Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

PDAT2 > 14/15 - DM Injectables > Flashcards

14/15 - DM Injectables Flashcards

1
Q

LipoAtrophy

A

thought to be due to insulin antibodies

or allergic-type reactions w/ destruction of FAT @ site of injection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Levemir Vial / 300-Unit Flexpen

Dosed / Onset / Duration

MoA

A

Long-Acting Insulin Detemir

Dose QD or BID

BID benefits patients with elevated PRE-Dinner BG

Onset = 1 hour, relatively FLAT peak

monomers are 98-99% albumin bound, delays the distribution into target tissues.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Initiating RX:

Mixed Insulin Regimen

A

Premixed Insulins like 70% NPH (LA) + 30% Regular (SA)

  1. ​Estimate total insulin needed per day:
    1. 0.4 - 0.5 units/kg/day (same as MDI)
  2. Before breakfast:
    1. 2/3 of total daily dose before breakfast
  3. ​Before Dinner
    1. 1/3 of total daily dose before dinner
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How are Insulin products CHARACTERIZED by?

A

All insulin products contain only ACTIVE insulin peptide

Onset

Duration of Action

Strength

Source

Analog

insulin that had AA within molecule modified for physiochemical / PK advantages

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Weight Gain from Insulin

In comparison to Metformin & SulfonylUreas

A

Insulin > Sulfonylurea > metformin (no weight gain)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

When to consider Dual Therapy for T2DM?

A

A1C > 9%

Lifestyle management + Metformin + ADDITIONAL AGENT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Diabetes KetoAcidosis

DKA

Criteria / Physical Findings

A

Typically seen in T1DM, rare in T2DM

  • Glucose > 250mg/d
  • Presence of serum ketones, serum pH < 7.3
  • Anion gap >10, plasma bicarb <18 meq/I
  • S/S of:
    • polyuria / polydipsia / N&V / Coma
    • dehydration, hypotention + tachycardia
    • fruity breath from ketones
    • MORE Respirations
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Insulin Sensitivity Factor

ISF

(correction Factor)

A

“1800 Rule” for RAPID-Acting Insulin

“1500 Rule”** for **short-acting insulin

  • Determines how much
    • Glucose is lowered by 1 unit of insulin
  • Based on ALL THE UNITS of insulin that person takes in 1 day
  • Ex. Used 54 units / day
    • 1800 / 54 units = 33.33
      • BG will be lowered by ~33mg/dL
        • ​for every 1 unit of humalog
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Insulin Release Kinetics

A

2 Phase Kinetics - difficult to replicate when dosing insulin

Acute 1st Phase - lasts a few minutes (0-10), high peak

Sustained Second Phase - SECRETION, persists for the duration of the high-glucose stimulus (10-80+)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

When to consider Injectable Therapy?

A

A1C > 10%

BG > 300mg/dl

or patient is markedly symptomatic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Fast-Acting Analog

Aspart (Fiasp) / Novo Nordisk

Dosed / Onset / Duration

A

Newly approved formulation of Novolog

+ niacinamide -> increase speed of initial absorption

+ L-arginine to boost stability

Dosed at the BEGINNING OF A MEAL or within

20 MIN AFTER STARTING A MEAL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Advantages & Disadvantages

of MDI Insulin Regimen

A

Basal = LA (Lantus or Levemir)

Bolus = RA (LAG - Humalog/Novolog)

  • Adv:
    • _​_Offers FLEXIBILITY in meal size & timing
    • ​​best MIMICS endogeneous insulin production
  • ​Disadv:
    • ​Required multiple injections
    • have to test BG often
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Insulin Therapy for

T1DM vs T2DM

A

T1DM

  • almost NO insulin secretion*
  • will be dependent on insulin for the rest of their lives*

T2DM** - **lower A1C >2%

most effective in lowering hyperglycemia,

Initiate AFTER optimized ORAL therapy or failure to achieve target goals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Types of Premixed Insulins

A

•Humalog Mix 50/50

•Humalog Mix 75/25

•NovoLog Mix 70/30

•Humulin 70/30

•Novolin 70/30

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Types of Short-Acting (Regular) Insulins

+ Concentrated Regular Insulin

A

Considered Bolus / R = Regular

Humulin R

Humulin R U-500

Novoin R

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Sliding Scale Insulin

SSI

A

Reactive, not PROACTIVE

NOT RECOMMENDED TYPICALLY, only seen in Hospital care

  • Does not provide physiologic insulin needs:
  • “Chasing” of BG
  • supplementation / correction scale
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Types of Long-Acting Insulins

A

Glargine (Lantus)

Detemir (Levemir)

  • can not be mixed*
  • considered Basal*
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Resolving GDM

gestational diabetes

A

Insulin -> reduction in fetal moridities

similar efficacy among VARIOUS insulin regimens

TARGET A1C = 6-6.5%

A1C target is *LOWER* due to INCREASED RBC turnover

FPG <95 mg/dl

1hr PPG < 140mg/dl or 2hr PPG < 120mg/dl

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

HHS

Hyperglycemic Hyperosmolar State

A

Similar to DKA except patients are

NOT acidotic

Fluid Deficit is GREAT

common in T2DM, mortality rate is 50%

Treatment is the SAME as DKA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Insulin to Carbohydrate Ratio

ICR

A

“Rule of 500”

T1DM on average = 1unit:10g

T2DM on average = 1unit:15g

  • Divide 500 by the TDD of Insulin
    • Ex. TDD = 54 units
      • 500 / 54units = ~10g
        • therefore - 1 unit of insulin per 10g of carbs
  • Each person has their OWN ICR
    • used to figure out meal BOLUS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Premixed Insulin Regimen Effects

of PM=EVENING- Short-Acting (Bolus) insulin

major action time & effect reflected?

A

Major action is between Supper & Bedtime

Effect is reflected in the Bedtime BG levels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Types of Ultra Long-Acting Insulin

A

Glargine

( Toujeo U-300 )

Degludec

(Tresiba U-100 / U-200)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Sick Day Management

A

MUST FOR T1DM

  • Continue insulin therapy 50-100% of basic insulin dose
    • even when NOT eating
    • or presence of N/V
  • ​Test BG & Ketone MORE frequently
    • Q3-4
    • may need to supplement insulin
  • ​FLUID REPLACEMENT
    • very important
    • jello / chicken broth / soup
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Treatment of DKA

A

FLUID REPLACEMENT

Insulin supplement

Potassium Replacement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
**DM for Special Populations** **Older Adults (Elderly)**
* **_Need to consider risks_** * ***hypoglycemia*** * *comorbiditiesm, **microvascular disease + CVD*** * **dexterity / self-care** * **Nutrition** * Social support / mental status / life expectency * **FALLS RISK** * *Decline in **renal function** needs to be considered*
26
**3 Primary Physiological Actions** **of Insulin**
INCREASE **glucose disposal** * Decrease* ***hepatic glucose*** *production* * Supresses* ***ketogenesis***
27
**Intermediate-Acting Insulin / NPH** Humulin N / Novolin N Dosed / Onset / Duration
**_DOSED BID_** Onset = **_1-3 hours_** LONG Duration = **12-16 hours** Prominent Peak = **8 HOURS** (4-10 hours) --\> risk of *hypoglycemia @ time of PEAK* **Weight GAIN** Major factor in limiting insulin adjustments
28
**Basal Insulin / (Ultra) Long-Acting Insulin** Glargine / Detemir / Degludec Dosed / Onset / Duration
***_Onset & Duration_*** ***VARIES*** *between each formulation* _MIMICS normal pancreatic basal insulin secretion_ ***Peakless***, predictable effects *Reduced risk of **nocturnal hypoglycemia***
29
**Switching Insulin Products** **NPH** --\> **Basal** (Intermediate Acting, -**N**) --\> (Long Acting, Lantus/levemir) ***Basal --\> NPH***
*don't need to know these specifics* **QD NPH -\> QD Basal (LA)** *same dose 1 to 1* **BID NPH -\> QD Basal (LA)** *initiate w/ 80% of TDD*
30
**LipoHYPERtrophy**
Injection site complication caused by **Many injections into SAME SITE** thick / rubbery scar *avoid by* **_ROTATING INJECTION SITES_** use larger injection zone \>1cm frome ach *do not reuse needles*
31
**Initiating RX:** **Basal + Bolus Regimen** (**MDI** = multiple dose insulin, Regimen)
**_LA (Lantus or Levemir)_ + *RA (LAG - Humalog/Novolog)*** 1. Start insulin based on **_WEIGHT_** 1. **_0.4 - 0.5 units/kg/day_** 2. ​***BOLUS*** *(LAG)*​ 1. *​*20% of starting dose (calculated above) @ each meal 1. **_20% x Dose TID-AC_** 3. **_​​_****_Basal_** (NPH - glargine/detemir/degludec) 1. 40% of starting dose @ bedtime 1. **​_40% x Dose QHS_**
32
**Premixed Insulin Regimen Effects** of **AM-_Intermediate-Acting (Basal)_ insulin** major action time & effect reflected?
Major action is between **BREAKFAST & Supper** Effect is reflected in the **Pre-SUPPER BG levels**
33
**Dosage Adjustment for** **Basal + Bolus MDI Regiment**
_Basal = LA (Lantus or Levemir)_ **_Morning glucose reading, PRE meal_** *Bolus = RA (LAG - Humalog/Novolog)* ***POSTPRANDIAL***
34
**What differs between Insulin Preparations**
*There is **NO DIFFERENCE** **IN EFFICACY** between newer & older formulations* its the **_PHARMACOKINETIC PROFILES_** that are different HIGHER DOSE for T2DM vs T1DM Adjusted based on BG results MAX DOSE = Based on effectively lowering BG
35
**Premixed Insulin Regimen Effects** of **AM-Short-Acting (Bolus) insulin** major action time & effect reflected?
Major action is between **BREAKFAST & LUNCH** Effect is reflected in the **Pre-Lunch BG Levels**
36
**Lantus, SolaSTAR Pen** Dosed / Onset / Duration MoA
_Long-Acting Insulin_ **_Glargine_** Administered **_ONCE A DAY_** & should be **_SAME TIME EACH DAY_** *no pronounced peak,* **1 hour Onset** Injection of **acidic solution** (pH 4.0) --\> **precipitation of Glargine** in subQ tissue (pH 7.4) --\> *slow dissolution* of glargine from **hexamers**
37
**GDM** **Gestational DM**
**Any Degree of _GLUCOSE INTOLERANCE_** with **onset or first recognition during pregnancy** *4-5% of ALL pregnancies* Increased Risk of **_Macrosomia_** (birth weight) & **_Birth Complications_** (spinal bifida, birth defect) **_Neonatal *hypoglycemia*_** **Maternal Hypertention**
38
Types of **Rapid-Acting Insulins**
Considered **_BOLUS_** L **L A G** **Lispro** (Humalog U-100 / U-200) **Lispro** (Admelog) **Aspart** (Novolog) **Glulisine** (Apidra) ***_Inhaled AFREZZA_***
39
**Concept of Basal + Bolus Insulin** LA (Lantus or Levemir) + RA (LAG - Humalog/Novolog)
* **Basal Insulin = Long Acting** * Supresses glucose production **between meals & overnight** * nearly consistant levels * covers 40-50% of daily needs * **BOLUS INSULIN = Rapid acting** * **​**for _mealtime/prandial_ * *limits **hyperglycemia AFTER meals*** * immediate rise / peak @ 1 hour * ~10-20% of total daily insulin req @ each meal *
40
**Toujeo** (U-300) Dosed / Onset / Duration MoA
_ULTRA Long-Acting Insulin **Glargine**_ Dose = **QD @ same time each day** LATE Onset: **6 hours** Duration = **36 Hours** *Same maker as LANTUS & **smaller volume***
41
***Disadvantages of Insulin***
***HYPOGLYCEMIA /*** ***WEIGHT GAIN*** Pt / provider RELUCTANCE Training requirements / Injectable (pulmonary toxicitiy\_
42
**ICR vs ISF** (Insulin to Carb ratio) vs (Insulin Sensitivity Factor
**_ICR_** _**Bolus** insulin,_ Determines how many **_grams of carbs are convered by 1 unit of insulin_** **_Units : Carbs_** ***ISF*** Used in ***correction or supplementation*** *of insulin doses when glucose levels are **too high/low BEFORE meals*** ***\_\_\_ mg/dl for every 1 unit of insulin***
43
**Premixed Insulin Regimen Effects** of **PM=Evening _-Intermediate-Acting (Bolus)_ insulin** major action time & effect reflected?
Effect is reflected in the **NEXT MORNING BG Reading**
44
**Tresiba** (U-100/U-200) Dosed / Onset / Duration MoA
_ULTRA Long-Acting Insulin **Degludec**_ Duration ~**42 hours** Onset = **_90 minutes_** *no peak, lower risk of **hypogllycemia*** Allows for **flexibility** in dosing, especially with a MISS *slow release from **subQ depot***
45
**Rapid - Acting Insulin** Lispro / Aspart / Glulisine Dosed / Onset / Duration
Compared to Regular/Short-Acting, ACTION is faster / PEAK is HIGHER / *dissapears faster* Convenient, take **immediately prior to means** Onset = **15 Minutes** Duration = **3-5 Hours**
46
**Resolution & *Prevention*** **of DKA**
* Resolution: * Patient is **clinically stable** * **BG \< 200mg/dl** * Serum **bicarbonate \> 18 meq/l** * **Venus pH \>7.3** * **​***Prevention:* * *​**educate patient about precipitating factors*** * ***sick day management***
47
**Options after Initiating Basal Insulin** **_A1C not Contolled_** **3**
**_Combination Injectable Therapy_** * Add 1 **Rapid-Acting** **Insulin** before largest meal * **4 units or 0.1 units/kg** * **​** (or 10% basal dose) * Add **GLP-1 RA** * *possibly not tolerated for A1C target* * **_Change_** to **premixed insulin BID** (b4 breakfast + supper * **_2/3 AM --\> 1/3PM_**
48
**Advantages of Pre-MIXED Insulin**
Increase **Glucose Disposal** * Decrease **hepatic glucose production*** * Supressess **Ketogenesis*** Mixing with other formulation in the _same syringe_ *prior to injection* is ***NOT RECOMMENDED***
49
**Dawn Effect**
*AE of Insulin* **_Elevated FBG_** due to **early morning CORTISOL & EPInephrine Release**
50
**Toujeo** (U-300) Other stuff
_ULTRA Long-Acting Insulin **Glargine**_ INITIATION in ***T1DM***, glucose lowering effect may take **_up to 5 days_** & first few doses may ***NOT be sufficient*** to cover needs After switch, temporary **RISE in FPG** in first WEEKS of therapy Titrate no more frequently than q3-4 days, to minimize *hypoglycemia risk*
51
**DM for Special Populations** **Children & Adolescents**
* **_METFORMIN is the ONLY FDA approved ORAL agent_** * 10-16 years of age * *​unfortunately, **monotherapy is POOR in many adolescents*** * ***​***​​​_Sulfonylureas_ are also commonly used * * **_INSULIN_** continues to be the standard of care * *when glycemic goals cant be reached with* * ***metformin/sulfonylureas***
52
**S/Sx of *hypoglycemia***
**Shaking / Sweating / *weakness fatigue*** **Fast Heartbeat / Anxious / Dizziness / Irritable** **Impaired VISION / HEADACHE / HUNGER**
53
**Somogyi Phenomenon**
*AE of INSULIN* **Nocturnal *hypoglycemia*** followed by **_REBOUND HYPERglycemia_**
54
**Treating GDM** Gestational Diabetes
**_Lifestyle modification is ESSENTIAL_** *restrict calories / carbs / **small meals** many times thru day* **INSULIN** is preffered medication, *does not cross placenta* ***metformin + glyburide** may be used but --\>* **crosses placenta**
55
**Advantages of Insulin**
*NEARLY* **Universal Response** Theoretically **Unlimited Efficacy** * Decrease **microvascular risk*** * (UKPDS)*
56
**Basaglar** KwikPen
First approved **"FOLLOW-ON"** insulin **LONG-acting Glargine** ***biologically similar to LANTUS***, same protein sequence & effects
57
**Humulin R U-500** Used for who? / Testing / onset+duration
**_CONCENTRATED_** human insulin, for those who require **\>200 units of insulin /day** *need proper training / special syringe* **BID/TID 30 min prior to meal** onset = ~**15 min** peak = 4-8 hours duration = ~**21 hours**
58
**Regular (Short-Acting) Insulin** Humulin-R / Novolin-R Dosed / Onset / Duration
* inconvenient administration*: **_20-40 minutes PRIOR to meals_** * Slow Onset =* **_30-60 min_** LONG duration = **5-8 hours** peak is @ 2-4 hours **multiple-injection regimen,** potential for **late PP-*hypoglycemia*** * caution with **PP-exercise***, * SLOW to correct hyperglycemia*
59
***Hypoglycemia*** Glucose Level / **2 categories of Symptoms**
Glucose **\< 70mg/dl** **2-3x** HIGHER RISK when needed to **intensively regimen dose** **_Adrenergic_** ( epi secretion ) *sweating / tremor / tacyCardia / anxiety / hunger* **_Neuroglycemic_** ( CNS dysfunction ) *dizziness / headache / blunted mental activity / loss of fine motor skill / confusion / abnormal behaviro / convulsion / loss of conciousness*
60
**Insulin Storage & Disposal**
*Avoid **Heat / Light / Freezing*** Store _UNOPENED_ products in _FRIDGE_ Pen can be kept at room temperature, keep storage in fridge check **exp date & appearance**
61
**Types of Fast-Acting Insulin**
**ASPART** (Fiasp) **Novo Nordisk** *new formulation of Novolog*
62
**Afrezza** Rapid-Acting Insulin
Human Insulin **INHALATION** powder Oral inhalation @ **beginning of each meal** * many NEGATIVES:* * need to **Assess Lung Function + Spirometry (FEV1)*** * Contraindicated in pts w/ **Chronic Lung Disease***
63
Types of **Intermediate-Acting** **Insulin / NPH**
**(NPH = isophane Insulin,** neural protamine Hagedorn) *N = NPH* Only one that **can be MIXED*****,*** ***also considered BASAL*** **Humulin N** **Novolin N**
64
**Initiation of Injectable Therapy**
Initiate **_BASAL INSULIN_** start: **10 U/day** or **0.1-0.2U/kg/day** * adjust 10-15% or 2-4 units QD/BID to reach FBG target* usually _**with Metformin +/- *noninsulin agent***_
65
**Adverse Effects** **of Insulin**
***hypoglycemia /* weight GAIN** ***LipoAtrophy & LipoHYPERtrophy*** **_Somogyi Phenomenon_** **_Dawn Effect_**

PDAT2 (22 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions