Pharmacotherapy of Injectable Medications Exam 2 Flashcards
What are the rapid acting insulin?
- Insulin lispro (Humalog, Admelog)
- Insulin aspart (Novolog, Fiasp)
- Insulin glulisine (Apidra)
- Afrezza
When can you take Fiasp?
- before meals
- during meals
- 20 min after meals
Rapid acting advantages
- Quicker onset
- Shorter duration
- Less hypoglycemia
Rapid acting disadvantages
• Expensive
• Patients who
graze may need a longer acting insulin
Rapid acting pearls
• Can be administered closer to meals
• More closely mimics
physiologic action of insulin
• Insurance tends to dictate insulin chosen
What are the short acting insulin?
Regular insulin (Humulin R, Novolin R)
Short acting advantages
- Less expensive
* Relion brand $24.99/vial
Short acting disadvantages
- More hypoglycemia
* Less convenient time course (PK) of activity
Short acting pearls
Administered 30 min before meal
What are the intermediate acting insulin?
Insulin (Humulin N, Novolin N)
Intermediate acting advantages
- Less expensive Relion $24.99
- Can be mixed with other insulins
- Peak can be helpful in some patients to cover lunch
Intermediate acting disadvantages
• Less consistent absorption
• With peak, hypoglycemia is a risk
• Does not
provide 24-hr coverage
Intermediate acting pearls
Converting NPH to
glargine, dose glargine at 80% of the total daily NPH dose
What are the long acting insulin?
- Insulin Glargine (Lantus, Toujeo, Basaglar)
- Insulin Detemir (Levemir)
- Insulin Degludec (Tresiba)
Long acting advantages
- Effective once daily
* Peak-less
Long acting disadvantages
- Can’t be mixed with other insulin
- Expensive
- May need twice daily dosing
Long acting pearls
Insurances usually have 1 brand they prefer over another
What are the combination insulin products?
- 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)
How do you mimic the natural physiologic process of insulin release in the body?
- pure basal with bolus insulin regimen
- true basal (Lantus and Levemir) and a true rapid (Humalog and Novolog)
What are the different concentrations of insulin?
- U-300 Toujeo
- U-200 Humalog
- U-500 Humulin R
- everything else is U-100
monitoring parameters for insulin to assess efficacy
- A1c is inadequate at assessing the effectiveness
* Time frame after the duration of action to asses previous dose
Afrezza
- 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
What are things to educate the pt about in order to avoid short term complications?
- 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
What are things to educate the pt about in order to avoid long term complications?
- Maintain euglycemia and adjust with lifestyle changes
- Maintain normal growth and development
- Prevent macrovascular / microvascular disease
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
Afrezza stability
- cartridges good for 15 days
- good for 10 days at room temp
- opened cartridges must be used within 3 days
insulin and hypoglycemia
- more common
- unawareness more common
What are potential causes of hypoglycemia?
- Too much insulin
- Skipped, delayed or smaller meal
- Greater than usual physical activity
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
What are the lipodystrophy?
- Lipoatrophy
- Lipohypertrophy
Lipoatrophy
- concavities around the injection sites resulting from loss of adipose tissues
- likely from insulin antibody destruction
- looks like a crater
Lipohypertrophy
- abnormal growth of fat
- results from many months to years of injection into the same site
- rotation of injection sites prevents this
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
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
What is the fixed dose approach?
- for DM I
- set amount of insulin per meal
- 30% of daily dose / 3
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)
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
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
effects of insulin
- Lowers hepatic glucose output
- Increases endogenous insulin secretion
- Increases incidence of hypoglycemia
- Does not worsen insulin resistance or worsen cardiac disease
Disadvantages of insulin
- Weight gain
* Hypoglycemia (lower occurrence in DM II than DM I)
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
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
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
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
What is the disadvantages of concurrent oral and insulin DM therapy?
- Cost
- Increase risk of hypoglycemia
- Pill burden
Insulin types in DM II
- basal insulin is usually the first step
* Pre and postprandial to assess need for bolus insulin
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
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
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
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
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%
How do you make an I:CHO tighter / looser?
- Tighter ratio = decrease CHO number
* Looser ratio = increase CHO number
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
What are the insulin used with insulin pump therapy?
- Novolog (more heat stable)
- Humalog
- Apidra
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
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
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
Rapid acting onset, peak, duration
- Onset: 5-15 min
- Peak: 1-2 hrs
- Duration: 2-4 hrs
Short acting onset, peak, duration
- Onset: 30-60 min
- Peak: 2-3 hrs
- Duration: 6-8 hrs
Intermediate acting onset, peak, duration
- Onset: 2-4 hrs
- Peak: 4-6 hrs
- Duration: 8-12 hrs
Long acting onset, peak, duration
- Onset: Variable
- Peak: Variable
- Duration: ~24
Levemir peak, duration
- Peak: 6-10 hrs
- Duration: ~24
Tresiba peak, duration
- Peak: 9 hrs
- Duration: 42
- being studied with every other day dosing
Basaglar peak, duration
- Peak: 12 hrs
- Duration: 30
