Type 1 Diabetes Management Flashcards
Insulin is a hormone secreted from ____ that helps to regulate ____
Pancreatic beta-cells to help regulate blood glucose
Human insulin was created using…
Recombinant DNA technology
Basal insulin refers to…
Secretion of small amounts of insulin throughout the day
Bolus insulin refers to…
Insulin that is rapidly released in response to food
The types of insulins that can be used to replace bolus doses are…
Rapid-acting insulin analogues and short-acting insulins
Short-acting insulins that are used are…
Insulin regular
Short-acting insulins are administered ____ prior to meals
30-45 minutes prior to meals
Cover for mealtime glucose excursions
Insulin regular U-500 is different from others, because…
Entirely different PK profile, used for those with extreme insulin resistance
Those who require >200 units per day
Rapid acting insulin analogues (RAIA’s) include the following…
Lispro, Aspart, and Glulisine
RAIA’s are administered ____ prior to meals
0-15 minutes prior to meals
Are bolus insulins clear or cloudy?
Clear
Onset of action for RAIA’s is usually…
10-15 minutes
Faster-acting insulin aspart is 4min
Peak of RAIA’s are reached around…
1-1.5 or 2 hours
Duration of RAIA’s last for about…
3-5 hours
Onset of action for insulin regular is…
Regular U-500 differs by…
30 minutes
U-500 - 15 minutes
Peak of insulin regular is reached in…
U-500 differs by…
2-3 hours
U-500: 4-8 hours
Duration of insulin regular lasts for…
U-500 differs by…
6.5 hours
U-500 - 17-24 hours
Advantages of RAIA’s over short acting insulin include the following…
More rapid absorption (faster onset, peak, shorter duration)
Convenience in administration timing
Better PPG, lower risk of hypoglycemia
But cost more
Is effectiveness of RAIA’s comparable to short-acting insulins?
YES, similar effectiveness in function
Types of insulins used for basal dosing include…
Intermediate-acting and Long-acting insulin
Intermediate acting insulin includes:
Insulin NPH
Insulin NPH is unique in its formulation, in that they appear…
Cloudy, because they are a suspension; must hand-roll and invert before use to re-suspend
Onset for insulin NPH is…
1-3 hours
Peak of insulin NPH is…
5-8 hours
Duration of insulin NPH lasts for…
Up to 18 hours
Long-acting Insulin Analogues include…
Glargine, Detemir, and Degludec
Onset for LAIA’s is…
90 minutes
Peak for LAIA’s is…
N/A - no peak obtained
Duration of LAIA’s is…
Different for each…
U-100 glargine 24h
U-300 glargine >30h
Detemir 16-24h
Degludec 42h
Advantages of LAIA’s over intermediate acting insulins are…
More consistent/less variable BG - “peakless”
Less hypoglycemia; mainly nocturnal
Use of intermediate acting is declining
Degludec and glargine U-300 have shown ____ compared to insulin glargine.
Lower risk of hypoglycemia (mainly nocturnal) and less glucose variability
Effectiveness of LAIA’s vs intermediate acting insulin is…
Similar efficacy
LAIA’s cost more money
Basal insulins are usually administered…
regimen?
Once daily, at the same time of day
NPH is twice daily. Detemir or glargine U100 may also be used BID
Traditional method of insulin delivery is via…
Syringe + vial
Some people may still prefer syringe + vial, for some reasons…
Least expensive
Familiarity
Prefer less injections and want to combine some insulins in same syringe
A continuous subcutaneous insulin infusion (CSII) is a…
Small computerized device that delivers insulin continuously 24 hours a day
Insulin pens have largely replaced syringe + vial, due to…
Portability, convenience, and ease of use
Precision dosing
The insulin cannula that feeds the insulin pump is changed…
How often?
Every 3 days
The type of insulin used in CSII is…
RAIA, delivered continuously, with increased amounts when a bolus is required
CSII rates of insulin delivery can be adjusted…
Manually, or some have the ability to correct the amount of basal insulin via closed loop system
Insulin pumps could be considered for those who…
Population?
Are poorly controleld with optimized injections
Significant glucose variability + frequent severe hypoglycemia
Pregnancy
Benefits of insulin pumps include…
Possible A1C benefit, when used with CGM
Improved QoL vs insulin injections
The most common adverse effect with insulin is ____ and occurs more frequently in ____
Hypoglycemia; occurs most frequently in those trying to achieve tight control
Weight gain can occur from insulin usage because…
Insulin promotes glucose uptake by target cells, and is an anabolic hormone that promotes glycogen, protein, and lipid synthesis
Depends on amount taken, and often result of “over-correcting”
Other adverse effects that can occur with insulin usage are…
Lipodystrophy
Blurry vision
Allergic reactions (rare)
Factors that may increase insulin absorption are…
Exercise of injected area
Massage
Heat
Consider absorption site as well
Factors that may delay insulin absorption are…
Lipodystrophy
Larger doses (short acting, NPH)
Consider site of injection as well
Preferred injection sites for insulin (SC) include…
Abdomen, upper thigh, buttocks, back of arm
Site of injection can influence rate of absorption for insulin; from fast to slow is…
Abdomen, arm, thigh, buttocks
Not much of an issue for RAIA or LAIA
Lipodystrophy can be minimized by…
Rotating injection sites
SC injection with syringe and vial can vary because of…
Different size of syringes
The most recommended syringe size for insulin injection is…
6mm
6mm insulin syringe injection can be done via…
With/without skin left, preferentially at a 90 degree angle
May need to inject at 45 degree angle if lean
8mm insulin syringe injection can be done via…
Skin left and injection at 90 degree angle
May need to inject at 45 degree angle if lean
12mm insulin syringe injection is…
Not recommended
After insulin injection, the needle should…
Duration?
Be held in place for 10 seconds, then removed
Skin should look normal
When doing a skin lift, the needle should be inserted…
Directions?
Completely into the skin lift, plunger depressed completely, and removed at the same angle it was inserted
For insulin pens, a new needle…
Needs to be used every time
Priming an insulin pen means that before injecting…
The pen should be primed as per manufacturer specs (2 units); with needle pointing up, press plunger and see if a stream of insulin is released
When using an insulin pen, it should be injected…
How?
At a 90 degree angle with no skin lift; press injection button, count to 10, then release and remove
Dose window should say 0
Unopened insulin should remain
Environment?
Refridgerated
In-use insulin can remain…
Environment?
At room-temperature
In-use insulin should be discarded…
After 28 days, up to 56 days (whatever the manufacturer recommends)
In order to preserve insulin, the following should be avoided…
Environment?
Freezing, extreme heat, direct sunlight
If clear insulin appears cloudy, or without particles, it needs to be…
Discarded
EXCEPT for NPH
The following insulins could be mixed together:
R + NPH - pre-mixed + stored together
RAIA + NPH - mix together in same syringe and administer immediately
LAIA’s cannot be mixed with any other insulins
Daily insulin requirements for a patient initially diagnosed with T1DM is usually…
0.5-0.6 units/kg
Daily insulin requirements for a patient in the honeymoon phase of T1DM is usually…
0.1-0.4 units/kg
Daily insulin requirements for a T1DM in ketosis or acute illness is usually…
0.5-1.0 units/kg
Daily initial dosing for a T2DM patient starting initial dosing is usually…
10 units of basal insulin HS, or 0.1 units/kg
Insulin resistance can cause T2DM patient’s daily insulin requirements to increase up to…
2.5 units/kg, or greater
To try and mimic physiologic release, insulin should be administered via…
Multiple daily injections (MDI) or via CSII
Multiple daily injections consists of…
Regimen?
A regimen of bolus injections of insulin before each meal, and an evening basal insulin
The total daily dose (TDD) of insulin should be…
How much basal? How much prandial?
Basal: >40% (40-50%)
Prandial: <60% (50-60%)
It is important to remember that the regimen and dose of insulin will often chang,e based on individual…
Age, goals, general health, glucose levels, and physical activity
The carbohydrate to insulin (C:I) ratio is used to estimate…
How many grams of carbs each unit of meal-time insulin will cover
A typical C:I ratio is…
15g to 1 unit
May be higher or lower
An initial C:I ratio can be estimated by dividing…
500 or 550 by the total daily dose of insulin
A correction factor is the expected amount that…
The expected amount that 1 unit of insulin will normally decrease BG by
An initial CF can be estimated by dividing…
100 by the total daily dose (TDD) of insulin
For someone who is counting carbs, utilizing a correction factor…
Can help to bring down high BG detected before meals
The equation that can be used to correct a high BG reading is as follows…
Current glucose - target glucose/CF
This should be prioritized when interpreting BG/adjusting doses:
Fixing the lows first (risk of hypoglycemia)
ADJUST 1 DOSE AT A TIME
We should adjust by 1-2 units at a time, because one unit of insulin can be expected to drop BG by…
2-3 mmol/L
The cause unexplained morning hyperglycemia can be uncovered by…
Checking glucose levels while one is sleeping for several nights
Either via 3am CBG or via CGM
If night-time glucose is <4 mmol/L while investing unexplained morning hyperglycemia, this suggests ____ effect.
Somogyi effect
If night-time glucose is >4mmol/L when investigating unexplained morning hyperglycemia, this suggests _______
The dawn phenomenon
The somogyi effect is when the body experiences…
Unrecognized nocturnal hypoglycemia that the patient sleeps through - body increases production of counter-regulatory hormones and rebound hyperglycemia occurs
The somogyi effect could be rectified by…
Fixing excess/ill-timed insulin
Consider bedtime snack and evaluate meals/alcohol/exercise
The dawn phenomenon is when the body experiences…
Fasting hyperglycemia, resulting from growth hormones, cortisol, and glucagon being released before waking
Possible ways to rectify the dawn phenomenon are…
Avoid eating carbs after dinner, or eat earlier
Be active after dinner
Adjust basal insulin type/dose/time
Consider insulin pump
