T1DM 2

Question 1

Insulin
- General Considerations

Answer 1

Schedule II
- Can be sold without prescription, just have to do a pharmacist assessment and document

Question 2

Insulin
- Adverse Effects

Answer 2

Weight Gain
Hypoglycemia
Lipohypertrophy
Lipoatrophy

Question 3

What is Lipohypertrophy

Answer 3

Thickened area of tissue from accumulation of fat at injection sites
- Causes insulin release from injection site to be delayed and unpredictable

Question 4

What is Lipoatrophy

Answer 4

Loss of subcutaneous fat at injection site
- Immune response
- Less common now with recombinant human DNA formulation of insulin

Question 5

What to consider when tailoring insulin regimen

Answer 5

Age
Lifestyle/Activity Level
Diet

General Health
Treatment Goals
Hypoglycemia Awareness

Ability to self-manage treatment
Motivation
Financial Consideration

Question 6

Insulin (Children)
- General Considerations

Answer 6

When children start insulin they only need minimal insulin (<0.5 units/kg/day)
- Lasts weeks to months, but can last up to 2 years

Question 7

Which insulins are preferred for patients with no drug coverage

Answer 7

Bolus (Short)
- Regular

Basal (Intermediate)
- NPH

Question 8

How much insulin should be used for Basal and Bolus?

Answer 8

1. Round Weight to a whole workable number
2. Select a starting dose
   - 0.4, 0.5, 0.6, 1.0
3. Calculate Proportions
   40% Basal/60% Bolus
   50% Basal/50% Bolus
4. Split Bolus into 3 doses

Question 9

Where to use insulin

Answer 9

Abdomen
Lateral Thigh
Upper Arms
Superior Buttocks

Question 10

Where to use insulin
- Abdomen

Answer 10

Fast and Consistient Absorption

Question 11

Where to use insulin
- Lateral Thigh

Answer 11

Slow and Variable Absorption

Question 12

Where to use insulin
- Upper Arms

Answer 12

Slow and Variable Absorption
- Hard to reach (need help from someone else)

Question 13

Where to use insulin
- Superior Buttocks

Answer 13

Slowest Absorption
- Hard to reach

Question 14

How to Rotate Site of Insulin Injection

Answer 14

Inject in one area for one week, then rotate to next site
- Each injection in the area should be 2-3 cm apart

Question 15

Why do we have to Rotate Site of Insulin Injection

Answer 15

Prevent Lipohypertrophy and Maintain a consistient insulin absorption

Question 16

Injection Technique

Answer 16

Inject needle into subcutaneous (fatty) tissue.
- Needles are thin and short so no need for deep pinching

Question 17

What influences Blood Glucose

Answer 17

Diet
Physical Activity
Insulin Regimen

Question 18

Targets to achieve A1c<=7%

Answer 18

FPG: 4.0-7.0 mmol/L

2-Hour Post Prandial BG: 5.0-10.0 mmol/L

Question 19

Steps for Insulin Dose Adjustment

Answer 19

1. Look for lows (<4.0)
2. Start the day well
   3a. Look for consistient highs
   3b. Any explanations (exercise, extra meals, missed dose)
3. Change one insulin by one or two units

Question 20

Adjusting Basal Doses

Answer 20

If morning levels are low then decrease nightly basal dose

If morning levels are high then increase nightly basal dose

Question 21

Adjusting Bolus Doses

Answer 21

Change the last recent bolus dose
- If noon levels are high then increase morning bolus dose

Question 22

Hypoglycemia Symptoms

Answer 22

1. • Disturbed Sleep
   • Weird Dreams
   • Drowsiness
   • Anxiety
2. • Sweating
   • Trembling
   • Palpitations
   • Tingling
3. • Hunger
   • Nausea
   • Headache
   • Vision Changes
4. • Difficulty Speaking
   • Weakness/Dizziness
   • Difficulty Concentrating
   • Unconsciousness

Question 23

Management of Hypoglycemia (Fast acting sugar)

Answer 23

15 g of glucose
1 tbsp (15 mL) of sugar in water
1 tbsp (15 mL) of honey
2/3 cup (150 mL) of regular soft drink/juice
15 g of fast acting sugar

Question 24

Management of Hypoglycemia (More severe symptoms)

Answer 24

If able to swallow: 20 g of fast acting sugar
If not able to swallow:
- 3mg intranasal glucagon
- 1mg SC/IM glucagon

Question 25

Management of Hypoglycemia (Rule of 15)

Answer 25

1. Feeling symptoms of hypoglycemia
2. Check blood glucose (If levels below 4.0 continue)
3. 15g of simple carbohydrate (no protein)
4. Recheck in 15 minutes
   5a. If blood glucose is still below 4.0, repeat 15g of simple carbohydrate
   5b. If blood glucose is above 4.0, consume snack containing protein