Module 10: Diabetes/Insulin (b)

Question 1

Insulin in T2DM

Answer 1

1. Indications for Unstable T2DM
   -Insulin need may NOT be permanent
   —High A1C (>8.5%, and definitely >10%)
   —Fasting plasma glucose >250 mg/dL
   —Random glucose >300 mg/dL
2. Primary A/E — Hypoglycemia & Weight gain

Question 2

Basal Analogues Insulin

-Info — Lantus & Levemir

Answer 2

1. CANNOT be mixed in syringe w/ other insulin

2. 24-hr insulin’s — can be dosed q12 hrs (esp Levemir)

Question 3

Initiating Insulin Therapy

Answer 3

1. Start at 10 units per day — Or initial dose is 0.1-0.2 units/kg/day
2. Decrease dose by about 20% if hypoglycemia — 40% decrease if severe hypoglycemia, such as BG <40

Question 4

Basal Insulin + GLP-1 RA?

Answer 4

1.Combined effect is to decrease both fasting blood glucose and postprandial glucose excursions

2. Insulin will increase body weight and has relatively high hypoglycemia risk
3. GLP-1 RA will decrease body weight and has a low hypoglycemia risk

Question 5

Intensifying Insulin for T2DM

Answer 5

1. If Basal insulin + GLP-1 RA is NOT working, rapid-acting prandial insulin can be added
2. Start with only 1 meal coverage, not all 3 — Ex: 4 units w/ meal (or no more than 10% of basal dose)

Question 6

Pre-Mixed Insulin Therapy for T2DM

-70/30 or 75/25

Answer 6

1. Administer TWICE daily w/ meals — Before breakfast and evening meal

Question 7

Intensive Insulin Therapy

-Multiple Daily Injections/Basal-Bolus Reg

Answer 7

1. Basal insulin PLUS Rapid-acting insulin w/ all meals

2. REFER to endocrinologist

Question 8

Inhaled Insulin

-Afrezza

Answer 8

1. Dry powder formulation of RAPID-ACTING insulin
2. Many patients still need to inject long-acting insulin
3. Indicated for use in adults >18 years — NOT for children or pregnancy
4. CONTRAINDICATED in patients w/ chronic lung disease, such as ASTHMA or COPD **TEST — NOT for Smoking or Lung cancer
5. MONITORING — Pulmonary function testing w/ Spirometry **TEST
   - Monitor baseline, 6 moths, and annually thereafter

PULMONARY TOXICITY**

Question 9

Sx’s of Hypoglycemia

Answer 9

1. Mild Hypoglycemia 50-70 mg/dL — palpitations, tremor, Humber, sweating, anxiety, paresthesia
2. Moderate Hypoglycemia 50-70 mg/dL — behavioral changes, emotional lability, difficulty thinking, confusion
3. Severe hypoglycemia <50 mg/dL — Severe confusion, unconsciousness, seizure, coma, death — Requires help from another individual

Question 10

Factors that Increase risk of Hypoglycemia

Answer 10

1. Impaired Renal or hepatic function
2. Longer duration of DM
3. Frailty and older age
4. Cognitive impairment
5. Impaired counter-regulatory response, hypoglycemia unawareness
6. Physical or intellectual disability
7. ETOH
8. Poly-pharmacy — especially ACEi, ARB, Non-selective BB

Question 11

Combination Therapy

-Do NOT combine?

Answer 11

1. NEVER COMBINE
   - DPP-4 inhibitor and GLP-1agonist
   - Meglitinides and Sulfonylurea’s

Question 12

Combination Therapy

-Combinations w/ Cautions Sulfonylurea + Basal Insulin

Answer 12

1. Sulfonylurea + Basal Insulin
   - Discontinuing sulfonylurea is often recommended w/ insulin use
2. This combo leads to
   - HIGH glucose lowering
   - HIEST RISK for hypoglycemia — Additive effects
   - WEIGHT GAIN -Additive effects
   - Variable cost

Question 13

Combination Therapy

-Combinations w/ Caution TZD + Basal Insulin

Answer 13

1. HIGH glucose lowering
2. HIGH RISK for hypoglycemia
3. Weight gain — additive effects
4. Edema — additive effects
5. Variable cost

Question 14

T2DM and CVD Considerations

Answer 14

1. The following options have CV even risk reduction
   - SGLT-2i’s — “flozin’s”
   - GLP-1 RAs — “glutide”

Question 15

General Considerations for DM and other systems?

Answer 15

1. Albuminuria — Consider ACE or ARB
2. HTN? — Consider ACE or ARB PLUS CCB and/or thiazide as needed
3. Dyslipidemia — Statin — Consider ASCVD risk calculation

Question 16

Child or Adolescent w/ T2DM

-Goals

Answer 16

1. Avoid unplanned pregnancies in young women w/ T2DM, d/t high risk of adverse outcomes
2. Prevent vascular complications of T2DM

Question 17

Child or Adolescent w/ T2DM

-Care of the Adolescent

Answer 17

1. Start w/ Metformin — Okay for Pt’s >10 years old
   - If Metformin doesn’t work — REFER to endocrinologist
2. Get family involvement

Question 18

Child or Adolescent w/ T2DM

-Approved Pharm options

Answer 18

1. Metformin >10 yrs age
2. Liraglutide (GLP-1 RA, T2DM >10 yrs age
3. Insulin — Consider basal insulin for T2DM — Lantus or Levemir

Question 19

Older adults in T2DM

-Class considerations

Answer 19

1. Insulin — Consider how you can Keep it SAFE and SIMPLE
2. GLP-1 RA — Appetite/Weight loss may be an issue — CVD protective
3. SGLT2i — CVD protective
4. TZD (pioglitazone) — AVOID in heart failure, fluid retention and weight gain risk — Potential for fractures

Question 20

Preconception Counseling

-A1C Goal?

Answer 20

1. Preconception counseling should address importance of achieving glucose levels as close to normal as possible
   —Ideally A1C <6.5% to reduce risk of congenital anomalies, preeclampsia, macrossomia, and other complications

Question 21

Management of DM in Pregnancy

Answer 21

1. Fasting glucose — 70-95 mg/dL
2. One-Hour postprandial glucose — 110-140 mg/dL
3. Two-hour postprandial glucose — 100 -120 mg/dL

Question 22

Management of DM in Pregnancy

-Preferred medication?

Answer 22

1. INSULIN ** RECOMMENDATION TEST
   - NO Metformin
2. NPH (Intermediate-acting insulin) Recommended in pregnancy — Good safety data

Question 23

Contraindicated Meds in Pregnancy **TEST

Answer 23

1. AVOID
   - ACEi & ARBs
   - Statins