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Diabetes Therapeutics > Type-1 Diabetes Mangement > Flashcards

Type-1 Diabetes Mangement Flashcards

1
Q

What is insulin?

A

A hormone secreted from pancreatic β-cells to help regulate blood glucose

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2
Q

How is insulin released in the body? Does commercially available insulin go through the same process?

A

In the body, proinsulin is cleaved to release Insulin + C-peptide

Commercially available products only contain insulin

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3
Q

How do people with diabetes take insulin?

A

Those requiring insulin take it via:
Syringes
Pen needles
Continuous subcutaneous insulin infusion (CSII)

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4
Q

What lab test can be used to determine natural insulin?

A

Serum C-peptide

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5
Q

Where was insulin originally derived from? Is it still available?

A

insulin was originally derived from the pancreases of cows and pigs

Pork insulin (Hypurin®; differs from human insulin by 1 AA) is still available; although it is uncommonly used

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6
Q

What is Humulin? What is its structure? What is it’s benefit?

A

Humulin; the first human insulin created using rDNA technology

Human insulin produced via rDNA technology has an amino acid sequence identical to human insulin

With rDNA technology, the concerns of purity, hypersensitivity, and lipodystrophy are much less common (rare!) vs. animal sources

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7
Q

Describe the structure of insulin?

A

Consists of 51 amino acids in 2 chains (A and B) linked by 2 disulfide bonds

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8
Q

Describe normal pancreatic function in regards to insulin throughout the day?

A

Basal: Beta cells secrete small amounts of insulin
throughout the day.

Bolus: At mealtime, insulin is rapidly released in response to food.

Insulin secretion follows food

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9
Q

Other names for bolus insulin

A
  • Mealtime Insulin
  • Prandial Insulin
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10
Q

What are the two types of bolus insulin? Colour?

A

1) Rapid-acting insulin analogues (clear)
2) Short-acting insulin analogues (clear)

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11
Q

What are the names of the rapid acting insulin analogues?

A
  • Insulin Aspart (Novorapid)
  • Insulin Glulisine - Apidra
  • Insulin Lispro - Humalog
  • Faster acting insulin Aspart (fiasp)

Ruin A Nat* Girl A* Love Has Amazing Fates

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12
Q

What are the names of the short acting insulins?

A
  • Insulin regular (Humulin R, Novolin Toronto)
  • Insulin Regular U-500 (entuzity)
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13
Q

Insulin Aspart Onset, Peak and Duration

A

Onset: 9-20 min
Peak: 1-1.5 h
Duration: 3-5 h

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14
Q

Insulin Glulisine Onset, Peak and Duration

A

Onset: 10-15 min
Peak: 1-1.5 h
Duration: 3.5-5 h

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15
Q

Insulin Lispro Onset, Peak and Duration

A

Onset: 10-15 min
Peak: 1-2 h
Duration: 3-4.75 h

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16
Q

Faster-acting insulin Aspart (Fiasp) Onset, Peak and Duration

A

Onset: 4 min
Peak: 0.5-1.5h
Duration: 3-5h

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17
Q

Insulin Regular (Humulin, Toronto) Onset, Peak, and Duration

A

Onset: 30 min
Peak: 2-3h
Duration: 6.5h

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18
Q

Insulin Regular U-500 Onset, Peak, and Duration

A

Onset: 15 min
Peak: 4-8h
Duration: 17-24h

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19
Q

When are short acting insulins administered? Colour?

A

Administered (30-45min) prior to meals to cover mealtime glucose excursions

Are clear solutions (SQ vial or cartridge)

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20
Q

When short acting insulins are used through IV, what is being treated?

A
  • DKA
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21
Q

How is insulin regular U-500 different than other short acting insulins?

A
  • A more concentrated version for those with extreme insulin resistance
  • Entirely different PK profile
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22
Q

How are rapid acting analagoues different in structure to short acting analogues? Release?

A

Have modifications made to the structure of Humulin insulin

These modifications allow them to have more rapid absorption vs. short-acting insulins and more closely mimic endogenous insulin release

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23
Q

When are rapid acting analogues administered? Colour?

A

Administered with (or just prior to) meals (0-15min) to cover mealtime excursions

Are clear solutions

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24
Q

What are the advantages of rapid acting insulin analogues?

A

More rapid absorption:
Faster onset
Quicker peak
Shorter duration of action

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25
Q

When can the different insulins be taken before a meal?

A

Short-acting: 30-45 minutes before a meal

RAIAs: 0-15 minutes before a meal, or within 15 minutes of eating

Fiasp: up to 2 min before or 20 minutes after starting meal
Note: although can take after a meal, still preferable before a meal

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26
Q

Which type of insulin has better post prandial glucose control?

A

Rapid acting insulin analogues have better post-prandial glucose control than short acting insulins

  • Decreased risk of hypoglycemia
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27
Q

Is Fiasp better at PPG control?

A

Fiasp: better PPG in T1 studies; not T2
- Similar risk of hypo

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28
Q

What are the disadvantages of RAIA’s compared to short acting insulin?

A

On the other hand, RAIA’s Cost more $ & have similar effectiveness

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29
Q

Insulin Lispro U-200 KWIKPEN Pt Counselling ?

A

Humalog (insulin lispro) 200 units/mL solution for injection should ONLY be injected using the KwikPen in which it is supplied

Using any other type of device, like a syringe or infusion pump may result in an overdose causing severe low blood sugar.

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30
Q

Pt Counselling Humalog Kwik Pen 100 U vs. 200 U Dosage?

A

When switching between one concentration of Humalog KwikPen and the other, it is important to understand that the dose-counter window (Dose Knob) on each of the two insulin KwikPen (100 units/mL and 200 units/mL) indicates the number of units of insulin to be injected.

As a result the same number of units of insulin would be chosen for both devices. The Kwikpen automatically delivers the correct volume of insulin so conversion of dose between devices is not needed.”

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31
Q

What is Insulin regular u-500?

A

A very concentrated form of insulin (500U/ml)

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32
Q

Who is insulin regular u-500 used for? Why?

A

For those who require >200U/d (total daily dose)
More comfortable for those who require this much –> less volume injected

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33
Q

How many times is insulin u-500 given in a day?

A
  • 2-3 times a day
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34
Q

Insulin regular U-500 administration before a meal

A

Short-acting: therefore administer 30min before a meal
Can dial up in 5U increments

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35
Q

When using a kwikpen, a dose conversion is…… A1C impact? Warning for Regular U-500?

A

Switching from basal-bolus or pre-mixed insulin can be done on a unit-to-unit basis – no dose conversion is required when using this KwikPen

However, if A1C is ≤8%, decrease the total daily dose of insulin regular u-500 by 20%

Regular U-500 - Extreme caution is required to avoid inadvertent overdose

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36
Q

What are the two types of basal insulins? COLOUR?

A

a) Intermediate acting (cloudy)
b) Long acting insulin (clear)

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37
Q

What are the intermediate acting insulins?

A
  • Insulin neutral protamine Hagedorn (NPH) (Humulin N, Novolin NPH)
  • CLOUDY
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38
Q

Intermediate acting insulin (NPH) Onset, Peak and Duration

A

Onset: 1-3h
Peak: 5-8h
Duration: Up to 18h

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39
Q

What are the long acting insulins?

A
  • Insulin Detemir U-100 - Levemir
  • Insulin Glargine U-100 - Lantus
  • Insulin Glargine U-300 - Toujeo
    -Insulin Degludec U-100, U-200- Tresiba
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40
Q

Insulin Detemir U-100 Onset, Peak, Duration

A

Onset: 90 min
Peak: N/A Peakless
Duration: 16-24h

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41
Q

Insulin Glargine U-100 Onset, Peak, Duration

A

Onset: 90 min
Peak: N/A Peakless
Duration: 24h

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42
Q

Insulin Glargine U-300 Toujeo Onset, Peak, Duration

A

Onset: 90 min
Peak: N/A Peakless
Duration: >30h

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43
Q

Insulin Degludec U-100, U-200 Onset, Peak, Duration

A

Onset: 90 min
Peak: N/A Peakless
Duration: 42 hours

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44
Q

Intermediate Acting Insulins Dosing

A

Administered once or twice daily to provide a ‘background’ amount of insulin –> depends on person

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45
Q

Physical Appearance of Intermediate Acting Insulins

A

Appear cloudy (they are a suspension): must hand-roll and invert (10x) before use to re-suspend

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46
Q

What structure are long-acting insulin analogues? How does this occur?

A

Modifications have been made to AA sequence of human insulin, which results in an extended and more flat absorption

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47
Q

What are the advantages of Long acting insulin analogues over intermediate acting insulin?

A

“Peakless”
More consistent / less variable BG
Less hypoglycemia (Mainly nocturnal)

Clinical trials of the newer, longer-acting ones (degludec and glargine U-300) have shown lower risk of hypo (mainly nocturnal) and less glucose variability than insulin glargine

LAIAs cost more $
They all have similar efficacy

48
Q

Dosing of Insulin NPH

A

Usually dosed twice daily

49
Q

Dosing of Insulin Detemir

A

Insulin detemir: the D of A is dose dependant: 0.2U/kg ~12hrs, 0.4U/kg ~20 hrs; therefore it may be used once or twice daily

50
Q

Dosing of Insulin Glargine U-100

A

usually once daily but some will also use it BID

51
Q

Toujeo SoloStar and DoubleStar Dosing

A

Dosed OD, same time of day

52
Q

Insulin Degludec (Tresiba) is avilable in….. of what dose? Dosing?

A

Flextouch Prefilled Pens: 100 U/ml and 200 Units/ml

Dosed once daily at any time of day. If miss a dose, inject when realize the omission. Ensure at least 8 hours between injections

53
Q

What is the max administered dose w/t reloading?
a) Insulin NPH
b) Glargine U-100
c) Detemir U-100
d) Degludec U-100
e) Degludec U200
f) Toujeo DoubleStar

A

a) 30-60 U
b) 80 U
c) 80 U
d) 80 U
e) 160 U
f) 160 U

54
Q

Switching from Insulin Glargine 300 units/ml (Toujeo) OD to:

a) Glargine 100 units/ml (Basaglar)
b) Degludec (Tresiba)

A

a) Reduce by 20%
b) Reduce by 20%

55
Q

Switching from Insulin glargine 100 units/mL (lantus) OD to:

a) Insulin Glargine 300 units/mL (Toujeo)
b) Glargine 100 units/mL (Basaglar)
c) Degludec (Tresiba)

A

a) Same dose
b) Same dose
c) Same dose

56
Q

Switching from insulin glargine 100 units/ml (lantus) BID to:

a) Insulin Glargine 300 units/mL (Toujeo)
b) Glargine 100 units/mL (Basaglar)
c) Degludec (Tresiba)

A

a) Same Dose
b) Same Dose BID
c) Reduce by 20%

Glargine to Degludec –> Decrease by 20%

57
Q

Switching from insulin NPH BID to: a) Insulin Glargine 300 units/mL (Toujeo)
b) Glargine 100 units/mL (Basaglar)
c) Degludec (Tresiba)

A

a) Reduce by 20%
b) Reduce by 20%
c) Reduce by 20%

If switching from NPH to Long-acting, reduce dose by 20%

58
Q

How can insulin be delivered?

A

Syringes and vials
Insulin pens
Insulin pumps

59
Q

What is the traditional way to give insulin? Why is it still preferred for some?

A

The traditional method of insulin delivery; some still prefer for various reasons:

Least expensive
Used to it (familiarity)
Prefer less injections and want to combine some insulins in same syringe

60
Q

What are the sizes and volumes of syringes available?

A

Syringes are available in differing volumes (3/10, ½, 1 cc) and differing lengths: (E.g. BD 6mm and 8mm) and differing thickness (30 and 31 gauge)

61
Q

Why have insulin pens largely supplanted vials/syringes?

A

Portable / convenient / easier to use
Advantageous if dexterity/visually impaired
Allows for precision dosing

62
Q

Counselling tip on insulin pens. Sizes and volumes?

A

A new pen needle tip must be attached each time, and they are available in differing lengths:
Eg. BD pen needles 4,5, and 8mm
Available as 31 and 32 gauge

63
Q

What is a continous subcutaneous insulin infusion (CSII) (insulin pump)? How often is it changed?

A

A small computerized device that delivers insulin continuously 24 hours a day

The pump is worn on the outside of the body, and delivers insulin via a tube, which is attached to a cannula placed under the skin – this is changed every 3 days

64
Q

What type of insulin does a What is a continous subcutaneous insulin infusion (CSII) (insulin pump) use?

A

It only uses one type of insulin (a RAIA) and delivers it continuously, as well as increased amounts when a bolus is required (i.e. meals)

65
Q

Can a continous subcutaneous insulin infusion (CSII) dose be adjusted?

A

Can adjust rates manually or some have the ability to automatically correct the amount of basal insulin via a closed loop system

66
Q

A pharmacist should consider an insulin pump for people who….

A

Patient / guardian should be motivated and able to understand what is all entailed before deciding on if this is right for them

Consider for those:
poorly controlled with optimized injections
significant glucose variability
frequent severe hypoglycemia
pregnancy

67
Q

What are some benefits of an insulin pump?

A

May provide an A1C benefit (when used with CGM)
No increased risk of hypoglycemia vs. non-pump
Some improved QOL vs. insulin injections

68
Q

How can an insulin pump and a CGMS (capillary glucose monitoring system) be used together?

A

A closed loop system – the pump and CGM automatically communicate to one another via a computer program to create somewhat of an ‘artificial pancreas’

69
Q

What are some common adverse effects of insulin? Why do they occur?

A

a) Hypoglycemia –> most common one
b) Weight Gain –> Promotes glucose uptake by target cells
- Anabolic hormone that promotes glycogen, protein and lipid synthesis
c) Localized fat hypertrophy
d) Blurry vision –> Sugars changing, can occur when initiate for a few weeks
e) Allergic reactions –> Rare

70
Q

What are some factors that influence insulin absorption?

A

Site of Injection
Exercise of Injected Area
Massage
Temperature
Lipohypertrophy
Dose
Renal Function
Depth of Injection

71
Q

How can the site of injection affect insulin absorption?

A

Absorbed fastest (and most consistently) from the abdomen followed by the arm, thigh, and slowest from buttocks (not as much of an issue for R / LAIA)

72
Q

How can exercise of the injected area affect insulin absorption?

A

Strenuous exercise of a limb within 1hr will speed absorption

73
Q

How can massage affect insulin absorption?

A

Vigorous massage will speed absorption

74
Q

How can temperature affect insulin absorption?

A

Heat can increase the rate of absorption

75
Q

How can lipohypertrophy affect insulin absorption?

A

Delays absorption

76
Q

How can the dose of insulin affect absorption?

A

Larger doses delay absorption and prolong action (for short acing and NPH)

77
Q

How can renal function affect insulin absorption?

A

Renal failure decreases insulin clearance

78
Q

How can the depth of injection affect insulin absorption?

A

IV > IM>SC

79
Q

How can one minimize lipohypertrophy?

A

Rotation of injection site

80
Q

What is some advice for injection technique?

A

Wash your hands

Alcohol swabs: use to clean cartridge/vial – not the body

Rotate injections systematically within the same anatomical region
–> Rates of absorption
–> Lipohypertrophy effects

Avoid moles, scars, etc.

Use a quick, smooth movement

81
Q

What are the preferred injection sites?

A

Abdomen
Thigh
Love Handles
Under the upper arm

82
Q

How can one rotate the injection sites on the abdomen?

A
  • 4 Quadrants
  • 4 quadrants within each quadrant
83
Q

How to dial up insulin in a syringe?

A
  • Pull air into syringe up to the correct amount
  • Push the air into the bottle
  • Invert vial. Draw up a small amount of insulin, push it out to remove air bubbles
  • Pull your exact dose of insulin into the syringe
84
Q

What size of syringe is recommended? What is the recommended technique?

A
  • 6 mm Syringe
  • Do with or without skin lift.
  • 90 Degree angle recommended. May need to do a 45 degree angle if particularily lean.
85
Q

Technique for an 8 mm Syringe

A

Do a skin lift and inject at 90 angle.
If lean, may need to inject at a 45 angle

86
Q

12 mm Syringe

A

Not recommended

87
Q

After injecting insulin, how long should one hold it

A

Hold needle in place for 10 seconds

88
Q

What should the skin look like after removing the needle?

A

When needle is removed, the skin should look normal
Occasional bleeding or bruising will not affect the efficacy

89
Q

Technique for When Doing a Skin Lift

A

When doing a skin lift, insert the needle completely into the skin lift. Depress the plunger completely. Remove syringe at same angle it was inserted. Release the skin lift.

90
Q

Can you mix insulin’s together?

A

Just:

Humulin N is an intermediate-acting insulin and Humulin R is a short-acting insulin.

91
Q

Mixing and Administration of Insulin N +R in same syringe

A

1) Draw Up - If manually mixing 2 insulins in the same syringe, always draw up the quick acting insulin first
2) Fill the syringe with air up to the # of units needed of NPH
3) Insert the needle into the vial, expel air, remove the needle (Do not draw up the insulin)
4) Fill syringe with air to the # of units needed of R
5) Insert needle into vial, expel air, draw up desired of # of units of R, remove needle from vial
6) Insert needle back into NPH vial and draw up desired units of NPH
7) Make sure there are no air bubbles (tapping). Check at eye level
8) Quickly insert at a 90 degree angle (with or w/t a skin pinch). Push on plunger
9) Count to 10. Remove needle.

92
Q

Describe how to use a pen device.

A

Wash hands. Remove the pen cap

Wipe pen tip with alcohol swab. Attach the needle (screw on). Use a new needle every time

Safety test (priming): Before injecting, the pen should be primed as per the manufacturer specs (e.g. 2 units). With needle pointing up, press plunger and if see a stream of insulin, it is ready

Dial up amount of insulin required (i.e. 20U)

Inject at 90 degree angle with no skin lift for most. Press injection button, count to 10, release button and remove

Remove the needle; dose window should say 0

93
Q

Where should unopened insulin be stored?

A

Fridge

94
Q

When insulin is in use, where should it be stored?

A

Room Temp.

95
Q

When should used insulin be used before?

A

Depending on the insulin, the manufacturer recommends that in-use insulin should be discarded after 28 days (E.g. lispro) up to 56 days (E.g. degludec)

96
Q

When storing Insulin, avoid….

A

Avoid freezing, extreme heat, direct sunlight (effect composition and stability)
If clear insulin appears cloudy or with particles – discard

NPH is a suspension, so it is supposed to be cloudy. Must hand-roll and tipped 10 times before using

97
Q

Syringes and Vials and Types of Insulins that can be mixed and stored

A

R + NPH: may be pre-mixed and stored together
RAIA + NPH: may mix together in the same syringe, but must administer immediately (cannot store together)
LAIA: cannot mix in the same syringe as any other insulins

98
Q

Type-1 Diabetes Insulin Doses

A

a) Initial Dose –> 0.5-0.6 Units/kg
b) Honeymoon Phase –> 0.1-0.4 units/kg
c) Ketosis or acute illness –> 0.5-1.0 units/kg

99
Q

Type 2 Diabetes Insulin Doses

A

a) Initial Dose –> 0.1 units/kg (or more commonly 10 units of basal insulin HS)

b) Insulin Resistance –> Up to 2.5 Units/kg (or greater)

100
Q

What is the usual split of basal and bolus in T1DM and T2DM who are on MDI?

A

In T1DM or those who are on MDI (multiple daily injections) with T2DM, the usual split is:

basal: 40-50%

bolus: 50-60%

101
Q

In T1DM, insulin should be given in what pattern….

A

Insulin is necessary, and is ideally delivered in a manner that mimics normal physiologicinsulin secretion

To try and mimic physiologic release, insulin should be administered via MDI (multiple daily injections) or via CSII

102
Q

What should a schedule of multiple daily injections look like?

A

A regimen of bolus injections of insulin before each meal + an evening basal insulin

he TDD of insulin should be:
Basal: ≥40%
Prandial: ≤60%

103
Q

How is type-1 diabetes often diagnosed?

A

Clinical presentation: quite ill: initiated in-hospital
E.g. start at 0.5mg/kg/d and adjust based on glucose readings

104
Q

Type-1 Diabetes Dose at start of Diagnosis

A

The regimen and dose will change over time, and is rarely ever the same – the extent to how people adjust their insulin is up them

Changes are based on the individual’s age, goals, general health, glucose levels, physical activity, etc.

105
Q

If one is to adjust their insulin to try and achieve the best control, they need to ….

A

Be able to count carbohydrates

106
Q

What is the carbohydrate to insulin (C:I) ratio?

A

This ratio is used to estimate how many grams of CHO each unit of meal-time insulin will cover

A typical C:I ratio is 15:1 (15g CHO: 1 Unit insulin), but may be higher or lower

In other words, 1unit of insulin handles 15g CHO

107
Q

How can a C:I ratio be calculated?

A

An initial C:I ratio can be estimated by dividing 500 or 550 by the total daily dose (TDD) of insulin

108
Q

What is the correction factor?

A

For someone who is counting carbs, utilizing a correction factor (CF) can help bring down BG detected before meals

The CF is the expected amount that 1 unit ofinsulin will normally ↓BG by 2-3mmol/L over the next 2-4 hours

109
Q

How can an initial CF be calculated?

A

The initial CF is estimated by dividing 100 by the TDD

100/TDD

110
Q

How can one calculate how many units of insulin will be needed to correct the high reading?

A

Current glucose– target glucose / CF = units to give to correct the high reading

  • Add the value to the normal amount of insulin used
111
Q

What are the rules for adjusting insulin?

A

Fix the lows first (i.e. hypoglycemia)
Generally adjust by 1-2 units at a time. Remember that 1U of insulin can be expected to ↓ BG ~2 to 3 mmol/L

Only adjust 1 dose at a time; begin with correcting the 1st problem BG of the day

Make dose adjustments every few days based on glucose trends

112
Q

How should one evaluate morning hyperglycemia?

A

If there is unexplained morning hyperglycemia upon wakening, try to determine the cause before adjusting therapy

Do this by checking glucose levels while one is sleeping x several nights
3am CBG or via CGM

113
Q

In evaluating morning hyperglycemia and checking BG at night, what readings would suggest which effect?

A

If glucose is <4mmol/l, this suggests a Somogyi effect
If glucose >4mmol/l, this suggests the dawn phenomenon

114
Q

What are some signs of nocturnal hypoglycemia?

A

Nightmares, restless sleep, sweating (wet pillow/sheets), headache in am, hunger

115
Q

What is the Somgyi effect? How can it be corrected?

A

Unrecognized nocturnal hypoglycemia that patient sleeps through; as a result the body ↑’s prod’n of counter-regulatory hormones & see rebound hyperglycemia (in the morning)

Possible ways to rectify:
Fix the excess/ ill-timed insulin
↓ dose of insulin
Shift predinner basal (NPH) to hs
Consider a LAIA if on NPH
Consider a bedtime snack, evaluate meals/alcohol/exercise
The key is to prevent overnight lows

116
Q

What is dawn phenomenon? How can it be rectified?

A

This is fasting hyperglycemia that is the result of growth hormones, cortisol, glucagon being released in early am before waking (usually between 3-8am)

Possible ways to rectify:
Avoid eating CHO after dinner/eat earlier
Be active after dinner
Adjust basal insulin type / dose / time
Consider an insulin pump

Diabetes Therapeutics (4 decks)

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