Therapeutics Ii Exam 1- Diabetes Insulin

Front 1

insulin therapy goals- 3

Back 1

Avoiding insulin is NOT the goal
(Type 2 diabetes is a progressive disease!! can't avoid it forever)
•Goal is to maintain glucose levels as close to normal as possible
•Think ―Like a Pancreas (Want to mimic normal insulin secretion by pancreas)

Front 2

sources of insulin (4)

Back 2

•Animal (Pork)
•Human (Recombinant human insulin)
•Genetically modified insulin analogs (Rapid–acting (insulin lispro, insulin aspart, insulin glulisine) and Long-acting (insulin glargine, insulin detemir)
•Inhaled (Recombinant human insulin)

Front 3

Rapid-acting insulins (4)

Back 3

insulin lispro, aspart, glulisine, inhaled

Front 4

Short-acting insulin

Back 4

regular insulin

Front 5

intermediate acting insulin

Back 5

NPH

Front 6

Long-acting insulin (2)

Back 6

insulin glargine and detemir

Front 7

Mixtures/combinations of insulin products (3)

Back 7

•NPH/regular (50/50 and 70/30)
•Lispro analog mix (75/25 and 50/50)
•Aspart analog mix (70/30)

Front 8

Basal insulin- names (3)
purpose
% of insulin intake it should be

Back 8

NPH (cloudy), Glargine, Detemir
•A small amount of insulin needed to match the glucose made by the liver
•40-50% of insulin

Front 9

Bolus insulin- names (4)
purpose

Back 9

Regular, Lispro, Aspart, Glulisine
•Doses of insulin calculated to handle the glucose from meals, primarily due to carbohydrate intake

Front 10

rapid acting insulin- onset of action
peak action
effective duration

Back 10

5-15 minutes
30-90 minutes
3-5 hours

Front 11

regular (short acting) insulin- onset of action
peak action
effective duration

Back 11

30-60 minutes
2-3 hours
5-8 hours

Front 12

fast acting Analog insulin properties (5)

Back 12

•Lower A1c values better
•Lower postprandial levels better(especially compared to Regular right before meal)
•Fewer nocturnal hypoglycemia episodes
•Fewer severe hypoglycemia episodes
•Better patient satisfaction

Front 13

regular (short acting) insulin properties (4)

Back 13

•still has intravenous use in hospital (not injectable really)
•Inexpensive insulin
•Does not work fast enough to properly handle postprandial glucose rises (fast acting analogs peak faster)
•Lasts too long and causes higher incidences of hypoglycemia both nocturnally and between meals

Front 14

NPH- onset of action
peak action
effective duration

Back 14

2-4 hours
4-10 hours
10-16 hours- QD or BID dosing (BID makes more sense...)

(same as all intermediate/long acting- except peak varies)

Front 15

insulin glargine (lantus)
onset of action
peak action
effective duration

Back 15

2-4 hours
Peakless- just goes...in a line
20-24 hours- QD

Front 16

insulin detemir (levemir)-
onset of action
peak action
effective duration

Back 16

2-4 hours
6-14 hours
16-20 hours- QD or BID (controversial)

Front 17

Lantus vs. NPH (which is better? advantages of it (3)? disadvantage (2)?)

Back 17

taken daily, rather than QD-BID like NPH
•Lower total insulin doses
•Lower fasting glucose
•Lower incidence of hypoglycemia (Half incidence nocturnal hypoglycemia, Half incidence severe hypoglycemia)

disadvantage of lantus: costs more
if pt skips meals- NPH might be better (has peaks- can plan meals during them) for them because you don't just take it once and have it working the whole day at the same level

Front 18

Using Lantus/ Levemir- type 2 diabetes

Back 18

•Basal insulin once or twice daily
•With oral meds during day

Front 19

How to Switching from NPH to lantus or levemir** exam maybe

Back 19

•Determine total daily amount of insulin you are taking
•Start with 80% of previous NPH dose

said she'd go over more later- edit

Front 20

with type 2s, if you start them on insulin- which oral med would you most likely stop in this case?

Back 20

sulfonylureas- most hypoglycemia

or can start pt on lower dose of insulin than needed and keep on sulfonylureas while titrating insulin up, then when you reach optimal dose you take it off

Front 21

Avoiding hypoglycemia with lantus/levemir (2)

Back 21

•Morning dosing has lower risk than bedtime dosing- package insert of lantus says to dose at bedtime- if there is a peak, will be when they are sleeping and prob okay. but if they have issues with hypoglycemia its better to take in morning because they eat breakfast
•Sometimes need to dose BID to avoid peak and to prolong action

Front 22

70/30 (70%/30%) NPH /regular mixture-
onset of action, peak, effective duration
explain how it works
when to use (2)

Back 22

30-60 minutes
Dual
10-16 hours- take with breakfast and dinner- regular insulin takes care of carbs and hopefully the peak from NPH will occur during lunch (or whatever meal you aren't taking insulin)

good for pt with regular eating pt
pt doesn't want to take basal and bolus

Front 23

75/25, 50/50 lispro mixture-
onset of action, peak, effective duration

Back 23

5-15 minutes
Dual
10-16 hour

Front 24

70/30 aspart mixture-
onset of action, peak, effective duration

Back 24

5-15 minutes
Dual
10-16 hours

Front 25

50/50 NPH /regular mixture-
onset of action, peak, effective duration

Back 25

30-60 minutes
Dual
10-16 hours

Front 26

Premixed (Combination) Insulins advantages (3)

Back 26

•Better postprandial levels after breakfast and supper
•Less risk nocturnal hypoglycemia
•A1c levels comparable

Front 27

Disadvantages to combo insulin (2)

Back 27

•BID does not provide a true basal-bolus approach
•Lose ability to more accurately adjust each insulin

Front 28

combo insulin is appropriate choice for pt who are...(4)

Back 28

•Pt who absolutely refuses to take >2 injections a day
•Mentally or physically challenged patients
•Type 2 patients who still have substantial insulin production
•Patients with very scheduled routine lifestyle

Front 29

timing of Bolus insulins (humalog, novolog, apidra), when given for food
if you have hypoglycemia how can you adjust timing?

Back 29

Humalog (lispro)/ Novolog (aspart)/ Apidra (glulisine)
•5 to 15 minutes before meal
•Hypoglycemia - take after eating

Front 30

timing of Regular insulin when given for food
if you have hypoglycemia how can you adjust timing?

Back 30

•30 - 45 minutes before meal
•Hypoglycemia - take immediately before eating (cuz takes longer)

Front 31

Basal Insulins (Lantus/Levimir/NPH)- timing (3)

Back 31

CONSISTENCY
Take daily regardless of food or BG
•Do not adjust dose based on what current BG reading is

Front 32

NPH timing- if used to cover meals later

Back 32

•When using to cover meals later in day, usually 4 to 5 hours prior to that meal

Front 33

Administering Insulin Injection- EXAM Q (areas (3), route, rotating sites, consistency?, do not use what areas)

Back 33

•SQ injection: fat layer just beneath skin
•Absorption varies by area of body
(Abdomen, outer arm, outer* thigh- can do butt too but...kind of hard...to administer so don't really recommend)
•better to rotate within same site due to different absorption - @ 1" apart
•Do not use an area that will be exercised within the next few hours
•Use same area for same time of day

Front 34

Storage of Insulin- closed (1) and open vials (3), open cartridges, and opened prefilled pens

Back 34

•Unopened & Refrigerated - til expiration date

•Opened Vials: May store in refrigerator or at room temperature
•Recommend new vial every 28 days due to degradation of insulin activity - though its only 1.5% a month so not too bad
no extreme hot or cold (human/pork insulin susceptible to aggregation)

Opened cartridges at room temperature- expiration varies
Prefilled pens - must keep at room temperature after opening

Front 35

Insulin Absorption influenced by...(9)

Back 35

•Insulin type
•Injection volume
•Injection route
•Injection site
•Injection site rotation
•Injection depth
•Needle length/type
•Blood flow
•Renal impairment

Front 36

How many hours does it take to become a CDE

Back 36

1000 pt hours- 400 hours in the last year

Front 37

Type 1 diabetes dosing regimen (U/kg/day) for insulin: initial, usual dose towards the end, honeymoon, adolescents or sick people

Back 37

•Initial: 0.4 - 0.5 U/kg/day
•Usual dose you end up with: 0.7 - 0.8 U/kg/day with Range: 0.5 - 1.2 U/kg/day
•Honeymoon (beta cell surge before first sign of diabetes- one last try by the body to respond): as little as 0.1 U/kg/day
•Adolescents/ Illness (need more insulin- due to growing and stress): 1 - 1.5 U/kg/day

Front 38

type 2 insulin regimens: initial, end range that depends on insulin resistance

Back 38

•Initial therapy:
•0.1 Unit/lb or 0.2 Unit/kg with injectable
•Range with insulin resistance
•0.7 - 2.5 U/kg- note: need more than type 1 due to resistance (just think of 1U/kg for type2s)

Front 39

Insulin Regimens: Once Daily (how to take) (2)
never appropriate therapy for whom?

Back 39

Supper or Bedtime basal insulin in Type 2 diabetes
•Combine with oral therapy in Type 2 diabetes
•Never appropriate therapy for Type 1

Front 40

Twice Daily insulin regimen, requires what

Back 40

•Multiple daily injections (usually 2, may do 3)
•Requires consistency with food intake

Front 41

Basal-Bolus Therapy insulin regimens (1), benefits (2)

Back 41

•Multiple injection regimens
•Allows person to vary food intake
•can use Insulin pump

Front 42

RL is a 47 yo F on Glucotrol XL 20mg QD, Actos 45mg QD, metformin 1g BID. HbA1c=8.4. Cr=1.1. Weight 70 kg. Has microalbuminuria and HTN. Takes lisinopril 20mg QD.
•You decide to supplement this patient with basal insulin. How would you initiate basal insulin therapy in this pt?

Back 42

•Augmentation therapy- basal insulin + oral meds
Starting dose:
•0.2 units/kg/day (14 U NPH or lantus qd) OR
•10 units Lantus once daily (bed time) THEN
•Adjust based on FPG

Front 43

How to …Adjust Lantus Dose if FPG is...
<80
100-120
120-140
140-180
>180

OR do ..what

Back 43

depends on FPG-
Mean FPG from preceding 2 days:
<80- decrease 2 units
100-120- increase 2 units
120-140- increase 4
140-180- increase 6
>180- increase 8

OR
OR
↑ 1 unit every 1 day; continue until FPG <100 mg/dL

Front 44

How to … Start/titrate Lantus: Option 2- the less aggressive way (3 categories of FPG)**the one professor uses

Back 44

Mean FPG from preceding 2 days
<70 ↓ 2 units
150-250 ↑ 2 units
>250 ↑ 5 units

Front 45

insulin algorithm

Back 45

from readings

Front 46

Intensifying insulin to two Injections/Day process (6)

Back 46

•Bolus plus Intermediate acting at breakfast and supper (Premixed insulins often used with this regimen)
•2/3 total dose in AM and 1/3 of total daily dose before supper
•2/3 of each dose is Intermediate and 1/3 of each dose is Bolus
•Occasionally may eliminate short acting
•Requires consistency in food intake at set meal times from day to day
•Concern for middle of night hypoglycemia

Front 47

Intensifying Twice Daily Approach (basal (3)/bolus approach (3))

Back 47

Basal insulin covers only basal needs
•Do NOT try to cover food with basal insulin
•Mainly use Lantus or Levemir - can use NPH
•40-60% of insulin dose for basal needs

Bolus insulin to cover food
•Set doses prescribed for patient
•Must eat consistent to match insulin dose (or count carbs)
•Does allow flexibility with timing of meals

Front 48

replacement insulin therapy

Back 48

Replacement therapy
•Basal + Bolus

Front 49

Indications for replacement insulin (2)

Back 49

•Failed augmentation
•Need more aggressive control

Front 50

•RL is a 47 yo F on Glucotrol XL 20mg QD, Actos 45mg QD, metformin 1g BID. HbA1c=8.4 Cr=1.2 Weight 70 kg Has microalbuminuria and HTN. Takes lisinopril 20mg QD.
•You decide to completely convert RL to insulin. what to do with her oral meds? How would you initiate insulin therapy in this pt?

Back 50

stop sulfonylurea
decrease or stop actos

keep metformin

add bolus+basal insulin

Front 51

initiating basal/bolus insulin- starting dose (3)

Back 51

Starting dose
•0.5 units/kg/day
-50% as basal insulin
-50% as bolus insulin

Front 52

Which agents should you choose for initiating bolus/basal insulin regimen? why? (2)

Back 52

•Lantus vs. NPH
•Lantus has less hypoglycemia
•Lispro/Aspart vs. Regular
•Short acting insulins have lower 1 & 2 hour postprandial glucose levels

Front 53

Basal Bolus Insulin Therapy calculations. include what to do if pump (for basal) and describe when to take dose for the 3 basal insulins and how much % of daily dose it should be

Back 53

•Calculate initial dose on body weight
(if already on insulin, compare to patient’s current total daily dose (TDD)) and use lower amount
•Basal Insulin
-40-60% of total daily dose
-Lantus: Entire dose at bedtime or breakfast
-Levemir: 50% of dose in morning and evening
-NPH: 2/3 dose in AM and 1/3 dose PM
•May also give small amount at each meal to cover basal needs until next meal
•Pump: Divide by 24 for per hour basal

Front 54

Adjusting Insulin Dosages- things to do (5)

Back 54

• Pattern Control (look at 3-7 day before breakfast (fasting), before lunch, before dinner, bedtime levels and change if there is a pattern of consistently out of goal levels)
Identify patient’s desired goal range
• Watch for BG levels consistently higher or lower (patterns)
• Patient must be routinely testing BG
NEED CONSISTENCY WITH DOSING

Front 55

which insulin dosing (bolus breakfast, basal, etc) affects which BG level (6)

Back 55

morning bolus- before lunch BG
Noon Bolus Insulin- before supper
Supper Bolus Insulin- before bedtime
Morning NPH- Before Supper
Evening NPH- before breakfast (fasting)
Lantus (evening)- before breakfast

Front 56

how to identify patters in pt monitored BG (in journal, meters, etc) (3)

Back 56

• Compare BG results taken at same time
of day
• Always have ―3 or more readings
• Make sure other factors are not the cause of the high or low BG values (stress, activity, etc)

Front 57

Insulin Adjustment Guidelines- what do you need to do before/when you adjust (6)

Back 57

• Need at least 3 readings at test time
• Eliminate other possible causes
• Fix low blood sugar first (FIRST AND FOREMOST- NO HYPOGLYCEMIA- better to by hyper than hypo)- always ask if pt had hypoglycemia
• Change only one insulin at a time
• Change by no more than 10-20%
• Wait 3 days before making next change

Front 58

2 most important readings and what they tell you

Back 58

before supper- tells you about bolus (if fasting and before supper is the same- then bolus is fine- but if before supper >> fasting- need more bolus)

fasting- tells you your basal insulin needs

Front 59

Dawn Phenomenon- what is it, when's it occur, variation EXAM

Back 59

• Growth hormone
release results in
insulin resistance and
glycogenolysis
• Occurs about 3-6AM
• Impact varies among
patients

Front 60

Somogyi Phenomenon- causative factor, what is it, how to treat EXAM

Back 60

• Causative factor is
hypoglycemia
• Glycogenolysis and
increased BG levels as
result of hypoglycemia
• Treat by preventing
hypoglycemia

Front 61

• JS is a 33 yo male with Type 1 Diabetes on
NPH 20 units BID and Regular insulin 7
units TID before meals. Last A1c = 6.5%.
He just got insurance and does not like
giving himself 5 shots a day and was
wondering if he could decrease these.
• How would you convert JS’s NPH to
Lantus? (and vice versa)
• Would you change his Regular insulin?

Back 61

How to … Convert NPH to Lantus:
Lantus dose is 80% of total daily dose of NPH (40*0.8 = 32 lantus dose)

but if pt is on lantus and needs to convert to NPH- but when you convert back, it's an increase of 20%- 32*1.2 - 38 units ITS NOT JUST VICE VERSA

yes change regular insulin to analogs- cuz it has better data if cost isn't an issue

Front 62

Rule of 500- what is it? how to calc
use when (2)?

Back 62

how to figure out how much insulin you need per carb

500/tdd = grams of carb covered by 1 unit insulin

or tdd/500 = I:CHO ratio

•Use with regular or analog insulin
•Use every time eat a meal

Front 63

Rule of 1700- what is it? use with what?

Back 63

•Used to determine how much 1 unit of insulin will lower blood glucose
•1700/TDD = BG drop from 1 unit insulin
•Use with regular or analog insulin

is total daily dose ALL basal and bolus insulin??

Front 64

insulin TDD

Back 64

total daily dose- total amount of insulin (both basal and bolus) in units required to sustain a normal BG daily

Front 65

Corrective Insulin (Sliding Scale Insulin) (3)

Back 65

•Often used in hospital setting- acute care setting- when ppl are sick, need extra "corrective" insulin to help them get on their feet qiucker
•Unless basal insulin being provided, results in extreme BG fluctuations

•Needs to be replaced with basal/bolus approach!!!

Front 66

insulin pumps -prob no exam q on this- must be able to do what 3 things to use a pump, pump set up and filling can be done by? uses what type of insulin solutions only

Back 66

•Must be able to operate the pump to give bolus
•Must be able to test blood at four times daily
•Must be able to identify when pump is not working and use syringe instead (Ketone testing)
•Pump set-up and filling can be done by family member
•Uses clear insulin solutions only

Front 67

4 advantages to insulin pump therapy

Back 67

•More reliable insulin absorption
•Best control of Dawn Phenomenon
•Improved blood glucose control
•Allows flexible lifestyle

Front 68

5 disadvantages to insulin pump therapy

Back 68

•Ketoacidosis
•Hypoglycemia
•Skin infections/ abscesses
•Self-image of wearing pump
•Work and time involved in care

Front 69

2 types of "other" pumps (not typical insulin pump)

Back 69

•Disposable 3 day single-use pumps
•Implanted pump- delivers to portal system

Front 70

Pancreas Transplantation- option for whom? difficulties (3)

Back 70

•Option for ―very brittle‖ disease
•Technically difficult
•Rejection difficult to diagnosis
•Immunosuppression is toxic

Front 71

Islet cell Transplantation- process (2), efficacy

Back 71

Islets injected via portal vein to lodge in liver
•Need islets from 2 to 3 donor pancreas
•Treatment has become more effective