Therapy intensification: Technology & Pattern Management

Question 1

True or false: Higher A1c protects against hypoglycemia?

Answer 1

False; glycemic variability is likely more responsible for severe hypoglycemia

Question 2

In what order should oral DM medications be added/intensified?

Answer 2

1. Metformin
2. If goals not met in 3 months, add GLP-1 RA
3. Add SGLT inhibitor as third therapy

Question 3

Which SU is the most “renal friendly”

Answer 3

Glimepiride

Question 4

What is the Beers criteria?

Answer 4

List for potentially inappropriate med use for older adults > 65

Question 5

Which SU is on the Beers criteria?

Answer 5

Glyburide

Question 6

Contribution of ___ glucose measurements approached 70% of overall glucose mean as A1c neared 10% whereas ____ glucose contributes to about 70% to overall glucose profile when A1c value drops below 8.4%

Answer 6

fasting; postprandial

Question 7

How is basal insulin initiated in pt with DM2?

Answer 7

10 u/day or 0.2 u/kg/day. Titration in based on checked fasting BG, and increasing basal dose 2u every 3 days until FBG 70-110 mg/dL. A simpler method is to increase basal by 1 unit/day until FBG is <100 mg

Initial dose closer to the kg method is by basking starting dose on 10% of pt’s TBW

Question 8

How long do ultra long basals use to reach a steady state?

Answer 8

3-4 days; therefore, Degludec should not be titrated any more often than 3-7 days

Question 9

If BG is above or below target, but how much should NPH, DET, and U100 GLAR by adjusted?

Answer 9

BG above target: + 10% to 20%

BG at target: no change

BG below target: - 10% to 40%

Question 10

If BG is above or below target, by how much should U-300 glargine be adjusted?

Answer 10

Above: +3-6 units
Target: no change
Below: - 3 units

Question 11

By how much should U-100 or U-200 Degludec be adjusted if BG is above/below target?

Answer 11

Above: + 2 units
Target: no change
Below: - 2 units

Question 12

how should prandial insulin be dosed for pt’s with DM2?

Answer 12

Varies from 4-10 units/meal or 0.1 u to 0.15 u/kg/meal based on which meal is the largest

Question 13

If both basal and prandial insulin is initiated, the prandial should over about ___% of the daily dose

Answer 13

50%

Meal doses could be divided among the three meals, for ex:
Bkft: 30-40%
Lunch: 30%
Dinner: 30-40%

Question 14

True or false: Novolin R is available w/out a Rx

Answer 14

True; check good Rx for pricing

Question 15

When is correction dose insulin usually given?

Answer 15

Before meals (as adjunct to scheduled insulin)

Question 16

What is an ISF?

Answer 16

Used to calculate the amount of insulin needed to bring BG into target range and is used as a correction or supplemental amount of insulin when glucose levels are too high

Question 17

What is the iCR?

Answer 17

Based on matching rapid acting insulin to CHO/calorie content of food to be eaten

Question 18

For pump users, by how much should basal rates be adjusted (in terms of % per hour) depending on the type physical activity (light vs moderate vs weight lifting)

Answer 18

Light: 10-20% reduction for one hr before/after activity
Moderate/short duration (1-2 hrs): 30-50% reduction in basal for 1 hr before/after activity, including duration of activity itself

Isometric exercises such as weight lifting usually do not require an adjustement

Question 19

Insulin deficiency will likely occur after ____ hours of being disconnected from an insulin pump.

Answer 19

2 hours; to prevent hypo during short workout, consider reducing the pre meal bolus for pre meal exercise, lowering overnight basal by 10-20% following late afternoon/evening exercise, or consuming quick CHO before workout

Question 20

what antibody is positive in ~80% of pt’s with DM1 and LADA?

Answer 20

Anti GAD 65; can be run alone to confirm diagnosis

Question 21

How should an ICR be calculated?

Answer 21

By taking a pt’s TDD and divide by 500 this will determine how many g of CHO are covered by 1 unit of insulin

Question 22

How is ISF calculated?

Answer 22

To determine the mg/dL that 1 unit of insulin decreased the blood glucose value by, divide 1700 by the TDD

Question 23

How might ETOH effect blood glucose?

Answer 23

May cause glucose to spike at time of consumption, but 5-6 hours later hypo is seen. This is due to ETOH being detoxed in the liver which impairs liver’s ability to release glycogen stores

Question 24

True or false: ICR can change throughout the day

Answer 24

True

Question 25

True or false: in the event someone is ill and not eating, the body still requires insulin

Answer 25

True; body still requires insulin to counteract increases in glucose and ketone production to the liver d/t increased secretion of stress hormone

Question 26

What is insulin stacking?

Answer 26

Effect of insulins that overlap; pt’s should be cautioned to be patient and let insulin work for several hours to avoid frequent repeated bolus/injections that overcorrect glucose levels

Question 27

True or false: Insulin pumps should be allowed to be used during hospitalization

Answer 27

True (if pt is mentally/physically able)

Question 28

All persons with DM requesting benefits from Medicare for pump therapy must prove what?

Answer 28

That they are insulinopenic by requesting verification of complete absence of insulin production, C Peptide <10%. Private insurance coverage varies from plan to plan