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IPFC 3 Midterm 1 > Type 1 Diabetes Management > Flashcards

Type 1 Diabetes Management Flashcards

1
Q

What is the total daily insulin dose per kg/day for Type 1

A

0.5 units/kg/day
or 0.3-1 units/kg

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2
Q

What is the MOA of basal insulin in normal people

A

Secreted in small amounts during sleep or long-fasting hours
- suppresses gluconeogenesis + lipolysis

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3
Q

Describe the 2 phases of bolus insulin in normal people

A

Phase 1
- release of pre-formed insulin within 1 min of glucose consumption and lasts about 10 min

Phase 2:
- synthesis and release of newly formed insulin
- released until normoglycemic state restored

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4
Q

Who are premixed insulins for?

A

Someone with set meal/exercise times (nursing home)

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5
Q

What is the longest acting insulin? What is the benefit of it?

A

Degludec (tresiba)
- causes less nocturnal hypos

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6
Q

What is the benefit of Humalog U-200?

A

For patients requiring 20+ units of rapid insulin
(double the unit per pen)

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7
Q

What is the benefit of using entuzity U-500?

A
  • For patients requiring 200+ units of rapid insulin
  • delivers dose in 5 unit increments
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8
Q

Differentiate between endogenous and exogenous insulin absorption

A

Endogenous insulin is secreted into portal vein
- undergoes first-pass metabolism
- released in small bursts in response to glucose

Exogenous
- higher peripheral exposure than hepatic
- release is pre-determined via a time-action profile

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9
Q

What are benefits of insulin therapy?

A
  • delay microvascular (retinopaty, nephropathy, neuropathy) and CV complications
  • prevent ketoacidosis
  • prevent overt hyperglycemia symptoms
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10
Q

What are adverse effects of insulin

A

Hypoglycemia: more common with regular insulin than rapid-acting insulin
Weight gain: ~4-5kg
Allergic reactions: 0.1-3% (rare)
Lipohypertrophy: 49-64% prevalence

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11
Q

Is there evidence for adjunctive therapy in type 1 diabetic patients?

A

No
Metformin: did not provide sustained metabolic or CV benefits
SGLT2 inhibitors: some metabolic benefits, risk of DKA needs more study
Liraglutide: some metabolic benefits, NO indication for use in T1DM

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12
Q

What is the preferred insulin injection site?

A

Abdomen

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13
Q

When would you consider using an insulin pump in T1DM

A
  • Not able to reach targets despite optimized basal-bolus regimen
  • sig glucose variability
  • frequent severe hypoglycemia or hypoglycemic unawareness
  • Sig dawn phenomenon: release of GH and cortisol is early morning stimulates glucose release
  • Low insulin requirements
  • suboptimal treatment satisfaction and quality of life
  • women contemplating pregnancy
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14
Q

What factors influence insulin action?

A
  • Route of admin (IV > IM > SC)
  • Renal function (lowers clearance, intensifies action)
  • insulin antibodies (delays effect)
  • Thyroid function
  • Site of injection (stomach fastest, arm intermediate, thigh slowest)
  • Exercise, massaging inj site, higher temp (faster absorption)
  • insulin prep (cloudy -> gently rolled or tipped)
  • insulin dose and concentration
  • Lipohypertrophy (delay absorption)
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15
Q

Differentiate between conventional and intensive insulin therapy in T1DM

A

Conventional (not preferred)
- Use of premixed or self-mixed int and short or rapid acting insulin
- BID injections
- Fixed amount of insulin and consistent food and activity

Intensive therapy
- system of matching insulin doses to food, activity, and life events
- basal-bolus insulin injections or pumps
- requires patient self-management behaviours

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16
Q

Differentiate between human (short acting) and analogue (rapid acting) insulin

A

Human insulin
- slower onset
- delayed peak
- longer duration

Analogue insulin
- more closely mimics endogenous secretion
- lower risk of hypoglycemia

17
Q

Why are BID mixed insulin regimens not preferred (NPH)?

A

NPH in AM results peak at lunch (must eat lunch on time)
NPH at dinner results in peak during middle of night (inc risk of nocturnal hypoglycemia)

18
Q

What is the typical insulin dosing for T2DM

A

0.3-0.5 units/kg/day

19
Q

What is the honeymoon phase insulin dosing?

A

0.2-0.5 units/kg/day
- type 2 usually on the lower side since they already make insulin

20
Q

How do you dose adjust for basal insulin?

A

If high fasting levels in the morning
- increase dose by 1 unit

If pattern of hypoglycemia in the morning (under 4)
- decrease dose by 10-20%
- always check injection technique

21
Q

How do you dose adjust for bolus insulin dosing if they have a consistent carb consumption?

A

Give more insulin to the meals that raise BG more
ex. instead of 5-5-5 switch to 5-4-6

22
Q

How do you dose adjust for bolus insulin dosing if they have a variable bolus dose + advanced carbohydrate counting for type 1?

A

Use insulin to carb ration 1:C (consult dietician)
Use “500 rule”
- 500/TDD = # of grams of CHO that will be covered by 1 unit of insulin

23
Q

What other factors beyond CHO should be considered for insulin dosing?

A

Pre-meal glucose
Physical activity after the meal

24
Q

What is the correction factor? when is it used?

A

aka insulin sensitivity factor ISF
Used to correct for pre-meal HIGH BG levels

Rule of 100
100/TDD = 1 unit of insulin will lower BG by x mmol/L
- used for rapid-acting analogue

25
Q

If physical activity occurs within 2 hours after the meal how should you adjust insulin dose

A

Reduce bolus insulin dose

if activity 91+ minutes, adjust basal insulin as well

26
Q

What are symptoms of hypoglycemia? (4)

A
  1. neurogenic (autonomic, SNS, active)
    - trembling
    - palpitations
    - sweating
    - Anxiety
    - Hunger
    - Nausea

Neuroglycopenic (brain)
- difficulty concentrating
- confusion
- weakness
- drowsiness
- vision changes
- difficulty speaking
- dizziness
- Headache

  1. Low BG (under 4 mmol/L if on insulin)
  2. Response to carbohydrate load
27
Q

Differentiate between severity of hypoglycemia
Mild
Moderate
Severe

A

Mild
- autonomic symptoms
- able to self-treat

Moderate (both)
- Autonomic and neuro symptoms
- able to self-treat

Severe
- Requires assistance of another person
- unconsciousness may occur
- BG is under 2.8 mmol/L

28
Q

How to address mild - moderate hypoglycemia

A
  1. Recognize the anutonomic or neuro symptoms
  2. Confirm if possible. <4.0
  3. Treat with fast sugar 15g simple carb
  4. Retest in 15 min to ensure BG 4+. Retreat if needed
  5. If next meal is more than 1 hour away, have a snack with 15g carbs + protein
29
Q

What are examples of 15g simple carb

A

15g in glucose tablets
15mL (3 teaspons) or 3 packets of sugar dissolved in water
150mL of juice or regular soft drink
6 Lifesavers (1 = 2.5g of carbs)
15mL (1 tablespoon) of honey

30
Q

How to treat level 3 conscious hypoglycemia

A

Treat with oral ingestion of 20g carbs (glucose tabs preferred)
OR
3mg glucagon intranasal or 1mg SC/IM

Retreat with additional doses if remains under 4 mmol/L

31
Q

How to treat severe hypoglycemia in unconscious person with no IV access

A
  1. Treat with 3mg glucagon or 1mg glucagon SC/IM
  2. Call 911
  3. Discuss with diabetes health-care team
32
Q

What are some pattern management tips?

A

Look for 3 out of range values at the same time on consecutive days

Do not adjust inuslin dose based one 1 out of range
except a night time hypoglycemic event
- reduce basal insulin dose

33
Q

If A1C target of under 7% is not achieved with usual targets of FPG 4-7 and 2hPPG 5-10, what are the new targets?

A

FPG 4.0-5.5 mmol/L
PPG 5-8 mmol/L

34
Q

What factors can affect glucose if there is no pattern?

A

Diet
Physical activity
- mild/mod = dec glucose
- high intensity = inc glucose

Stress
Drugs
- corticosteroids, statins, thiazides

Hormonal changes = glucose inc
- before and during menses
- high GH during puberty

Gastroparesis
- peak insulin before gastric emptying
- Decreases BG

Altered insulin PK
Insulin injection technique
- measuring, timing, technique

Inactive insulin

IPFC 3 Midterm 1 (8 decks)

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