Pharmacotherapy of Injectable Medications Exam 2 Flashcards
1
Q
What are the rapid acting insulin?
A
- Insulin lispro (Humalog, Admelog)
- Insulin aspart (Novolog, Fiasp)
- Insulin glulisine (Apidra)
- Afrezza
2
Q
When can you take Fiasp?
A
- before meals
- during meals
- 20 min after meals
3
Q
Rapid acting advantages
A
- Quicker onset
- Shorter duration
- Less hypoglycemia
4
Q
Rapid acting disadvantages
A
• Expensive
• Patients who
graze may need a longer acting insulin
5
Q
Rapid acting pearls
A
• Can be administered closer to meals
• More closely mimics
physiologic action of insulin
• Insurance tends to dictate insulin chosen
6
Q
What are the short acting insulin?
A
Regular insulin (Humulin R, Novolin R)
7
Q
Short acting advantages
A
- Less expensive
* Relion brand $24.99/vial
8
Q
Short acting disadvantages
A
- More hypoglycemia
* Less convenient time course (PK) of activity
9
Q
Short acting pearls
A
Administered 30 min before meal
10
Q
What are the intermediate acting insulin?
A
Insulin (Humulin N, Novolin N)
11
Q
Intermediate acting advantages
A
- Less expensive Relion $24.99
- Can be mixed with other insulins
- Peak can be helpful in some patients to cover lunch
12
Q
Intermediate acting disadvantages
A
• Less consistent absorption
• With peak, hypoglycemia is a risk
• Does not
provide 24-hr coverage
13
Q
Intermediate acting pearls
A
Converting NPH to
glargine, dose glargine at 80% of the total daily NPH dose
14
Q
What are the long acting insulin?
A
- Insulin Glargine (Lantus, Toujeo, Basaglar)
- Insulin Detemir (Levemir)
- Insulin Degludec (Tresiba)
15
Q
Long acting advantages
A
- Effective once daily
* Peak-less
16
Q
Long acting disadvantages
A
- Can’t be mixed with other insulin
- Expensive
- May need twice daily dosing
17
Q
Long acting pearls
A
Insurances usually have 1 brand they prefer over another
18
Q
What are the combination insulin products?
A
- Humulin 70/30 (70% NPH* 30% Regular)
- Novolin 70/30 (70% NPH 30% Regular)
- Novolog Mix 70/30 (70% Aspart protamine 30% Aspart)
- Humalog Mix 75/25 or 50/50 (75% Lispro protamine 25% Lispro or 50% of each )
- Ryzodeg 70/30 (70% degludec 30% aspart)
19
Q
How do you mimic the natural physiologic process of insulin release in the body?
A
- pure basal with bolus insulin regimen
- true basal (Lantus and Levemir) and a true rapid (Humalog and Novolog)
20
Q
What are the different concentrations of insulin?
A
- U-300 Toujeo
- U-200 Humalog
- U-500 Humulin R
- everything else is U-100
21
Q
monitoring parameters for insulin to assess efficacy
A
- A1c is inadequate at assessing the effectiveness
* Time frame after the duration of action to asses previous dose
22
Q
Afrezza
A
- Bolus insulin delivered via inhalation
- 4, 8, or 12 unit cartridges
- Black box warning/BBW: risk of acute bronchospasm with patients who have chronic lung disease, COPD, or asthma
23
Q
What are things to educate the pt about in order to avoid short term complications?
A
- goal: help through adjustment period
- Insulin therapy (injection technique, time/action profile of insulin, hypoglycemia)
- Self-monitoring of blood glucose and technique
- Treating hypoglycemia (including glucagon use)
- Sick day rules
- Meal planning
- Urine testing for ketones
- Regain lost weight may be a good thing
24
Q
What are things to educate the pt about in order to avoid long term complications?
A
- Maintain euglycemia and adjust with lifestyle changes
- Maintain normal growth and development
- Prevent macrovascular / microvascular disease
25
What are diet related goals to avoid long term complications?
* Provide adequate calories to maintain normal growth and development of children and ideal body weight in all others
* Provide adequate calories for exogenous insulin
* Normalize glucose and lipid concentrations and blood pressure
* Minimize excursions in blood glucose
26
Afrezza stability
- cartridges good for 15 days
- good for 10 days at room temp
- opened cartridges must be used within 3 days
27
insulin and hypoglycemia
- more common
| - unawareness more common
28
What are potential causes of hypoglycemia?
* Too much insulin
* Skipped, delayed or smaller meal
* Greater than usual physical activity
29
insulin and weight gain
- more the blood glucose comes down as a result of insulin therapy, the more weight will be gained
- can avoid through diet and exercise
- may be a desired effect for patient with type 1 who is under-weight
30
What are the lipodystrophy?
- Lipoatrophy
| - Lipohypertrophy
31
Lipoatrophy
- concavities around the injection sites resulting from loss of adipose tissues
- likely from insulin antibody destruction
- looks like a crater
32
Lipohypertrophy
- abnormal growth of fat
- results from many months to years of injection into the same site
- rotation of injection sites prevents this
33
DM I broad concepts
- require basal and bolus
- typically do not have insulin resistance
- want to mimic body's normal physiologic production
- combo products are harder to manage
34
DM I insulin initiation
* Total daily insulin requirement usually ranges from 0.21.0 unit/kg/day
* 50-70% of daily insulin should be basal
* 30-50% should be bolus
35
What is the fixed dose approach?
- for DM I
- set amount of insulin per meal
- 30% of daily dose / 3
36
What is the CHO counting approach?
* Method of bolus dosing in which the patient estimates the total CHO contained in a meal and bases the bolus insulin dose accordingly
* 1 unit of bolus insulin will usually cover 15g of CHO
* Can use equation to more accurately define a starting ratio: 500* divided by total daily dose (TDD)
37
What is a correction factor?
* Adds additional units of insulin to the insulin dose if preprandial BS is elevated
* A common CF is 1 unit of insulin for every 50 mg/dL that BS is >130 mg/dL (common preprandial goal)
* Correction Factor Equation: 1500* div by TDD
38
DM II broad concepts
- want to mimic body's normal physiologic production
- needs insulin later in the disease process
- basal initiated first
- glucose levels do not fluctuate
- insulin doses are higher due to resistance
39
effects of insulin
* Lowers hepatic glucose output
* Increases endogenous insulin secretion
* Increases incidence of hypoglycemia
* Does not worsen insulin resistance or worsen cardiac disease
40
Disadvantages of insulin
* Weight gain
| * Hypoglycemia (lower occurrence in DM II than DM I)
41
Barriers to insulin use
* Insulin training
* Need for more SMBG
* Need for more intensive monitoring by health care provider
* Cost
* Fear of: needles, hypoglycemia, more severe disease, weight gain
* Association with failure
42
Indications to start insulin
* Hyperglycemia despite maximal doses of 2-3 oral agents
* Glucose toxicity
* Pregnancy
* C/I to oral agents
* Acute hyperglycemia
* Hospital admission
43
What do you do with oral treatment when pt is put on insulin?
* Metformin is always maintained unless C/I
* Oral agents often maintained when basal is added
* Once bolus added, other orals often titrated off
44
What is the advantages of concurrent oral and insulin DM therapy?
* Glycemic control is not worsened early in the titration phase of insulin
* Lower insulin dose can be administered
* Weight gain may be attenuated
45
What is the disadvantages of concurrent oral and insulin DM therapy?
* Cost
* Increase risk of hypoglycemia
* Pill burden
46
Insulin types in DM II
* basal insulin is usually the first step
| * Pre and postprandial to assess need for bolus insulin
47
DM II insulin initiation
* Start basal insulin at 10 units daily OR at 0.1 – 0.2 units/kg/day
* Basal: Titrate dose adjusting dose 10-15% or 2-4 units every 3-7 days
* Add bolus insulin if post prandial BS are elevated and morning fasting is at goal (bolus is usually 30% of daily insulin)
* Bolus: Titrate by ~10% increments
48
Dawn Phenomenon
- Diurnal physiologic pattern in which our bodies increase glucose production in response to awakening and usually accompanied by increase insulin production.
- Patients with diabetes don’t have the increase in insulin so hyperglycemia results
- elevated morning BS due to diurnal rise in glucose production
49
Smogyi effect
- Hyperreactive hyperglycemia in response to nocturnal hypoglycemia in which counter-regulatory hormones increase glucose production
- BS drops too low during the night causing release of counterregulatory hormones and elevated BS in the morning
- can be suspected if there is a normal bedtime BS
50
How do you assess if a pt has dawn pheno or smogyi effect?
• 3 AM or 3-4 hrs prior to waking FSBS are the best way to distinguish between
the two
• 3:00AM BS = LOW = SMOGYI = Bedtime insulin is too much
• 3:00AM BS = Normal to high = DAWN = Bedtime insulin not enough
51
insulin titration
- SMBG is needed for each time that insulin is dosed
- can be made every 3-7 days
- Basal insulin: Fasting BS (titrate by ~10-15% of TDD)
- Bolus insulin: Preprandial BS -> Adjust I:CHO ratio, usually increments of 2-3
- Fixed insulin dose, adjust by ~10%
52
How do you make an I:CHO tighter / looser?
* Tighter ratio = decrease CHO number
| * Looser ratio = increase CHO number
53
What are the components of insulin pumps?
* Basal rate: rate of insulin delivered per hour to replace basal insulin injections
* Bolus infusion: extra insulin to cover for food
* Reservoir: insulin container in the pump
* Insulin
54
What are the insulin used with insulin pump therapy?
- Novolog (more heat stable)
- Humalog
- Apidra
55
Advantages of pump over injections
* Avoids multiple daily injections
* Convenient and quick to dose for meals
* Automated help with CHO
* Considers “insulin on board”
* Ability to set different bolus patterns
* Adjust basal rate prior to waking for Dawn Phen.
* Typically improved control
56
Disadvantages of pump over injections
* Cost
* Wearing infusion set
* Training
* More glucose monitoring
* DKA risk if reservoir runs empty, tubing loose, etc.
* Need to revert to injections if pump malfunctions
* Scar tissue around cannula can occur
* Skin irritation
* Fluctuating glycemia around transition
57
What makes a person a candidate for insulin pump therapy?
* Current need for bolus and basal insulin
* Access to pump and ongoing access for supplies
* Ability and willingness to CHO-count
* Ability and willingness to learn to use the pump device
* Willingness to monitor
* Has at least 6 months of documented blood sugar logs
58
Rapid acting onset, peak, duration
- Onset: 5-15 min
- Peak: 1-2 hrs
- Duration: 2-4 hrs
59
Short acting onset, peak, duration
- Onset: 30-60 min
- Peak: 2-3 hrs
- Duration: 6-8 hrs
60
Intermediate acting onset, peak, duration
- Onset: 2-4 hrs
- Peak: 4-6 hrs
- Duration: 8-12 hrs
61
Long acting onset, peak, duration
- Onset: Variable
- Peak: Variable
- Duration: ~24
62
Levemir peak, duration
- Peak: 6-10 hrs
| - Duration: ~24
63
Tresiba peak, duration
- Peak: 9 hrs
- Duration: 42
- being studied with every other day dosing
64
Basaglar peak, duration
- Peak: 12 hrs
| - Duration: 30
