05 Thera VI Insulin and Injectables Lee Flashcards Preview

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Flashcards in 05 Thera VI Insulin and Injectables Lee Deck (75):
1

How is insulin stored?

Insulin molecules form inactive storage hexamers (2 Zn and 6 insulin molecules). Insulin hexamers dissociate back into monomers (active form) in order to be diffused into the blood stream (results in delay in insulin onset of action). Newer insulin analogs have minimal hexamerization and diffuse faster

2

What is the physiological action of insulin?

Binds to its receptor. Translocation of Glut-4 transporters to plasma membrane. Influx of glucose into cell (most prominently muscle and adipose tissue)

3

What are the physiological effects of Insulin?

Increase: glucose uptake, glycogen synthesis, protein synthesis, triglyceride synthesis, potassium uptake. Decrease: gluconeogenesis, glycogenolysis, proteinolysis, lipolysis

4

What are the pharmacokinetics of insulin?

Cleared primarily by liver and kidneys. Half-life: 3-5 minutes

5

What is the normal basal insulin release in your body?

About 1 unit/hour

6

What is the advantage of using insulin therapy?

Decrease microvascular risk. Minimal side effects. No max dose. Unlimited efficacy

7

What are the disadvantages of insulin therapy?

Frequent monitoring. Injectables only (risk of lipodystrophy with incorrect technique). Weight gain. Hypoglycemia. Requires extensive patient education and dedication

8

What are the different types of insulin?

Rapid-acting. Short-acting. Intermediate-acting. Long-acting. Premixed

9

Which types of insulin are bolus/meal insulin?

Rapid- and short-acting

10

Which types of insulin are basal insulin?

Intermediate- and long-acting

11

What are the Rapid-Acting insulins?

Aspart (Novolog). Lispro (Humalog). Glulisine (Apidra)

12

What is the onset time for rapid-acting insulin?

5-15 minutes

13

What is the peak time for rapid-acting insulin?

30-90 minutes

14

What is the duration for rapid-acting insulin?

3-5 hours

15

What are the advantages of Rapid-Acting insulin?

Stimulates physiologic insulin relative to meals. More flexibility in meal timing. Can mix with insulin NPH. Can be given IV (aspart, glulisine)

16

What are the disadvantages of Rapid-Acting insulin?

High cost. Frequent injections. Provides only prandial coverage, still need basal insulin

17

What are the Short-Acting insulin drugs?

Regular (Humilin R, Novolin R)

18

What is the onset time for Short-Acting insulin?

30 minutes

19

What is the peak time for Short-Acting insulin?

2-4 hours

20

What is the duration of Short-Acting insulin?

4-8 hours

21

What are the advantages of Short-Acting insulin?

Cheaper. Can mix with NPH. Can be given IV/IM

22

What are the disadvantages of Short-Acting insulin?

Requires proper timing of injection relative to meals. Variable PK

23

What are the Intermediate-Acting Insulins?

NPH (Humulin N, Novolin N). CLOUDY appearance

24

What is the onset time of Intermediate-Acting Insulin?

2 hours

25

What is the peak time of Intermediate-Acting Insulin?

4-12 hours

26

What is the duration of Intermediate-Acting Insulin?

14-24 hours

27

What are the advantages of Intermediate-Acting Insulin?

Cheaper. Can mix short- or rapid-acting insulin --> fewer # of injections

28

What are the disadvantages of Intermediate-Acting Insulin?

In most patients, require BID injections for basal coverage. Causes more hypoglycemic events due to peaks (nocturnal hypoglycemia)

29

How often is Intermediate-Acting Insulin given?

Inject SQ QD-BID (timing of SQ injection depends upon the insulin with which it is administered)

30

What are the Long-Acting Insulins?

Detemir (Levemir). Glargine (Lantus)

31

What is the onset time for Long-Acting Insulin?

2-4 hours

32

What is the peak like for Long-Acting Insulin?

Detemir (Levemir) is relatively flat. Glargine (Lantus) is flat

33

What is the duration of Long-Acting Insulin?

Detemir (Levemir) is 6-24 hours (depends on dose). Glargine (Lantus) is 24 hours

34

What are the advantages of Long-Acting Insulin?

Stimulates physiologic basal insulin. Less hypoglycemia compared to NPH. Use with rapid-acting insulin allows for physiological insulin regimen

35

What are the disadvantages of Long-Acting Insulin?

Cannot mix with other insulins. Cost. Only provides basal coverage, will require PPG coverage

36

What are the advantages of Pre-Mixed Combinations?

May be better for patients unable to mix/measure insulin. Fewer injections. May be less costly (NPH/Reg)

37

What are the disadvantages of Pre-Mixed Combinations?

Does not allow for fine tuning. Less flexibility in timing meals

38

What is the main Pre-Mixed Combination used?

NPH/Regular (Humulin 50/50, 70/30, Novolin 70/30)

39

What are the acceptable insulin injection sites?

Abdomen (2 inches away from navel). Upper outer thighs. Upper arm. Buttock. Rotate sites to avoid lipohypertrophy (rotate within one injection site)

40

What are the factors that can alter absorption of insulin?

Injection site (abdomen (fast) > arm > thigh > buttock). Exercise (increase absorption if muscle near injection site used immediately after injection). Temperature (heat increases absorption rate). Massaging (increases absorption, avoid rubbing injection site)

41

How can you minimize painful injections?

Keep open insulin at room temperature. Remove air bubbles. Allow alcohol to completely evaporate before injecting

42

What are the available syringe sizes?

1ml, 0.5ml, 0.3ml. Low dose (0.5, 0.3ml) syringes preferred for patients using smaller units and/or are insulin-sensitive

43

What are some alternate glucose testing sites?

Fingertips vs. forearm, upper arm, palm, thigh, calf. Lag time: 20-39 minutes

44

When should you NOT use alternative blood glucose testing sites?

BG rapidly changing. Suspect low BG. Hypoglycemic unawareness. Within 1-2 hours after meals (USE fingertips!)

45

When should you initiate insulin in T2DM according to ADA/EASD 2012?

A1c above goal after 3 months with metformin + lifestyle modifications. Significant hyperglycemic symptoms and/or dramatically elevated glucose level (>300-350) or A1c > 10. High baseline A1c (> 9%( may consider insulin

46

What is the general approach for Insulin use?

First, target FPG with basal insulin (intermediate or long-acting insulin). Then, target PPG with bolus/meal insulin (rapid- or short-acting)

47

What is the Treat-To-Target insulin dosing?

Initial dose: 10 units/day (6 units if FPG < 126 or BMI < 26). Increase dose 2 units every 3 months until target levels reached

48

What is the ADA/EASD 2012 insulin dosing?

Initial dose: 0.2 units/kg/day. Maintenance: 0.7-1.2 units/kg/day. Increase dose 2 units every 3 days until target levels reached

49

When taking insulin, what should be done if there are signs of hypoglycemia after injecting?

Decrease by 4 units or 10% (whichever is greater)

50

When should you initiate insulin in T1DM?

Initiate insulin ASAP

51

What are the ADA/EASD 2012 recommendations for T1DM?

Intensive insulin therapy (multiple-dose insulin injections, continuous SQ insulin infusion). Use of insulin analogs. Matching prandial insulin to carbohydrate intake, premeal blood glucose and anticipated activity

52

What is the general approach to insulin dosing in T1DM?

Empiric Total Daily Dose (TDD) dosing: 0.5-0.8 units/kg/day. Basal: 50-60% of total insulin requirement. Prandial: 40-50% of total insulin requirement

53

What is the usual starting dose for bolus/meal doses in T1DM?

4 units/meal. If 2h PPG values are not at goal, increase dose by 2 units every 3 days until PPG in target range

54

How can patients self-adjust bolus dose by calculating CHO intake for each meal?

>180 lbs: 1 unit/10 grams of CHO. If < 140lbs: 1 unit/15 grams of CHO

55

What are the recommended carbs per meal?

45-60g

56

What is the equation for bolus dose?

Bolus dose = (total carbs in meal) / (carb:insulin ratio)

57

What is the carbohydrate:insulin ratio?

The amount of carbs that can be covered by one unit of bolus insulin (1 units = 10-15g carbs, varies with individuals, time of day, physical activity)

58

What is the Rule of "500"?

Carbohydrate:Insulin ratio. 500 / TDD. Example: someone taking 50 units of insulin a day, 500/50 = 10. 1 unit of rapid acting insulin will cover 10g of carbs

59

What is the "Correction Factor = Rule of 1800"?

Correction dose is the amount of bolus insulin needed to correct episodes of hyperglycemia. Correction dose = (Actual BG - BG target) / CF. Correction Factor = 1800 / TDD. Correction factor estimates how much BG will be lowered with 1 unit of bolus insulin. Varies between individuals

60

What are common symptoms of hypoglycemia during the night?

Nightmares/crying out. Pajamas/sheets wet from perspiration. Feeling tired, irritable, or confused upon waking

61

How can being sick affect insulin treatment?

Illness may increase insulin requirements (continue usual insulin dose). Monitor blood glucose every 3-4 hours (administer supplemental doses of bolus insulin if needed, call MD if glucose remains over 240 after three insulin doses). Monitor ketones if SMBG > 240. Maintain fluids and carbohydrate intake

62

What are the Incretin Mimetics?

Exenatide (Byetta). Exenatide ER (Bydureon). Liraglutide (Victoza)

63

What is the MOA of Incretin Mimetics?

Increase glucose-dependent insulin secretion. Slow gastric emptying, suppress appetite, decrease glucagon secretion)

64

Which Incretin Mimetic does not need renal adjustment?

Liraglutide (Victoza)

65

How often is Exenatide ER (Bydureon) dosed?

2mg SQ every week

66

What are the ADRs associated with Incretin Mimetics?

GI (N/V). Low risk of hypoglycemia (increase concomitant SFU use). Weight loss (2-3kg). Pancreatitis

67

What is the Amylin analog drug?

Pramlintide (Symlin). Synthetic analog of amylin

68

What is the MOA of Amalin analogs?

Slows GI emptying (appetite suppression). Prevents post-prandial rise in glucose

69

What is Pramlintide (Symlin) indicated?

Adjunct therapy in T1DM and T2DM adults on insulin

70

What is the efficacy of Pramlintide (Symlin)?

Decrease A1c by 0.2-0.6%, decrease weight by 1.4kg

71

When is Pramlintide (Symlin) usually administered?

T1DM: 15mc SQ immediately before major meals. T2DM: 60mcg SQ immediately before major meals for 3-7 days

72

What is important to remember when taking Pramlintide (Symlin)?

DO NOT mix with insulin. Must reduce current insulin dose by 50%

73

What is the BBW associated with Pramlintide (Symlin)?

Severe hypoglycemia with insulin

74

What are the ADRs associated with Pramlintide (Symlin)?

Nausea (minimize with slow titration). Anorexia

75

What are the contraindications for Pramlintide (Symlin) use?

Gastroparesis. Hypoglycemia unawareness