Type 1 Pharmacotherapy Flashcards
What are the three rapid acting insulin analogs?
Insulin lispro Humalog
Insulin aspart. Novo rapid
Insulin glulisine Apidra
What is the: Onset Peak Duration Oh the rapid acting insulin analogs?
Onset 10-15 min
Peak. 1 to 1.5 hours
Duration. 3 to 5 hours
Except lispro.
Peaks in 1-2 hours
Duration 3.5 to 4.75 hours
What is the: Onset Peak Duration Oh the short acting insulin analogs?
Toronto and R What is the: Onset 30 minutes Peaks 2-3 hours Duration. 6.5 hours
What is the: Onset Peak Duration Of the intermediate acting insulin analogs?
NPH. N
Onset 1-3 hours
Peak. 5-8 hours
Duration. 18hours
What is the: Onset Peak Duration Of the long acting insulin analogs?
Glargine. Detemir. Onset 90 minutes. Peak. None Duration Glargine: up to 24 hours Detemir; 16 to 24 hours
Degludec??
What are the advantages of rapid acting vs short acting insulin? 3
1- better glycemic control. A1C and PP
2- less NOCTURNAL hypo
3- dose 0-15 min before eating rather than 30-45 minutes prior so improved qol
What are the advantages of using long acting vs. intermediate acting insulin. 3
1- less nocturnal hypo
2- lower FBG
3- improved QOL and patient reported satisfaction
What % of patients on glargine will experience pre-injection hyperglycemia and require bid dosing?
15-30%
What is the name of the ultra long acting insulin? What is its advantage compared to glargine?
Degludec. Tresiba
Comparable safety and tolerability but
1-less hypo.
2- reduced basal and total insulin doses needed
3- allows for some flexibility in timing without compromising safety and control
What is the role of metformin in overweight type 1?
Liraglutide?
SGLT2?
The use of metformin in type 1 diabetes reduces insulin requirements and the total cholesterol/low-density lipoprotein ratio and may lead to modest weight loss, but it does not result in improved A1C (48). Metformin use in type 1 diabetes is off-label and potentially harmful in the setting of renal or heart failure.
Lira- reduce weight and insulin dose BUT no change in A1C. No indication though
SGLT2 - reduced A1C BUT increase in DKA. No indication
How do you avoid nocturnal hypo in pts taking NPH as the basal insulin or in those individuals at high risk of severe hypoglycemia (regardless of insulin type), particularly when bedtime plasma glucose levels are
Give a bedtime snack
How does low to moderate exercise effect BG levels?
Low- to moderate-intensity exercise lowers blood glucose (BG) levels both during and after the activity, increasing the risk of a hypoglycemic episode. These effects on BG levels can be modified by altering diet, insulin, and the type and timing of exercise
How does high intensity exercise effect BG levels?
high-intensity exercise raises BG levels during and immediately after the event. SMBG before, during and especially for many hours after exercise is important for establishing response to exercise and guiding the appropriate management of exercise.
If ketosis is present should you exercise?
No. It could lead to metabolic deterioration.
Which long acting insulin is associated with LESS exercise induced hypoglycemia?
Detemir
What is hypoglycemia unawareness?
Occurs when the threshold for autonomic hypoglycemia warning sx is close to or below the level for development of neuroglycopenic symptoms. Ie: the first sign of hypo is loss of consciousness or confusion.
What time of day is most common to have severe hypo resulting in seizures?
Overnight. Nocturnal hypo Can last up to 4 hours.
How can you reduce the risk of a symptomatic nocturnal hypoglycemia?
Pts on intensive insulin therapy should periodically check their BG level in the middle of the night at a time that corresponds with the peak action time of their nocturnal insulin.
Hypoglycemia episodes average about 2 per week. What are the long term effects of repeated hypo events?
It can reduce normal response to hypoglycemia. Leading to hypoglycemia unawareness and defective glucose counter regulation. Both of these are reversible with strict avoidance of hypo for 2 days to 3 months
What strategies can be used to reduce hypoglycemia and regain hypoglycemia awareness:
1- increase SMBG including Monitor periodically overnight to detect nocturnal hypo
2- less stringent glycemic targets to avoid hypoglycemia for up to 3 months
3- education program targeting rigorous avoidance of hypo while maintaining glycemic control
4- CGM worn more than 70% of the time and or CSII
After initial start of insulin, why in some cases does insulin needs go down?
After insulin initiation, some patients go through a “honeymoon period,” during which insulin requirements may decrease. This period is, however, transient (usually weeks to months), and insulin requirements will increase with time.
Type 2 patients with previous severe hypoglycemia requiring hospitalization have an increased subsequent risk of what?
Dementia
List Autonomic (neurogenic) symptoms of hypoglycemia.
Trembling Palpitations Sweating Anxiety Hunger Nausea Tingling
How do you distinguish between mild, moderate and severe hypoglycemia.
MILD:autonomic symptoms present. Patient able to self treat.
MODERATE: Autonomc and neuroglycopenic symptoms present. Patient able to self treat
SEVERE: Individual requires assistance from another person. Unconsciousness may occur. PG typically
Which insulin can mixed?
How long can they be stored
Short acting with intermediate. Store for 30 days
Rapid acting with intermediate. Use within 15 minutes.
Glargine and Detemir CANNOT be mixed
If a type one patient is on a premixed bid insulin regimen how do you convert him to basal bolus?
Eg. 8 units R and 15 units NPH before breakfast.
And 5 units R and 9 units NPH supper?
Add up all insulin =37. Reduce by 20-25% to accommodate for a more physiologic insulin delivery.
Provide 40-50% as glargine or Detemir
And remaining 50-60% as rapid.
Eg. 15 lantus
15 Apidra divided up into 3 meals.
Usually bolus is divided as 35-30-35 due to higher activity levels in later morning/afternoon and smaller lunch.
So: 5-6 am. 4-5 lunch. 5-6 supper.
Of course insulin to CHO ratio is more precise.
What types of patients are at risk for hypoglycemia unawareness?
Long standing diabetes Requiring tight glycemic control Repeated hypo bouts Advanced age Smokers Obesity.
When should pancreas transplant be considered?
If patient ALSO has end stage renal disease. Consider transplanting pancrase WITH kidney. This results in much longer graft survival.
Will
Patients be immunosuppressive With pancreas R transplant or with islet cell transplant?
With EITHER procedure. Immunosuppressed for life
How is amylin analogues used in therapy?
As add on in type one or two treated with insulin.
Given by injection prandially to SLOW gastric emptying and CHO absorption and enhance satiety.
Causes nausea like GLP1.
Do not use is gastropareisis.
What is the one disadvantage of rapidly reducing BG?
Transient worsening of retinopathy?
How soon before a meal would you dose:
Short acting insulin R
Aspart, lispri, glulisine
Faster acting insulin aspart
30-45min
0-15min
Start or up to 20 min after though better control if before
Can CSII / insulin pump be used in women contemplating pregnancy?
Yes
Which insulins are used in CSII? Ie: insluin pumps
Lispro
Aspart
Glulisine
What is the benwfit of CSII in type one?
A1C lowering of 0.19 to 0.3%
Increase treatment satisfaction
Improve qol
What is the befit of CGM in tyoe one
A1C reduction of 0.4 to 0.6%. Greatest benefit is wearing senaor at least 70% of the time and when A1C is higher.
WITHOUT increase in hypo
How long can insulin be stored be stored at room temp?
What about detemir?
What about glarginr U 300
What about degludec?
28 days
42 days
42 days
8 weeks
How do you adjust pre mixed insulin?
Asjustments based on FBG and PP readings
If PP high then thr pre meal dose is increased. But hypo is a concern with pre mixed
Why is more insulin usually needed in the morning?
Due to the dawn effect.
an abnormal early-morning increase in blood sugar (glucose) — usually between 2 a.m. and 8 a.m. — in people with diabetes.
Some researchers believe the natural overnight release of the so-called counter-regulatory hormones — including growth hormone, cortisol, glucagon and epinephrine — increases insulin resistance, causing blood sugar to rise. High morning blood sugar may also be caused by insufficient insulin the night before, insufficient anti-diabetic medication dosages or carbohydrate snack consumption at bedtime.
How do you obtain the TDD of insulin for someone already on regimen of basal bolus? Or when switching regimens you need this
Add up All injections units. Then reduce by 10 %
What should you keep in mind when choosing a time of day to give glargine?
You will see elevation of BG around the time the next dose is due. 15-30% of people need it bid
Can you switch from NPH to glargine or detemit unit to unit?
Yes. Unless NPH is bid. If that’s the case then can reduce the basal total dose by 20%.
Do people on CSII require more or less TDD insulin that someone on basal bolus? How would you convert someone to CSII??
Less. Because it’s given in a more physiologic way.
Take TDD and reduce by 10-25%.
Basal would be 50% of this. Then divide this by 24 hours to get units per hour.
Eg. TDD = 40 units. Reduce by 25% TDD = 30 units 50% is basal 15 units basal. Divide by 24 0.625 units per hour.
Bolts is variable depending on pt and CHO etc.
How do you check for somogyi effect?
Check BG at 3am or 4am for a few nights to see if hypo. Could explain rebound hyper in am.
If you need to calculate a pump dose from scratch by weight how do you do it?
0.5u per kg if TDD
50% is basal.
Divide by 24 hours.
Eg. 65kg = 32.5u. Round down
32u x 50% = 16
Basal is 16/24 = 0,65u per hour
Remaining 50% can be divided by 3 or tailored to Cho
Why don’t you inj insulin next to a muscle being used for exercise
Hypo.
Rates of absorption of different sites. Fastest to slowest.
When does this NOT apply??
Abd
Arm
Thigh
Buttocks
Long acting basals like glargine and detemir have no difference in rate with different sites!
Which insulin’s have their duration of action lengthened by larger doses??
Short or intermediate (not rapid)
All long acting basal
So basically all insulin’s except rapid.
At what renal clearance should you be concerned about lowering insulin doses and be concerned about extended duration??
Less than 30
Which insulin’s need rolling and inverting t
Mixed.
NPH
There can be up
To 30% variability in insulin absorption on the same day at the same site. T or F
True
Should alcohol CHO be added into consideration for insulin dosing?
No. Alcohol does not convert to glucose. BUT can cause hypo for up to 24 hours after consumption
Do you give more or less insulin when flying
East
West
Only
Change of time change is more than ____ hours
Less
More
3
What is typical unit per kg insulin requirement for type one
0.3-1 unit per kg
When would you choose a different FBG target to titration basal?
If A1C is still not <7 can target FBG 4-5.5
Which basal insulin should NOT be titrates every 1-2 days
Degludec. 2 units every 3-4 days OR 4 units per week.
When do you stop titrations basal based on hypo?
If 2 episodes of hypo in one week OR ANY nocturnal.
When adding ONE bolus to a basa regimen, what two ways can you monitor BG?
2 hours PP < 8
Or
Pre-prandial of NEXT meal 4-7
Calculate a basal bolus for type two based on weight and how is TDD distributed.
0.3-0.5 units per kg
40% basal
20-20-20
Or customize to meals of course
How long before meals should per mix be given?
30-45 min.
