Diabetes Insulins Flashcards
(58 cards)
1
Q
Type 1
A
-an absolute deficiency of insulin secretion
-insulin dependent (~10–20%)
-Most common in youth, can be diagnosed at any age
immune
-Not overweight
-Low endogenous insulin, Low C-peptide, A proinsulin that is made at the same time as insulin, Good indicator of insulin production, Positive autoantibodies, Insulin antibodies, Glutamic acid decarboxylase (GAD), Islet cell antibodies
-Diabetic kitatosis (DKA): high ketone levels
-Produced when no insulin in production
-Body must break down fats instead of carbohydrates as a source of energy
-Ketones are the by-product of that process
2
Q
Type 2
A
- a combination of resistance to insulin action and inadequate compensatory insulin secretory response
- Patients do not make enough insulin to keep blood glucose levels within target range
- insulin resistance (~80–90%)
- Most common in adults, on the rise in youth
- Sedentary lifestyle, diet, refined foods, and rising rates of obesity
- Obesity could be associated with either type
- nonimmune
- Overweight (BMI: > 80 percentile)
- High endogenous insulin levels
- Body must work hard to keep glucose levels within target range
- High C-peptide, Indicator of insulin production, Negative autoantibodies
- Low ketone levels
3
Q
Diabetes
A
- hyperglycemia
- Poor glycemic control can lead to the development of long-term complications: retinopathy, neuropathy, nephropathy, and cardiovascular disease
4
Q
Other Diabetes
A
- Gestational (2–5% of all pregnancies)
- Ends after delivery but 40–50% are at risk for type 2 diabetes
- Secondary and other forms
- Maturity-onset diabetes of youth (MODY)
- Cystic fibrosis–related diabetes (CFRD)
5
Q
Diabetes Kids
A
- Type 1:
- Increasing incidence/prevalence
- Shift towards younger age of onset
- More intensive in younger ages: more resistant and require higher doses
- Increasing frequency of DKA diagnosis
- Type 2:
- Increasing occurrence due to obesity
- Programs started to encourage increasing physical activity and changing diet
- More likely to have a genetic component
6
Q
Diagnosing Diabetes
A
- Hemoglobin A1C >6.5%
- Fasting glucose >126 mg/dl
- 2-hour glucose >200 mg/dl
- Random glucose >200 mg/dl
- Symptoms: increase in thirst, hunger, urination, weight loss, and fatigue
7
Q
Hemaglobin A1C
A
- A glycoprotein formed when glucose binds to hemoglobin A in the blood
- Typically measured 3 or 4 times a year
- A1C goals are age-specific
- Hemoglobin A1C >6.5%
8
Q
Diabetes Goals
A
- To maintain normal growth and development
- To avoid symptomatic hyperglycemia and hypoglycemia
- To intervene early for high blood glucose and rising glycohemoglobins
- To provide realistic expectations
- To prevent parent/child burnout and isolation
- To prevent deterioration of glycemic control during adolescence
- To identify and treat behavioral/adjustment dilemmas
- To provide positive medical experiences
9
Q
Differential Dx: Type 1
A
- Type 1: Immune
- Not overweight
- Low-endogenous insulin
- Low C-peptide
- Positive autoantibodies
- High ketone levels (DKA 30–40%)
10
Q
Differential Dx: Type 2
A
- Type 2: Nonimmune
- Overweight (85%)
- High-endogenous insulin
- High C-peptide
- Negative autoantibodies
- Low ketone levels (≤33% ketonuria; DKA 5–25%)
11
Q
Insulin Affects Many Organs
A
- skeletal muscle fibers
- liver cells
- fat cells
- heart
- eyes
12
Q
Insulin: Synthesis, Storage, Secretion
A
- Produced within the pancreas by β cells: islets of Langerhans
- Insulin mRNA is translated as a single chain precursor called preproinsulin
- Removal of signal peptide during insertion into the endoplasmic reticulum generates proinsulin
- Within the endoplasmic reticulum, proinsulin is exposed to several specific endopeptidases that excise the C peptide, thereby generating the mature form of insulin
- Stored as β granules
13
Q
Mechanism of Insulin Action
A
- Acts on target tissues to regulate metabolism of carbohydrate, protein, and fats
- Target organs for insulin include the liver, skeletal muscle, and adipose tissue
- Stimulates hepatic glycogen synthesis
14
Q
Classification of Insulin
A
- Short acting
- Rapid acting
- Intermediate acting
- Long acting
15
Q
Mixing Insulin
A
- Regular Clear Fast Acting First
- NPH Cloudy Long Acting Last
- Humalog/Humulin Mixes
- Fixed-ratio insulins are typically administered as two daily doses with each dose intended to cover two meals and a snack.
- More difficult to achieve complete glycemic control using fixed combinations of insulins.
16
Q
Insulin Analogues
A
- Insulin Lispro (Humalog®)
- Insulin Aspart (NovoLog®)
- Insulin Glargine (Lantus®)
- Insulin Detemir (Levemir®)
- Insulin Glulisine (Apidra®)
17
Q
Rapid-Acting Insulin
A
- ONSET 5-15 mins
- PEAK .5-4 hrs
- DURATION 3-5 hrs
- Insulin Lispro (Humalog®)
- Insulin Aspart (NovoLog®)
- Insulin Glulisine (Apidra®)
- Action more closely matches the postprandial glucose excursions
- More rapid onset and shorter duration of activity
- Administered 15 minutes before meals
- Clear insulin
- Decrease frequency of hypoglycemia
18
Q
Short Acting Insulin
A
- ONSET 30-60 mins
- PEAK 2-5 hrs
- DURATION 6-12 hrs
- Regular (Humulin, Novolin)
- Only IV insulin used to treat diabetic ketoacidosis
- Administered 30–60 minutes before meals
- Administered SQ via syringe, pen, or continuous subcutaneous infusion
- Clear insulin
- Mixing regular insulin with other preparations of insulin, regular insulin should be drawn into syringe first
19
Q
Intermediate Acting Insulin
A
- ONSET 1-2 hrs
- PEAK 4-14 hrs
- DURATION 10-24 hrs
- NPH
- Administered once or twice daily
- Slower onset and longer duration
- May be mixed with short- and rapid-acting insulin
- Must be second insulin drawn up in syringe
- Cloudy insulin
- Administered SQ via syringe, pen
20
Q
Long Acting Insulin
A
- ONSET 1 hr
- PEAK 6-8 hrs
- DURATION 6-24 hrs
- Levemir
- Given once or twice daily when used as the basal insulin component of therapy
- Has a slower, more prolonged duration than NPH
21
Q
Initial Insulin Dosing
A
-Non-DKA patient:
Prepubertal 0.25–0.5 units/kg/day
Pubertal 0.5–0.75 units/kg/day
-Post-DKA patient:
Prepubertal 0.75 units/kg/day
Pubertal 1 unit/kg/day
-
-Total daily dose should be divided as follows:
-TID injection regimen:
2/3 of TDD is given before breakfast (2/3 as NPH and 1/3 as rapid-acting insulin; 1/3 of the remaining TDD is given as predinner rapid-acting insulin (1/3) and prebedtime NPH(2/3)
-BID injection regimen:
2/3 of TDD is given before breakfast and 1/3 of TDD is given before dinner
2/3 of each dose should be given as NPH and 1/3 as rapid-acting insulin
22
Q
Initial Insulin Dosing
A
Non-DKA patient:
Prepubertal 0.25–0.5 units/kg/day
Pubertal 0.5–0.75 units/kg/day
-Post-DKA patient:
Prepubertal 0.75 units/kg/day
Pubertal 1 unit/kg/day
23
Q
Insulin SE
A
-Primary symptoms of hypoglycemia:
Cardiovascular: pallor, palpitation, tachycardia
Central nervous system: fatigue, headache, hypothermia, loss of consciousness, mental confusion
Dermatologic: redness, urticaria
Endocrine and metabolic: hypoglycemia, hypokalemia
Gastrointestinal: hunger, nausea, numbness of mouth
Local: atrophy or hypertrophy of SubQ fat tissue; edema, itching, pain, or warmth at injection site; stinging
Neuromuscular and skeletal: muscle weakness, paresthesia, tremor
Ocular: transient presbyopia or blurred vision
Miscellaneous: anaphylaxis, diaphoresis, local, and/or systemic hypersensitivity reactions
24
Q
Drug Interactions
Increase hypoglycemic effect of insulin
A
- Increase hypoglycemic effect of insulin
- Alcohol, anabolic steroids, beta blockers, chloroquine guanethidine, lithium carbonate, MAOI, mebendazole, octreotide, pentamidine, phenylbutazone, pyridoxine, salicylates, sulfinpyrazone, sulfonamides, tetracyclines
25
Drug Interactions
| Decrease hypoglycemic effect
- Decrease hypoglycemic effect
- Asparaginase, acetazolamides, AIDS antivirals, calcitonin, corticosteroids, cyclophosphamides, dextrothyroxine, diazoxide, diltiazem, dobutamides, epinephrine, estrogens, ethacrynic acid, isoniazid, lithium carbonate, morphine sulfate, niacin, phenothiazines, phenytoin, nicotine, thiazide diuretics, thyroid hormones
26
ABX + Lithium
- decrease efficacy
| - increase blood sugars
27
Regimen
| Fixed Doses
Fixed doses
- Intermediate-, long-, rapid-acting, and premixed ------Breakfast and dinner and/or bedtime
- 2–3 shots/day
28
Regimen
| Sliding scales
Sliding Scale
- Intermediate-, long-, rapid-acting, and premixed --Breakfast, lunch and/or dinner and/or bedtime
- 2–4 shots/day
29
Regimen
| BID Injections
BID injections
- Intermediate- and rapid-acting, or premixed
- Before breakfast and main evening meal
- 2 shots/day
30
Regimen
| TID Injections
TID injections
- Rapid- and intermediate-acting
- Before breakfast, dinner, and bedtime
- 3 shots/day
31
Regimen
| Basal Bolus Regimen
Basal-bolus regime
- Rapid-long-acting
- Rapid-acting before meals, long-acting usually at bedtime
- 4 shots/day
32
Regimen
| Modified Basal Bolus
Modified basal-bolus
- Intermediate, long-, and rapid-acting
- Before breakfast, lunch, and dinner
- 3 shots/day
33
Basal
Multiple Injections
- Uses a long-acting (peakless or nearly peakless) insulin analog for basal insulin
- Rapid-acting insulin analog to cover meals and correct elevated blood glucose readings
34
Basal-Bolus Therapy
-Closely mimic the pattern of basal and bolus insulin using exogenous insulin
-Delivered in two methods:
Multiple daily injections
Continuous subcutaneous insulin (CSII)
35
Diluted Insulin
- Used for patients who require very small doses
- Used in infants, toddlers, and newly diagnosed school-aged children
- Diluted to U10 or U25: doses usually consisting of .10 or .25 units
36
Humulin R U500
- May be considered in people requiring more than 200 units a day
- Allows 1/5 of the volume of insulin to be injected
- Used in extreme insulin resistance
- Type 2 diabetes, diabetes patients being treated with long-term high-dose steroids
- Humulin R U-500 vial contains 20 ml
37
Designing an Insulin Treatment
-Determine the number of daily insulin doses and timing of each injection
-Decide whether or not to have doses adjusted each time they are given
-Assess patient's:
Metabolic needs
Schedule and lifestyle
Willingness to self-monitor blood glucose readings
Willingness to take injections
Ability to comprehend the complexities of an insulin program
Age? Schedule? Compliance? Cost?
-Initiate the program
-Increase insulin dose to target normoglycemia
-Consider cost
38
Intensive: Basal-Bolus
- Basal: insulin used to cover and suppress glucose production between meals and overnight, mimics normal insulin secretion
- Bolus: the insulin taken to cover the carbohydrate content of food
39
Target
- A number in the middle of the "target range"
- Target can be different for different times of day
- Calculating the target
- Target range 80–120 mg/dl
- Target 100 mg/dl
40
Insulin-to-Carbohydrate Ratio
- Used to determine the amount of insulin used to cover carbohydrates to be consumed
- Blood Sugar Minus Target Blood Sugar Divided by Correction Factor
41
Sensitivity/Correction Factor
- The sensitivity factor or correction factor is the change in blood glucose brought about by 1 unit of insulin
- Sensitivity factor used to correct the bolus dose to bring an out-of-range blood glucose level into the target range
42
Insulin Sensitivity Factor
-1500 Rule: 1500/85 = 18
1 unit of Humalog/Novolog ↓ bg 18 mg/dl
-1800 Rule: 1800/85 = 21
1 unit of Humalog/Novolog ↓ bg 21 mg/dl
-1650 Rule: 1650/85 = 19
1 unit of Humalog ↓ bg 19 mg/dl
-TDD is 85 units.
43
Basal-Bolus Calculation
Basal insulin consists of 30–40% of total daily dose of insulin
44
Rules: Injected Insulin
- Look for patterns for 3–5 days: e.g., continuously elevated at dinner
- Consider what type of insulin the child is on, its peak, and its duration
- Insulin doses adjusted in 10% increments
- Rule out other causes of hyperglycemia: e.g., illness
- Won't set up pump, teach how to fix
45
Dose Adjustment Considerations
- Factors affecting blood glucose:
- Illness
- Medication
- Physical activity
- Change in routine
- Change in diet
- Insulin omission to manage weight loss
46
Continuous Subcutaneous Insulin Infusion
- The most precise way to mimic normal insulin secretions
| - Provides continuous insulin administration to normalize blood glucose levels throughout a 24-hour period
47
Criteria for Successful Pump Management
- Child must want pump; not only parents or health care team
- Good family and school support
- Demonstrated comfort level with conventional management tools
- Diabetes team with 24-hour support system
- Ability to count carbohydrates
48
Pump Benefits
-Improvement in blood glucose levels is possible with pump
-Greater flexibility, including flexibility of timing and size of:
Meals and snacks (less/more)
Exercise (timing, duration and intensity
-Ability to intensify blood sugar control
-Fewer severe low blood sugars
-Immediate access to insulin
Ease at delivering insulin
-More predictable insulin absorption from a continuous insulin depot
-Dawn Phenomenon effects are easier to manage with the basal rate and can be set to accommodate the rise in insulin requirements overnight
-Basal insulin rates can be quickly changed to accommodate growth spurts in children or increased insulin needs during pregnancy
-Improvement in the safety profile is possible
Reducing the basal rate during periods of low physiological requirements can minimize nocturnal or daytime hypoglycemia
Using a temp basal rate to meet short-term physiological needs
49
Pump Challenges
- Increased frequency of monitoring
- Increased chance of hyperglycemia and DKA due to crimped infusion sets, air bubbles, and dislodged cannula
- Potential for skin abscess
- Change in hypoglycemic symptoms
- Constant attachment to pump
- Technical or mechanical failure is possible with a pump
- Weight gain is possible with improved glycemic control
- Cost of insulin pumps usually almost $6,000 not including cost for supplies
50
Troubleshooting Hyperglycemia Insulin Pump Therapy
- Red, tender, and swollen catheter site: the insulin not being absorbed correctly and adds to high blood glucose
- Leakage, breakage, or kinking of tubing
- Battery failure
- Empty reservoir or cartridge
- Mechanical failure
- Improper basal rate programming
- Air in tubing
- Illness
- Menstrual cycle fluctuations
- Omitted bolus or improper dosing
- Crimping of cannula
51
Insulin Pen
- It is more portable than traditional syringe and vial.
- Injection technique is the same as syringe except that once pen needle has been injected into the skin, needle needs to be held in place for 5 to 10 seconds.
- Select site that has no hypertrophy or scar tissue.
- Use insulin that is at room temperature.
- Make sure that air bubbles are purged from delivery device.
- Rotate injection sites.
52
Factors Effecting Insulin Absorption
- Heat: increases absorption rate
- Site: absorbs faster from abdomen
- Lipohypertrophy: overused site, looks caved in, delays insulin absorption
- Insulin dose: large doses have a delay in action and duration
53
Insulin Storage and Expiration Date
- Unopened insulin should be refrigerated; it can be kept until its expiration date.
- Insulin being used need not be refrigerated; it should be stored at room temperature between 36 °F (2 °C) and 86 °F (30 °C).
- Insulin is dated by the manufacturer and should be used before the expiration date.
- Opened insulin in use should be stored at room temperature or in a refrigerator and discarded after 28 days.
- In-use prefilled pens/cartridges of aspart, glulisine, lispro, detemir, glargine, and regular should be stored at room temperature and are good for 28 days.
- Premixed insulin and intermediate-acting insulin (NPH) cartridges and pens can be stored at room temperature for a maximum of 10 to 14 days (must be rolled prior to use).
54
Risk Factors for Complication
- Uncontrolled diabetes: HbA1C >8%
- Infrequent follow-up diabetes care
- Identify barriers to improving diabetes control
- Goal: Implement intensive therapy teamwork: family, school, community, health care.
55
Treatment for Severe Hypoglycemia
- Glucagon (Gluca-Gen: Glucagon emergency kit)
- Management of hypoglycemia, promotes hepatic glycogenolysis and glucogenesis, causing an increase in blood glucose levels
- Dose: infants/children ≤20 kg .02–0.03 mg/kg; children ≥20 kg and adults 1 mg
- Administration: IM or SQ
- Side effects: nausea, vomiting, hypertension, tachycardia
56
Minidose Glucagon
- Used when a child or adolescent with type 1 diabetes is unable to consume or absorb oral carbohydrate because of nausea and vomiting associated with gastroenteritis
- Used to prevent impending hypoglycemia
- Drawn up in a standard U-100 insulin syringe
- Two "units" on the insulin syringe for children ages 2 years and one unit per each year of age in children ages 2–15 years (150 mg)
- Patients ages >15 years receive only 15 units
- Monitor blood glucose q 30 minutes for the first hour, then hourly until blood glucose is at 100 mg/dl
- If blood glucose unchanged after 30 minutes, may repeat and double the dose
57
IGE mediated
Remember that asthma is IGE mediated (allergic kind of stuff, whether it is pollen or a cat,
allergic to a medication IS AN ACUTE IGE MEDIATED reaction)
Or if you have a true allergic reaction to a medication, it Is IGE mediated
There are some that are NOT IGE mediated: reaction to aspirin, exercise induced asthma
(EIA). Cold air asthma is NOT IGE mediated.
58
anti-cholinergic not working
What happens when they are on anti-cholinergic and it is not effective?
Move up to step 2 – LABA/LACA and ICS (For example, Serevent and Flovent)
