
A Insulin
is the preferred agent for the management of type 2 diabetes in pregnancy. E
Either multiple daily injections or insulin pump technology can be used in
pregnancy complicated by type 1 diabetes. C
Insulin resistance decreases dramatically immediately
postpartum, and insulin
requirements need to be evaluated and adjusted as they are often roughly half the
prepregnancy requirements for the initial few
Level 1 hypoglycemia is defined as a
a measurable glucose concentration <70 mg/dL (3.9
mmol/L) but ≥54 mg/dL (3.0 mmol/L).
Level 2 hypoglycemia (defined as a blood glucose concentration
<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
Level 3 hypoglycemia is defined as a severe
event characterized by altered mental and/or
physical functioning that requires assistance from another person for recovery.
treatment ffor hypoglycemia
◦ 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.
Hypoglycemia unawareness occurs more frequently in those who:
• 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).
things that are helpful for hypoglycemia unawareness
- CMG with alarm is helpful
- Improved by avoiding hypoglycemia for several weeks
- Increase target blood sugar
- Accept higher A1c
