Diabetes Flashcards
(87 cards)
1
Q
Insulin is produced by what? and where are these cells located?
A
Beta-cells (islet cells) located in the pancreas
2
Q
What is insulin responsible for?
A
moving glucose out of the blood and into body cells to be used as energy
3
Q
if insulin is stored for later use by the liver… what is the name of the product it’s stored as?
If glycogen is depleted, glucagon will signal fat cells to make what? What is this newly made product used for?
A
Glycogen
ketones
alternative energy source
4
Q
What counteracts insulin?
Where is it created?
When does it work? How?
What happens when glycogen is unfortunately depleted?
A
Glucagon
alpha cells in pancreas
when BG is low . pulls glucose back into blood by releasing glucose from glycogen
Glucagon will signal fat cells to make ketones as alt energy source
5
Q
What’s t1diabetes caused by?
what can high ketone levels cause?
In T1Diabetes, what can you test for to distinguish it from t2DM?
What happens to c-peptide levels in T1DM?
A
autoimmune destruction of beta cells in pancreas
DKA
Islet autoantibodies, C-peptide
its very low or absent (undetectable)
6
Q
What’s FDA approved to delay the onset of symptomatic disease in t1D?
A
Teplizumab (Tzield) (mAB)
7
Q
What is T2DM due to?
It’s strongly associated with ? (3)
How can T2DM be handled?
A
Insulin resistance (decr insulin sensitivity) and relative insulin deficiency
obesity, physical inactivity, family history
lifestyle mods alone OR oral/inj meds
8
Q
For patients with pre-diabetes, what does this mean?
How can they control BG levels?
A
It means there’s an incr risk of developing diabetes . BG higher than normal, but not high enough for diagnosis
following dietary and exercise reccs reduces risk of progression to diabetes
9
Q
What could be used in pre-diabetes pt’s?
Especially in pt’s with which criteria? (3)
What is recc for these pt’s in terms of monitoring?
A
Metformin (to help improve BG levels)
BMI >= 35, age 25-29 yrs, women w/hx of gestational diabetes
Annual monitoring for devel of diabetes and tx of modifiable CVD risk factors
10
Q
Diabetes in Preg:
- BG goals are more?
- Hyperglycemia during preg can lead to an infant that is? and incr risk for developing ? (2)
- What’s used to test for gestational diabetes?
- for these pt’s how should diabetes be treated? What’s preferred if meds r needed? What’s sometimes used?
A
- stringent
- larger than norm (macrosomia)
- obesity and diabetes later in life for mother and baby - tested at 24-28 weeks using OGTT
- First with lifestyle mods
- insulin preferred
- metformin + glyburide
11
Q
Risk factors:
1. A
2. P
3. Overweight such as which BMI?
4. High risk of r or e such as
5. HX of ___
6. A1C >= _____ (pre diabetes)
7. ___ with diabetes (sibling or parent)
8. HDL __ and or TG > ___
9. HTN with value __
10. ___ or ___ history
11. conditions that cause insulin resistance such as ?
A
- age
- physical inactivity
- BMI >= 25 or >= 23 in asian americans
- race, ethnicity such as AA, asian, latino, native American or pacific islander
- gestational diabetes
- 5.7%
- first degree relative
- < 25 , > 250
- > = 130/80 or taking BP med
- CVD, smoking
- PCOS, acanthosis nigricans
12
Q
Classic sx’s of hyperglycemia?
Other sx’s include
4.
5.
6.
T1D initial presentation ? (7.)
A
Polyuria, polyphagia (exessive hunger), polydipsia
- fatigue
- blurry vision
- weight loss
- DKA
13
Q
Everyone should be tested for diabetes beginning at what age?
WHo else?
If result is normal…. when should repeat testing occur?
A
35 yrs
all asx’s adults who are overweight (BMI>=25 or >=23 in asians) or obese with at least 1 other risk factor (i.e. physical inactivity)
At a min, every 3 yrs
14
Q
Diagnostic criteria: Diabetes & Pre Diabetes
- A1C?
- FPG?
- random BG?
- OGTT (2hr BG)
A
- > = 6.5
5.7-6.4 - > =126
100-125 - for diabetes >=200 in addition to classic sx’s of hyperglycemia
- > =200
140-199
15
Q
What are the glycemic targets in diabetes for:
Not Preg
1. A1C
2. preprandial BG
3. 2 hr PPG
Preg
4. pre prandial BG?
5. 1 hour PPG
6. 2 hour PPG?
A
- <7%
- 80-130
- <180
- < 95
- <140
- <120
16
Q
Glycemic Control should be assessed:
- When if NOT meeting goals?
- When if AT GOAL?
A
- quarterly (q3months)
- Bi-annually (every 6 months or twice per year)
17
Q
Estimated Average Glucose (eAG):
- An A1C of 6% is equiv to an eAG of?
- each additional 1% increases the eAG by?
A
- 126 mg/dL
- ~28 mg/dL
18
Q
Patients with T1D should use ____ where the prandial insulin dose is adjusted to carb intake
A Carbohydrate serving is measured as ? which is ~ one small piece of ___, 1 slice of __, or 1/3 cup of ___
A
carbohydrate counting
15 grams
-fruit, bread
-cooked rice/pasta
19
Q
How much physical activity should be done per week?
how often should pt’s stand?
Smoking?
A
150 mins of mod-intensity aerobic activity per week spread over at least 3 days
q30 mins at a minimum
quit it
20
Q
Diabetes Complications:
A. Microvascular Diseases (4)
B. Macrovascular disease (3)
A
A. Retinopathy
- diabetic kidney disease
-periph neuropathy , incr risk of foot infections and amputations
-autonomic neuropathy (gastroparesis, loss of bladder control, ED)
B. CAD, including MI
-Cerebrovascular disease including stroke (CVA)
-PAD
21
Q
Review Comprehensive Care Chart on Page 579
A
22
Q
What is diabetic kidney disease defined as?
what would be the tx options?
BP Goals ?
TX for BP in patients with diabetes?
A
- eGFR < 60 and/or albuminuria (urine albumin >= 30 mg/24hrs or UACR >= 30 mg/g)
- ACEI or ARB
SGLT2I (if EGFR >=20)
Finerenone (once on a max tolerated dose of ACEI or ARB) - < 130/80
- No albuminuria or CAD: thiazide, DHP CCB, ACEI or arb
Albuminuria or CAD: ACEI or ARB
23
Q
Treatment For T2DM:
- If pt has ASCVD , HF, or CKD, start what at baseline?
- When should u start 2 drugs at baseline?
- When can insulin be used initially?
A
- SGLT2I or GLP1 agonist
- if a1c is 8.5-10%
- for severe hyperglycemia: A1C>10% or BG >= 300 mg/dL
or if evidence of catabolism (weight loss), or if sx’s of hyperglycemia r present
24
Q
TREATMENT ALGORITHM: After lifestyle changes
- GOAL IS CARDIORENAL RISK REDUCTION what 1st drug should be used in each case?
a. ASCVD or high risk (age >= 55 w/2 or more additional RF such as obesity, htn, smoking, dyslipidemia, albuminuria)
b. HF
c. CKD
- A1C is still above goal, what do u add on for each scenario?
A
1a. GLP1-A or SGLT2I with proven benefit
1b. SGLT2I w/benefit
1c. SGLT2I w/benefit or GLP-1A wi/cvd benefit
2a. GLP-1A or sglt2i if not yet started, or TZD
2b. additional glycemic control or cardiorenal risk reduction needed such as BG reduction measures or weight loss
2c. GLP-1A if not yet started
25
TX Algorithm: After lifestyle changes
1. IF GOAL IS GLYCEMIC CONTROL AND WEIGHT MANAGEMENT
a. for BG reduction what should you use? very high (7) vs intermediate (1)
b. for weight loss what should u use?: very high/high (4) , intermediate (2), or neutral for weight loss (2)
1a. Very high/high:
GLP-1A, tirzepatide insulin, metformin, SGLT2I, SU, TZD
intermed: DPP-4I
1b. Very high/high: tirzepatide , semaglutide, dulaglutide, liraglutide
intermed: GLP-1A thats not listed above , SGLT2I
neutral: dpp-4i, metformin
26
Combinations to avoid? (2)
1. DPP-4I + GLP-1A
SU + Insulin
27
Which GLP-1A's have Cardiorenal benefits?
Which SGLT2i's have cardiorenal benefits?
dula, lira, SQ semaglutide
Canagliflozin, dapagliflozin, empagliflozin, ertugliflozin
28
What exactly is GLP-1?
What does it do?
1. Analogs of the incretin hormone GLP-1
2. incr glucose dependent insulin secretion, decr glucagon secretion , slows gastric emptyping and improves satiety
29
For each GLP-1A state the Brand name and dosing
1. Liraglutide (2)
2. Dulaglutide
3. Semaglutide (3)
4. Exenatide
- not recc in what CrCL?
5. Exenatide ER
-not recc in what eGFr?
Dual GLP-1 and GIP Agonist
6. Tirzepatide (2)
1. Victoza or Saxenda is for weight loss
- 0.6 mg SQ daily x 1 wk, then incr to 1.2 mg SQ daily; can incr to 1.8 mg sq daily
2. Trulicity
-0.75 mg once weekly; can incr to 4.5 mg SQ once weekly
3. Ozempic (SC), rybelsus (PO)
Wegovy (for weight loss)
-0.25 mg SQ once weekly x4weeks, then 0.5 mg SQ weekly, can incr to 2 mg SQ weekly (for ozempic)
wegovy goes 0.25 mg, 0.5 mg, 1 mg, 1.7mg, 2.4 mg
- 3 mg PO daily x 30 days then 7 mg daily, can go up to 14 mg daily
4. Byetta : 5 mcg SQ BID x 1 month; cango up to 10 mcg SQ BID
not recc in CrCL< 30
5. Bydureon BCise : 2 mg SQ once weekly
- eGFR < 45
6. Mounjaro or zepbound for weight loss
-2.5 mg SQ weekly x 4 weeks then 5 mg SQ weekly; can go up to 15 mg SQ weekly
30
BBW for GLP-1A's? (except byetta)
Risk of thyroid c cell carcinomas: dont use if personal or fam hx of medullary thyroid carcinoma or with multiple endocrine neoplasia syndrome type 2 (MEN2)
31
GLP-1 RA: Warnings
1. List the 3
2. GLP-1RA Not recc in pt's with?
3. Bydureon BCise Warnings?
4. Ozempic, trulicity, mounjaro incr complications w?
1. Pancreatitis (rf are gallstones, alcoholism or incr TGs) , AKI, gallbladder disease
2. Severe GI disease including gastroparesis
3. Serious injection site reactions (abscess, cellulitis, necrosis) w/or w/o SQ nodules
4. Diabetic retinopathy
32
GLP-1RA's: AE's
Tirzepatide specific ae?
weight loss
N/V/D (reduced with dose titration
hypoglycemia
inj site reactions
Incr HR
33
How much can GLP-1RAs lower A1C?
Hypoglycemia risk?
DONT USE WITH?
Specific counseling for Byetta? Rybelsus?
which 2 meds are pen needles NOT provided with?
For mounjaro/zepbound patients using OCPs are advised to switch to?
Exenatide can do what to INR?
1. About 0.5-1.5%
2. low unless used with insulin
3. DPP-4I's due to overlapping mechanism
4. Give dose within 60 mins before meals
take dose >= 30 mins before first food/drink/med of the day with 4 oz of plain water
Byetta or Victoza
non-oral or barrier method of contraception for 4 wks after initiation and for 4 weeks after each dose escalation
INCR inr for pt's on warfarin
34
SGLT2I: MOA
Which SGLT2Is have shown benefits in pt's with HF, CKD, and or ASCVD?
inhibits SGLT2, which reduces reabsorption of glucose and increases urinary glucose excretion which decr BG concentrations
Cana, dapa, empa, ertugliflozin
35
For each SGLT2I, state the brand name and the dosing
1. Canagliflozin
-eGFR 30-69?
2. Dapagliflozin
3. Empagliflozin
4. Bexagliflozin
5. Ertugliflozin
1. Invokana: 100 mg daily prior to 1st meal of the day; can incr to 300 mg daily
for egfr 30-59: max dose is 100 mg/day
2. Farxiga:
5 mg daily in the morning; max is 10 mg daily
3. Jardiance : 10 mg daily in the morning but can incr to 25 mg daily
4. Brenzavvy: 20 mg daily in the morning
5. Steglatro : 5 mg daily in morning; can incr to 15 mg daily
36
SGLT2I's: Warnings
K
G
U
N
H
A
R
Canagliflozin and Bexagliflozin specificially have warning of? (2)
Ketoacidosis (can occur with BG < 250), risk increases with acute illness, dehydration and renal impairment. DC prior to surgery to decr risk
Genital mycotic infections
UTI's (including urosepsis, pyelonephritis)
Necrotizing fasciitis
Hypotension
AKI
Renal impairment due to intravasc volume depletion
risk of leg and foot amputations ; risk of fractures
37
SGLT2I's: AE's
Incr U and T
H
Incr ___ and ___
Canagliflozin has a ___ risk when used with other drugs that incr K
SGLT2I's: How much does it lower A1C ?
Can it be used in dialysis?
Urination , thirst
hypoglycemia
mg and po4
hyperkalemia
0.7-1%
not recc
38
SGLT2Is': DDI
what happens when used in combo with diuretics, RAAS inhibs, or NSAIDS?
What interacts with Invokana?
incr risk of intravasc volume depletion causing hypotension and AKI
UGT inducers (rifampin, phenytoin, phenobarb) can decr levels of invokana --> consider using higher doses up to 300 mg if used in combo and eGFR >= 60
39
Metformin primarily works by?
Decr hepatic glucose production, incr insulin sensitivity and decr intestinal absorption of glucose
40
Metformin : What are the brand names?
IR/ER/Riomet Liquid is provided in which mg?
Dosing for IR/ER?
How often to titrate?
Usual maintenance dose?
Max Dosing?
Fortamet, Glumetza, glucophage, glucophage ER, riomet
IR: 500, 850, 1000 mg
ER: 500, 750, 1000 mg
Riomet: 500 mg/5mL
IR: 500 mg daily or BID
ER: 500-1000 mg daily usually w/dinner
Titrate weekly
1000 mg BID
2000-2550 mg/day
41
Metformin: Boxed Warning?
CI's ? (2)
Warnings:
-Not recc to start if eGFR is?
-___ deficiency w/long term use... how often should this level be monitored?
Lactic acidosis--> risk incr with renal impaired, contrast dye, excessive alc or drugs (topiramate) and hypoxia
eGFR < 30, acute/chronic metab acidosis (dka included)
eGFR 30-45
B12; every 1-2 yrs
42
Metformin: AEs?
How much can it lower A1C?
ER formulation should be? but note it can leave a ___ in stool
Metformin DDI with Iodinated Contrast --> what can it cause and how should it be handled?
GI: diarrhea, nausea, flatulence, cramping
1-2%
swallowed whole; ghost tab
Can cause renal dysfunction leading to an incr risk of lactic acidosis. discontinue metformin before procedure
-Restart 48 hrs after if eGFR stable
43
SUs and Meglitinides are known as insulin secretagogues; How do they work?
What makes meglitinides diff?
STimulating insulin secretion from the pancreatic beta-cells to decr postprandial BG
faster onset of 15-60 mins and shorter duration of action
44
For each SU state the brand name and dosing
1. Glipizide
2. Glimepiride
3. Glyburide
1. Glucotrol XL, glucotrol, Glipizide XL
IR: 5 mg daily, maxdose 40 mg/day
Doses > 15 mg should be divided BID
XL: 5 mg daily, max dose of 20 mg/day
2. Amaryl : 1-2 mg daily, max dose of 8 mg/day
3. Glyburide or micronized glyburide is Glynase
Glyburide: 2.5-5 mg daily, titrate to a max dose of 20 mg/day
Glynase: 1.5-3 mg daily, max dose of 12 mg/day
45
SU's CI's? (3)
Warnings?
AE's?
How much can lower A1C? Long term use causes?
Glipizide IR needs to be taken when? all other products?
Glucotrol XL can do what?
Glimep + Glyburide not preferred in elderly due to?
Pt's with G6PD deficiency?
Sulfa allergy, T1D, DKA
Hypoglycemia
Weight gain + nausea
1-2%, decr efficacy
30 mins before a meal
-w/breakfast or first meal of the day; hold dose if NPO
leave ghost tab in stool
risk of hypoglycemia
incr risk of hemolytic anemia
46
Name 2 Meglitinides
Warnings?
AE's ?
When should a dose be skipped?
repaglinide +nateglinide
hypglycemia, caution with severe liver/renal impairment
weight gain, HA, URTIs
When meal is skipped
47
SU and Meglitinide DDI
1. SU's are __ substrates. use caution
2. Which drugs can incr repaglinide? Which drug CI with repag?
1. CYP2C9
2. gemfibrozil + plavix (incr repaglinide)
- gemfibrozil
48
How do DPP4I's work?
Prevent the enzyme DPP-4 from breaking down incretin hormones, GLP-1 and GIP
-incr glucose depend insulin secretion and decr glucagon secretion (which decr hepatic glucose production)
49
For each DPP4I, state brand name and dosing
1. Sitagliptin
eGFR 30-45?
eGFR < 30?
2. Linagliptin
3. Saxagliptin
-Egfr < 45?
4. Alogliptin
CrCL 30-59?
CrCL < 30?
1. Januvia : 100 mg daily
-50 mg daily
-25 mg daily
2. tradjenta : 5 mg daily
3. 2.5-5mg daily
2.5 mg daily
4. Nesina: 25 mg daily
12.5 mg daily
6.25 mg daily
50
1. DPP4I's Warnings? (4)
-Risk of ___ seen with saxa + alo
-Alo specific warning?
2. AE's?
3. Lowers A1C how much? Weight? Dont use with?
1. pancreatitis, severe athralgia , acute renal failure, bullous pemphigoid
HF
hepatotoxicity
2. well tolerated but can cause nasopharyngitis, URTIs, HA, rash
3. 0.5-0.8%, neutral, GLP-1 agonists
51
DPP4I DDI's
1. Saxa is a major substrate of?
-What should be done in this scenario?
2. Lina is a major substrate of?
-What happens to linagliptin levels?
1. CYP450 3A4 and PGP
-Limit dose to 2.5 mg w/strong CYP3A4 inhibs (including PI such as atazanavir, ritonavir, claritho, itra+ketoconazole)
2. CYP3A4 +PGP
-decr by strong CYP3A4 and pgp inducers (carbamazpine, phenytoin, rifampin SJW)
52
What are TZD's?
What is Pioglitazones brand name and dosing?
BBW?
Warnings?
AE's? (4)
DDI's with which CYP? and which drugs?
PPAR Gamma Agonists that incr peripheral insulin sensitivity
Actos
Cause or exacerbate HF; DONT USE with NYHA Class 3/4 HF
Edema, risk of fractures, hepatic failure, can stim ovulation (unintended preg), incr risk of bladder cancer
Peripheral edema, weight gain, URTIs, myalgias
CYP2C8 (its a substrate), use caution with CYP2C8 inducers (rifampin) or inhibs (gemfibrozil)
53
What are the 3 types of basal insulin?
What are their usual onset times?
These mainly impact what kind of glucose?
1. Glargine, detemir, and degludec
2. 3-4 hours
3. fasting glucose
54
Which insulin is intermediate acting? But it can also be used as?
Onset?
Peaks at ___ which can cause ____
What is the variable and unpredictable duration of action?
1. NPH
-basal insulin
2. 1-2 hours
3. 4-12 hours , hypoglycemia
4. 14-24 hrs
55
What are the 3 rapid acting insulins?
onset?
peak?
duration?
aspart, lispro, and glulisine
fast onset of ~15 mins
1-2 hours
3-5 hours (gone by next meal)
56
Which is considered a short acting insulin?
Can be given as a ___ during mealtimes like rapid acting insulin but has slower onset and lasts longer.
Whats the onset?
peak?
Lasts how long?
For regular U-500 insulin, what distinguishes it from U-100?
-how often is it dosed?
Regular Insulin U-100
bolus
30 mins
~2hrs
6-10 hours
it's v concentrated, with a duration that's closer to NPH and can last up to 24 hours
BID, or TID before meals
57
INSULIN SAFETY:
1. CI's?
2. warnings?
3. AE's?
4.most vials r how many mLs? Pens?
5. Insulin concentrations?
6. How should u store an unopened insulin pen/vial? what if its opened?
7. What color is regular insulin? What color is NPH? How would u go about mixing the two ?
1. dont give during episodes of hypoglycemia
2. hypoglycemia + hypokalemia
3. Weight gain , lipoatrophy , lipohypertrophy
4. 10 mL , 3 mL
5. 100 IU/mL
6. fridge, room temp
7. clear. NPH is cloudy. U need to draw up regular insulin first
58
Rapid Acting (Bolus) Insulin: State brand names
1. Aspart
2. Lispro
3. Glulisine
4. What color?
5. When to inject?
6. Lispro can also be injected when?
7. Fiasp and Lyumjev can be injected with?
8. These insulins should be used as?
9. Whats the name of the inhaled insulin?
- CI?
-requires lung monitoring with?
-When should inhaler be replaced?
1. Novolog or Fiasp
2. Humalog, admelog, lyumjev
3. Apidra
4. Clear and colorless
5. 5-15 mins before meals
6. right after eating
7. first vite or within 20 mins of starting a meal
8. prandial insulin and for correction doses using a sliding scale
9. Afrezza
- any lung disease (asthma, copd, any smokers)
-monitoring w/pulm function tests (FEV1)
-every 15 days
59
Short Acting Insulin: State brand name
1. Regular
2. What color?
3. Available otc?
4. When to inject?
5. Use as ?
6. WHat is preferred for IV infusions and for TPN?
7. IV regular insulin should be prepared in a ?
1. Humulin R, Novolin R
2. clear, colorless
3. otc and RX
4. sq 30 mins before meals
5. prandial insulin and for correction doses (often using a sliding sale)
6. regular insulin
7. non pvc container
60
Concentrated Regular U-500:
1. Whats the brand name?
2. When is this reccomended?
3. What is needed with this insulin vial?
4. Can you mix this insulin with otehrs?
1. Humulin R U-500
2. when pt's require > 200 units of insulin per day
3. Specific U-500 insulin syringes
4. NOOOOO! U can only admin this insulin SQ (not IV, IM or in pump)
61
Intermediate Insulin: NPH
1. Whats the brand names?
2. Color?
3. Available rx or otc?
4. how often typically dosed? usually given as?
5. Can be less expensive, but causes more ____
6. If nocturnal hypoglycemia occurs with NPH dosed QHS, what can u do?
1. Humulin N, Novolin N
2. Cloudy
3. BOTH rx and OTC
4. BID as an add on to oral drugs. usually given as basal insulin
5. hypoglycemia
6. split dosing 2/3 QAM and 1/3 QHS
62
Long acting Basal Insulin: State Brand names
1. Insulin Detemir
2. Insulin Glargine
3. What are some biosimilars to Lantus? (2)
4. What color?
5. Usually injected how often?; detemir may needa be given how often?
6. Concentration for Lantus vs Toujeo?
7. When is toujeo's max effect? Why is this a problem?
8. Can u mix this with other insulins?
1. Levemir
2. Lantus, Toujeo, Basaglar
3. Rezvoglar, semglee
4. clear + colorless
5. Once daily; twice daily
6. U-100; 300 IU/mL
7. 5th day. coverage may not be adequate initially
8. NO
63
ULTRA Long Acting Insulin (basal): Brand Name
1. Insulin Degludec
2. Comes in ___ and ___
3. Vial has ____ but what are the concentrations for pens?
4. When can this product be useful?
1. Tresiba
2. Vials and Tresiba Flextouch pen
3. 100 IU/mL, pens come in 100 IU/mL and 200 IU/mL
4. when insulin detemir or glargine causes nocturnal hypoglycemia
64
Premixed Insulin: For each mix, state whats in there and what the brand name is
1. 70/30
2. 75/25
3. 50/50
4. How often are these given?
5. If mix contains rapid acting insulin when should u inject?
6. if it containers regular insulin when should u inject?
7. What color r these mixes and why?
1. 70% NPH, 30% regular
-humulin 70/30 or novolin 70/30
70% aspart protamine/30% aspart
-Novolog Mix 70/30
(rx and otc)
2. 75% lispro protamine/25%lispro
-Humalog Mix 75/25
3. 50% lispro protamine/50% lispro
-Humalog mix 50/50
4. BID (before breakf and dinner), sometimes TID (mixes w/rapid acting insulin)
5. 15 mins before meal
6. 30 mins before meal
7. cloudy due to NPH or protamine
65
DDI with Insulin:
1. Avoid concurrent usage with? (2)
2. DDI with pramlintide. what needs to be done?
1. SU or meglitinides
2. Must reduce mealtime insulin by 50% when starting pramlintide to avoid severe hypoglycemia
66
Which insulins r available OTC?
regular, NPH, premixed 70% NPH/30% regular insulins
67
Starting Insulin T2DM: Algorithm
1. Begin with Adding Basal insulin --> What units should you dose it at?
If FPG not at goal...
2. Add prandial insulin at what unit dosage?
Still not at A1C goal..
3. What two options could you do?
1. 10 units SQ daily or 0.1-0.2 IU/kg/day SQ
2. 4 units or 10% of basal dose SC once daily prior to largest meal
3. Full basal/bolus regimen (basal daily + prandial insulin before each meal)
or
Mixed insulin regimen (Twice daily NPH + short/rapid self mixed or premixed)
68
Starting Insulin in T1D:
1. Which insulins r preferred?
2. Whats the typical starting dose for T1D insulin?
3. Insulin is dosed using ?
4. Commonly, 50% of the TDD is administered as __ and the other 50% as __
1. rapid acting injectable insulins and long acting basal insulins
2. 0.5 units/kg/day
3. TBW
4. basal insulin , prandial (bolus) insulin
69
Although starting a regimen with NPH and Regular insulin is not preferred in T1D... how would u design a regimen for a T1D pt?
0.5 IU/kg/day for TDD
NPH is 30% of TDD given in morning and 20% TDD given in evening
50% of TDD given as regular insulin
70
What kind of insulin goes into an insulin pump?
Which two methods could an insulin pump release insulin?
rapid acting insulin
Continous dosing: small amounts released qfew mins to provide basal insulin level
bolus dosing: specific insulin units released to match carbs in a meal (calculated dosing using pt's insulin to carb ratio or ICR)
71
Whats the ICR Rule for regular insulin vs rapid acting ?
whats the correction factor for regular vs rapid acting?
whats the correction dose equation for both types of insulin?
Regular:
450/TDD= grams of carbs covered by 1 IU insulin
rapid:
500/TDD = grams of carbs covered by 1 IU insulin
regular: 1500/TDD = correction factor for 1 unit of regular insulin
rapid: 1800/TDD = correction factor for 1 unit of rapid acting insulin
Correction Dose :
(BG now) - (Target BG)/correction factor
72
Exceptions to Insulin Conversions:
1. Usually Insulin conversions are what?
2. Exception #1 is when you go from NPH dosed BID to Insulin Glargine dosed daily: how would you convert the NPH dosing to Glargine?
3. Exception #2 is when you switch from Toujeo specifically to Insulin glargine (lantus, basaglar) or detemir (levemir): how would you convert?
1. 1 to 1 or 1:1
2. Use 80% of the total NPH dose as insulin glargine dose that is given once daily
3. Use 80% of the Toujeo dose (reminder that this is an exception because toujeo is more concentrated than the other glargine insulins)
73
Humulin R U-500 comes in what size vial? (it also comes in a pen)
All insulin pens contain how much mL? Except for Toujeo which is available in what sizes?
20 mL
3mL
1.5 mL and 3 mL
74
1. Which rapid acting insulins come concentrated and whats their dose?
2. Which SHORT acting insulins come concentrated and whats their dose?
3. Which LONG acting insulins come concentrated and whats their dose?
1. Humalog Kwikpen, lyumjev kwikpen --> 200 IU/mL
2. Humulin R U-500 kwikpen and vial --> 500 IU/mL
3. Tresiba Flextouch Pen (degludec): 200 iu/mL
Toujeo Solostar, Toujeo MAX Solostar pens (glargine) --> 300 IU/mL
75
Room Temp Stability of Insulin: For each, state which insulins are stable at room temp for the designated time
1. 10 days
2. 14 days
3. 28 days
4. 31 days
5. 40 days
6. 42 days
7. 56 Days
1. Humalog Mix 50/50 and 75/25 pens, Humulin 70/30 pen
2. Humulin N Pen , Novolog Mix 70/30 pen
3. Apidra, Humalog, novolog, admelog, lyumjev, fiasp vials and pens
-Humalog mix 75/25 vial
-Novolog mix 70/30 vial
-Novolin R U-100 , N, and 70/30 pens
-Humulin r U500 pen
-Lantus, Basaglar, semglee vials + pens
4. Humulin R U-100, N, and 70/30 vials
5. Humulin R U-500 Vials
6. Novolin R U-100 , N, and 70/30 vials, Levemir vial and pen
7. Tresiba and Toujeo Pen
76
Which insulin syringe should be used for the following Units:
1. Less than 30 units
2. 30-50 units
3. 51-100 units
1. 0.3 mL
2. 0.5 mL
3. 1 mL
77
PEN NEEDLES:
1. Which ones cause less pain?
2. Shortest needles are how long in length? Requires pinching of skin?
3. Which needles are long enough for most patients and do u pinch skin?
4. which needles may be necessary for obese pt's?
1. Ones with higher gauge and shorter length
2. 4 mm or 5 mm . no pinching
3. 8 mm , pinch up skin before injecting
4. 12.7 mm; pinch up skin
78
Define Hypoglycemia
Symptoms?
Severe Hypoglycemia can cause?
BG < 70 mg/dL
Dizziness, Anxiety/irritability
shakiness
HA
diaphoresis (sweating)
hunger
confusion
nausea
ataxia
tremors
palpitaions
tachycardia + blurred vision
seizures, coma, death
79
Rule of 15 to Treat HYPOglycemia:
1. Ingest how much grams of glucose or simple carbs?
2. recheck BG in how much time?
3. If hypoglycemia continues?
4. Once BG is norm, what should u do?
5. Name some examples of 15 grams of simple carbs
IF UNCONSCIOUS how should you treat hypoglycemia?
What are glucagon options?
1. 15-20 grams
2. 15 mins
3. repeat steps 1 and 2
4. eat small snack or meal
5. 4 oz of juice (1/2 cup), 8 oz of milk (1 cup), 4 oz reg soda, 1 Tbsp sugar, honey or corn syrup, 3-4 glucose tabs or 1 serving of glucose gel
TX with dextrose (if IV access) or with glucagon
Glucagon 1 mg SQ Injection (GlucaGen, Gvoke) or Nasal Spray (Baqsimi)
80
Why use caution with Beta blockers if pt's on insulin or SUs?
beta blockers can enhance hypoglycemic effects and mask some sx's of hypoglycemia (shakiness, palps) . U will still sweat though
81
Which drugs INCR BG?
1. T and L
2. T and C
3. P
4. Q (hypo or hyper)
5. A
6. S
7. S (systemic)
8. C
9. N
10. A (systemic)
11. B
12. B (hypo or hyper)
13. O (hypo or hyper)
1. thiazide and loop diuretics
2. tacro and cyclosporine
3. protease inhibs
4. quinolones
5. antipsychs (olanz and quetiapine)
6. statins
7. steroids
8. cough syrups
9. Niacin
10. azole antifungals
11. beta agonists
12. beta blockers
13. octreotide
82
Which drugs DECR BG?
1. B
2. Q
3. T
4. L
5. O
6. P
7. Q
1. beta blockers
2. quinolones
3. tramadol
4. linezolid
5. octreotide
6. pentamidine
7. quinine
83
Inpatient BG Control
1. TX should be initiated for hospitalized pt's with persistent hyperglycemia with BG that is?
2. Maintained between which values for non critically Ill?
3. Maintained between which values for critically ill?
1. >=180
2. 100-180
3. 140-180
84
DKA is a life threatening crisis with high __, keto___ and keto__.
DKA is recognized by
-BG > ___
-Ketones (urine and serum resulting in ___), ___ pain, N/V, D__
-A
BG, acidosis, nuria
250
fruity breath
abdominal
dehydration
Anion gap acidosis (arterial pH < 7.35 , anion gap >12)
85
Hyperosmolar Hyperglycemic State:
Commonly occurs in which pt's?
Primary cause?
Leads to?
Recognized by:
-C or D
-BG > _____
-Extreme ____
-pH > __ and bicarb > __
T2DM
illness that leads to less fluid intake
severe dehydration w/altered consciousness
-confusion/delirium
-> 600 w/high >320 serum osmolality
-dehydration
->7.3, 15 mEq/L
86
DKA and HHS Treatment:
1. Primary tx?
2. WHen starting fluids, begin with ___. When do u switch to D5W1/2 NS?
3. Starting regular insulin infusion --> State bolus to continuous or just continuous dosing
4. PREVENT ___ . Where to keep serum level?
5. If pH < 6.9, treat acidosis by giving?
1. aggressive fluids then insulin
2. NS, when BG reaches 200 mg/dL
3. 0.1 IU/kg bolus then 0.1 IU/kg/hr
OR
Just 0.14 IU/kg/hr
4. Hypokalemia
keep at 4-5 mEq/L
5. sodium bicarb
87
See Summary of Drug Safety Issues on page 597
