Test 2 Type 1 DM Therapeutics

Question 1

Type 1 DM

Answer 1

• Patient does not have b-cell activity
• Autoimmune mediated
  
  • Most often seen
• Idopathic – don’t know what is causing it
• Most often a disease of young children
• Requires exogenous insulin – both basal and bolus
• Some patients have an insulin pump – dosed based on carb intake
• Patients must learn how to carb count

Question 2

Classification

Answer 2

Question 3

Clinical Presentation

Answer 3

Question 4

Classic Symptoms Type 1

Answer 4

• Hyperglycemia - 3 P’s
  
  • Polyuria
  • Polydypsia
  • Polyphagia
• Weight loss – in spite of increased appetite
• Diabetic ketoacidosis (DKA)

Question 5

Type 1 Diagnosis

Answer 5

• Fasting glucose is the primary tool used for the diagnosis of diabetes
• Four possible ways to diagnose diabetes
  
  • Fasting plasma glucose (2 confirmed tests) or
  • Casual plasma glucose + presence of symptoms or
  • 2 hour plasma glucose during an OGTT
  • Hgb A1c ≥ 6.5% (New ADA Clinical Practice Recommendation)

Question 6

Type 1 Glycemic Goals

Answer 6

Question 7

Glycemic Control

Answer 7

Question 8

Treatment for Type 1 Diabetes

Answer 8

• Medial Nutrition Therapy (MNT)
  
  • Carb counting
• Exercise
• Insulin – Basal and Bolus
  
  • Mainstay treatment

Question 9

Pivotal Trial in Type 1 Diabetes (“The Evidence)

Answer 9

• Diabetes Control and Complications Trial (DCCT)
  
  • Conventional therapy (1 – 2 injections/day) vs intensive therapy (3+ injections/day)
  • Intensive therapy reduced the risk of microvascular complications

Question 10

Insulin Therapy – Regimen Choices

Answer 10

Question 11

Various Types of Insulin

Answer 11

Question 12

Insulin Properties

Answer 12

Question 13

Insulin Profiles

Answer 13

Question 14

Insulin Pharmacokinetics

Answer 14

Question 15

Insulin Adverse Effects

Answer 15

Hypoglycemia

Weight gain

Question 16

Insulin Storage

Answer 16

Question 17

Basal Insulin Products

Answer 17

• suppress fasting sugars
  
  • NPH
  • Glargine (U-100)-Lantus
  • Detemir
  • Glargine (U-300)-Toujeo
  • Degludec

Question 18

NPH

Answer 18

• Basal Insulin-supress fasting sugars
  
  • Cloudy suspension
  • Stored in refrigerator until opened
  • DOA: 12 – 18 hours
    
    • Need 2 injections for 24 hour coverage
    • When first started, given as a bedtime dose
      
      • Target fasting sugars → will see full effect of insulin in the morning
    • Give a morning dose to target mid-afternoon/evening sugars

Question 19

Glargine (U-100) *Lantus

Answer 19

• Basal Insulin-supresses fasting sugars
  
  • True 24-hour peakless insulin
  • Typically dosed at bedtime or in the morning – patient preference
    
    • Some patients with very high glucose levels may need to dose BID
  • Split dose if > 90 units – due to PK properties (may not be absorbing all of the insulin)

Question 20

Detemir

Answer 20

Question 21

Glargine (U-300)*Toujeo

Answer 21

• Basal Insulin-supresses fasting sugars
  
  • more concentrated
    
    • Supplied as a pen (restricted dosing) – only delivers up to 80 units/injection
  • Typically, it takes 2 – 3 days to see decline in blood sugar level
    
    • It takes ~5 days with U-300

Question 22

Degludec

Answer 22

• Basal insulin-supresses fasting sugars
  
  • Ultra-long acting
    
    • DOA: 42 hours
  • Different dosages available
  • If the patient misses a dose, may administer within an 8-hour window of missed dose

Question 23

Mealtime Bolus Insulin Products

Answer 23

• Mealtime Bolus Insulin Products– suppresses post-prandial sugars – typically administered before a meal
  
  • If the patient skips a meal, they should not take their insulin (may lead to hypoglycemia)
    
    • Rapid acting
      
      • Lasts 4 – 6 hours
      • Inject 5 – 15 minutes before they eat
        
        • Can inject once food is in front of them
    • Short acting
      
      • Lasts 6 – 8 hours
      • Regular – must be administered 30 – 60 minutes before a meal
        
        • Dosing takes more time and discipline
    • Inhaled Insulin
      
      • Afrezza
        
        • Rapid acting insulin – bolus
        • Cartridge based dosing (4 or 8 units)
          
          • May cause adherence issues
        • Adverse effects: coughing, dry mouth, throat irritation, hypoglycemia
        • Avoid in patients with asthma or COPD
        • Pregnancy category C

Question 24

Insulin Adjustments

Answer 24

Question 25

Insulin Conversions: NPH to glargine (U-100)

Answer 25

• NPH to glargine (U-100)
  
  • How many units?
  • Once daily or BID NPH?
  • Once daily NPH à once daily glargine = 1:1
  • BID NPH → once daily glargine = calculate total daily NPH dose and decrease by 20%
  • Example:
    
    • NPH 25 units BID = 50 units x 0.8 = 40 units
      *

Question 26

Insulin Conversions: NPH to Detemir

Answer 26

• NPH to Detemir
  
  • Once daily NPH to once daily detemir = 1:1
  • BID NPH to once daily detemir = calculate total daily NPH dose and decrease by 20%

Question 27

Insulin Conversions: Glargine to Detemir

Answer 27

• Glargine to Detemir
  
  • Once daily glargine to once daily detemir = 1:1

Question 28

Insulin Conversions: Insulin 70/30 to NPH

Answer 28

• Insulin 70/30 to NPH
• 70% NPH/30% Regular to NPH
• Regular to aspart = 1:1
  
  • Example:
    
    • 70/30 25 units BID = 50 units total à 35 units NPH total daily dose / 2 = 18 units NPH BID
    • Regular component will be dosed separately (dosing depends on the number of meals)