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T1DM Flashcards

1
Q

Diagnosing Diabetes

A
  • FPG >= 126 mg/dL
  • OGTT 2-hr postload >=200 mg/dL
  • A1C >= 6.5%
  • Random plasma glucose >= 200 mg/dL with symptoms of hyperglycemia/hyperglycemic crisis
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2
Q

Hyperglycemia Symptoms

A
  • Polyuria
  • Polydipsia
  • Polyphagia
  • Weight loss
  • Fatigue
  • Infections
  • Blurred vision
  • Poor healing
  • Growth failure in children
  • N/V
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3
Q

Basal Insulin

A
  • Suppresses glucose between meals and overnight
  • Maintains nearly constant levels
  • Provides ~50% of daily insulin needs
  • Target fasting glucose: 80-130 mg/dL
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4
Q

Prandial Insulin

A
  • Limits hyperglycemia after meals
  • Provides ~10-20% of daily requirement per meal
  • Target 1-2 hours post-prandial glucose <180 mg/dL
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5
Q

Insulin Detemir

A
  • Levemir
  • Long acting/basal insulin
  • 100 U/mL
  • Fatty acid side chain that bides to albumin at SC site to prolong absorption
  • Must dissociate form albumin and bind tot insulin receptors
  • DO NOT MIX IN SYRINGE WITH OTHER INSULINS
  • Lasts ~24 hours, typically BID dosing
  • Store at room temp for 42 days
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6
Q

Lantus/Basaglar

A
  • Insulin Glargine
  • 100 U/mL
  • Soluble at pH of 4
  • Microprecipitates when injected into body which slowly dissolves into monomers
  • Basaglar/Lantus are not interchangable like generics
  • DO NOT MIX IN SYRINGE WITH OTHER INSULINS
  • Lasts ~24 hours
  • Dosing once a day at the same time each day
  • Store at room temp for 28 days
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7
Q

Toujeo

A
  • Insulin glargine
  • 300 U/mL
  • Pen only
  • Lasts slightly longer than U-100
  • Less nocturnal hypoglycemia than U-100
  • Dose once a day at the same time each day
  • Store at room temperature for 42 days
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8
Q

Tresiba

A
  • Insulin Degludec
  • Ultra-long lasting insulin
  • Lasts up to 42 hours
  • Injected once a day at ANY time of day
  • U-100 and U-200 available
  • Less nocturnal hypoglycemia compared to U-100 glargine
  • Store at room temperature for 56 days
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9
Q

NPH

A
  • Novolin N (vial) or Humulin N (vial or pen)
  • 100 U/mL
  • Lasts about 12-18 hours
  • OTC
  • Can be used for basal insulin when given multiple times a day
  • Suspension, must be rolled/inverted 10 times before using
  • Pens: store at room temperature for 14 days
  • Humulin N stores at room temperature for 31 days
  • Novolin N stores at room temperature for 42 days
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10
Q

Regular Insulin

A
  • Novolin R or Humulin R (vials)
  • 100 U/mL
  • Lasts about 4-6 hours
  • OTC
  • Inject ~30 minutes before eating
  • Requires more meal planning (inconvenient)
  • Helpful for those with gastroparesis (delayed onset)
  • Can mix with NPH in same syringe
  • Humulin R stores at room temperature for 31 days
  • Novolin R stores at room temperature for 42 days
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11
Q

Rapid Acting Insulin

A
  • 100 U/mL
  • Lispro (Humalog, Admelog), Aspart (Novolog), Glulisine (Apidra)
  • Lasts about 3- 5 hours
  • Mimics body’s response to glucose absorption
  • Inject immediately before eating
  • Fiasp the only one with lenience (30 minutes before or after start of meal)
  • Can mix with NPH, but must inject within 5 minutes of mixing
  • Store at room temperature for 28 days
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12
Q

Afrezza

A
  • Rapid-acting inhaled meal time insulin
  • 4, 8, 12 U cartridges
  • Give at start of meal
  • Still need basal insulin
  • CI: Asthma and COPD due to bronchospasms
  • May need multiple cartridges to achieve necessary dose
  • Replace inhaler every 15 days
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13
Q

NPH + Regular Insulin

A
  • 70/30 mixtures
  • Novolin 70/30 or Humulin 70/30
  • Give 30 minutes before meals
  • Cloudy appearances
  • Mix before administering
  • Pens store for 10 days at room temperature
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14
Q

NPH + Rapid Insulin

A
  • Novolog 70/30 and Humalog 75/25
  • Give immediately before meal
  • Cloudy appearance
  • Mix before administering
  • Novolog stores at room temperature for 14 days
  • Humalog stores at room temperature for 10 days
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15
Q

Converting NPH => Long-Acting

A
  • 1 unit NPH = 1 unit detemir or degludec
  • Once daily NPH: 1 unit NPH = 1 unit glargine
  • Twice daily NPH: 80% of total daily NPH = once daily glargine dose
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16
Q

Converting U-100 => U-300 Glargine

A
  • 1:1
  • Then titrate up
  • Usually need a higher dose of Toujeo compared to Lantus
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17
Q

Converting U-300 => U-100 Glargine

A

-80% of the Toujeo dose

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18
Q

1:1 Insulin Converions

A
  • Levemir/Tresiba can be converted to other long acting insulins in 1:1
  • Regular to rapid acting is 1:1
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19
Q

160 U Max Dose Pens

A
  • Tresiba Flextouch U-200 (increments of 2 U)
  • Toujeo Max (increments of 2 U)
  • ALL OTHERS ARE MAX OF 80 U WITH 1 U INCREMENTS
20
Q

Insulin Storage

A
  • Can store at room temperature for 28-56 days

- Keep in-use pens at room temp and all others in refrigerator

21
Q

Insulin AE

A
  • Hypoglycemia: blood glucose < 70 mg/dL: caused from excess insulin, decreased/delayed meals, increases in exercise
  • Weight gain
  • Lipohypertrophy: rotate injection sites
  • Allergic reactions: rare
  • Insulin antibodies: rare
22
Q

Hypoglycemia Symptoms

A
  • Tremors, palpitations, sweating
  • Excessive hunger
  • Headache
  • Mood changes, irritability
  • Unconsciousness
  • Seizures
23
Q

Hypoglycemia Treatment

A
  • Rule of 15
  • Test FIRST, only treat if glucose < 70 mg/dL
  • Take 15 g of glucose, wait 15 minutes, retest
  • If still <70, take another 15 g and keep repeating until over 70 mg/dL
  • Once in normal range, eat a small snack or meal to prevent regression
24
Q

15 g Glucose Examples

A
  • Tablets/gel
  • 1/2 cup of juice or soda
  • 3 graham crackers
  • 6 saltines
25
Q

Hypoglycemic Unawareness

A
  • Unconscious from low glucose levels
  • Treat with glucagon kit or Baqsimi intranasal glucagon
  • Should response within 15 minutes of administering
  • Prescribe to all patients at risk of severe hypoglycemia (historically significant hypoglycemia of glucose <54 mg/dL)
26
Q

Insulin Administration Sites

A
  • Abdomen
  • Back of arm
  • Thigh
  • Butt
  • ROTATE
27
Q

Pramlintide

A
  • Symlin
  • Synthetic analog of human amylin
  • Amylin is deficient in Type I and Type II DM
  • Co-secreted with insulin form pancreas in response to a meal
  • Approved for any DM patient on optimal insulin therapy who aren’t at goal
  • Not used often due to frequency of dosing
28
Q

Symlin MoA

A
  1. Suppresses postprandial glucagon secretion
  2. Regulates the rate of gastric emptying
  3. Reduces food intake
29
Q

Symlin Efficacy/Dose

A
  • Efficacy: A1C decreases ~0.1-0.4% in T1DM, 0.3-0.7% in T2DM
  • Dosing: 15 mcg SQ before meals (meals must be >30 g carbs); 60 mcg before major meals in T2DM
  • Reduce pre-prandial insulin doses when starting pramlintide, given in conjunction with meal-time insulin
30
Q

Symlin AE/DDI

A
  • Hypoglycemia - reason to reduce prandial insulin
  • Nausea - titrate dose slowly
  • Drug interactions: delayed gastric emptying
  • Administer oral meds that need rapid onset 1 hour before or 2 hours after pramlintide
31
Q

Pramtintide CI/Precautions

A
  • Gastroparesis
  • Hypoglycemic unawareness
  • Recurrent episodes of hypoglycemia in the last 6 months
  • A1C > 9%
32
Q

Glycemic Goals

A
  • A1C < 7.0%: less stringent goals for those with severe hypoglycemic
  • Fasting glucose: 80-130 mg/dL
  • Postprandial glucose <180 mg/dL (1-2 hours after meal start)
  • *GOALS FOR TYPE 1 AND 2 DIABETES**
33
Q

Recommended Therapy

A
  1. Use of multiple insulin injection: 3-4 injections/day of basal/prandial insulin
  2. Matching prandial insulin to carb intake, premeal BG and anticipated activity
  3. Use of insulin analogs as prandial insulin
34
Q

Long-Acting + Rapid-Acting Insulin Regimen

A
  • Standard of care in T1DM
  • Minimum of 4 injections
  • Basal administered once a day, usually at bedtime
  • Give rapid acting just before meals
35
Q

Long-Acting + Regular Insulin Regimen

A
  • Option for gastroparesis

- Regular insulin delayed onset ideal for these patients

36
Q

NPH + Rapid Acting Insulin Regimen (Bedtime option)

A
  • Limited use in T1DM patients
  • NPH at breakfast and bedtime
  • Basal doesn’t last 24 hours
  • Greater risk hypoglycemia: peak form NPH
  • Less expensive regimen
37
Q

NPH + Rapid Acting Insulin Regimen (Dinner option)

A
  • NPH at breakfast and dinner
  • Disadvantage: NPH may not last all night leading to fasting hyperglycemia in the morning
  • Hypoglycemic risk during dase
  • Difficult to adjust if premixed
38
Q

NPH + Regular Insulin Regimen

A
  • NPH at breakfast at bedtime
  • Regular at breakfast and dinner, can also give at lunch
  • Least expensive regimen
39
Q

Dosing Basal Insulin

A
  • Dosed for T1DM based on weight
  • 0.5units/kg/DAY
  • ~50% of TDD is basal insulin
  • Split remaining 50% into prandial insulin doses
40
Q

When to inject Prandial Insulin

A
  • Rapid-acting: inject immediately (up to 15 minutes before meal)
  • Regular insulin: inject 30-45 minutes before meal
  • Conversion from regular to rapid is 1:1
41
Q

2 Parts of Prandial Insulin Dosing

A
  1. Insulin to carb ratio (I:C)
    - Grams of carbs 1 unit of insulin will cover
  2. Correction factor (CF)
    - Number of mg/dL the blood glucose will dorp after injecting 1 unit of rapid or regular insulin
42
Q

Calculating I:C

A
  • Assume daily carbs is 500

- Divide by TDD

43
Q

Counting Carbs

A
  • 1 serving = 15 g
    1. Basic carb counting: limit patient to specific number of carbs/meal and have the patient on a set insulin dose +/- CF
    2. Advanced carb counting (T1DM) - count carbs according to meal and inject corresponding insulin amount based on I:C
44
Q

Correction Factor

A
  • Use when blood glucose is elevated before a meal

- Add 1 unit of insulin for every 50 mg/dL above 100 (midpoint fasting glucose target)

45
Q

Calculating CF

A
  • 1800 rule

- Divide by TDD to see how far blood glucose will drop for 1 unit of insulin

46
Q

How to know which insulin to adjust…

A
  • ONLY ADJUST WHEN PATTERNS ARE OUT OF RANGE
  • Fasting hyperglycemia: basal insulin, increase by 1-2 units every 3 days until fasting glucose is in range
  • Post-prandial hyperglycemia: 1-2 hours after last meal, increase pre-meal insulin, adjust I:C ratio to minimize CF use
  • Pre-prandial hyperglycemia: not enough insulin given with previous meal
47
Q

Adjusting I:C

A
  • Adjust by 2-5 grams when post-prandial blood glucose is consistently >180 mg/dL OR pre-prandial >130 mg/dL
  • If consistently hypoglycemic, decrease the ratio
  • Verify that the patient is correctly counting carbs!!!

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