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Insulin regimens match insulin with _____ intake.



What are 2 types of insulin regimens?

1. Split and Mixed: regular or short-acting insulin mixed with intermediate, given before breakfast and dinner

2. Split and mixed with bedtime intermediate: For purposes of improving morning fasting reading control the second intermediate-acting insulin can be held until bedtime (9:00PM)


True or False: Insulin regimens are for patients that are on an insulin pump.


Regimens are only for patients NOT on an insulin pump


What types of insulin should be taken before breakfast, lunch, dinner, and bedtime?

Breakfast: Short-acting insulin
Lunch: Short-acting Insulin
Dinner: Short-acting insulin
Bedtime: long-acting peakless (glargine)


Glargine dose can be split for ___ daily Injections.



List 4 insulin injection sites.

1. Upper outer arms
2. Abdomen
3. Buttocks
4. Upper outer thighs


Why does the site of insulin injection need to be rotated?

Repetitively injecting the same site will lead to bubbling of the skin, so make sure that the patient alternates the injection site.


What should the PT avoid doing at the site of injection?

Avoid exercising the area with the site of injection because exercise increases the absorption of insulin.

Wait 2-3 hours before exercising that area to surpass peak insulin levels


List the normal ranges for blood glucose levels. (4)

Fasting: 70-100 mg/dL
Hypoglycemia: Below 70 mg/dL
Pre-diabetic: Above 100 mg/dL
Diabetic/Hyperglycemic: Above 126 mg/dL


List 10 symptoms associated with Hypoglycemia.

1. Anxiety
2. Headache
3. Hunger
4. Tachycardia
5. Sweating
6. Dizziness
7. Fatigue
8. Weakness
9. Confusion
10. Numbness in the fingers and around mouth—result from epinephrine release


List 3 causes of hypoglycemia.

1. If amount of insulin is too high
2. Missed meal
3. Strenuous exercise


Aside from hypoglycemia, list 3 other ADRs associated with the use of insulin.

1. Lipohypertrophy or lipoatrophy at injection site
2. Weight gain
3. Rebound hyperglycemia


Hypoglycemia is treated by ingesting foods high in ___.



______ is a key sign of hyperglycemia.

Frequent urination


List 9 symptoms associated with hyperglycemia.

1. Weak tired
2. Frequent urination
3. Increased thirst
4. Decreased appetite
5. Blurry vision
6. Fruity breath (secondary to metabolic acidosis)
7. Itchy dry skin
8. Seizures
9. Coma


List the 5 steps of the treatment protocol for hyperglycemia.

1. Immediately take a correction bolus
2. Recheck the glucose level in 1 hour and if the level is not dropping, take an injection of fast acting insulin with a syringe
3. Check for ketones in the urine
4. Change infusion site, tubing, and reservoir
5. Additional measures: drink no calorie beverages every 30 minutes, and recheck BG


List 4 functions of incretins.

1. Released from the GI tract when food is ingested and is an early stimulus to insulin secretion
2. Inhibit pancreatic glucagon secretion
3. Slow rate of absorption of digested food by reducing gastric emptying
4. Reduces appetite


_____ is the enzyme that terminates incretins.

Dipeptidyl peptidase-4 (DPP-4)


Incretin mimetics enhance ____ release and act as ____.

Insulin release


List 4 MOAs of incretin mimetics.

1. Glucagon-like peptide (GLP-1) analog
2. inhibit endogenous glucagon secretion
3. Suppress appetite and induce satiety
4. Reduce rate of gastric emptying


What is the dosing for incretin mimetics (Exenatide)?

Administered 2x/day by injection-pre morning and evening meals, one with breakfast and the second with dinner


List 4 ADRs associated with the use of incretin mimetics.

1. Nausea
2. Vomiting
3. Diarrhea
4. Risk of mild to moderate hypoglycemia when used with a sulfonylurea so reduce the sulfonylurea dose


Incretins have protective properties at the ____ and ____.

Heart (cardioprotective)
Brain (neuroprotective)


Incretins decrease ___ production and _____ secretion.

Glucose production
Glucagon secretion


Sulfonylureas increase ___ release.



What are 3 MOAs of Sulfonylureas?

1. Blocks ATP sensitive K+ channels
2. Facilitates insulin release
3. Suppresses glucagon, BUT stimulates appetite and causes weight gain


What is the dosing of sulfonylureas? List 3 ADRs associated with their use.

Dosage: 1/day dosing

1. Hypoglycemia especially in elderly
2. Mild wt gain
3. Bind to albumen


_____ causes greater drops in glucose levels when compared to regular insulin during exercise.



What type of insulin is Lispro?

Ultra short acting


When should ultra short acting insulin be taken? Duration? Peak action?

1. Take 5 min before meal
2. Duration 3-5 hours
3. Peaks at 1 hr


When should regular insulin be taken? Duration? Peak action?

1. Take 30 min before meal
2. Duration: 6-8 hours
3. Peaks at 2 hrs


What is the onset of intermediate insulin? Duration? Peak action?

1. Onset: 1-4 hours
2. Duration: 14-24 hours
3. Peak: 6-12 hours


What is the onset of peak-less long acting insulin (Glargine)? Duration? Peak action?

1. Active about 20 hours: represents basal level of insulin
2. Onset within 1 hour
3. Duration close to 24 hours
4. No peak- continuous


Incretins are protective of _____ cells.

Beta cells


______ is a type of intermediate insulin.

Neutral Protamine Hagedorn insulin (NPH)


Metformin decreases _____ in the liver by inhibiting gene expression and increases _____ sensitivity.

Decreases gluconeogenesis
Increases insulin sensitivity


_____ is the drug of first choice in treating diabetes unless there are ___ and ___ issues present.


Unless there are renal/hepatic issues present


List 6 additional MOAs of metformin.

1. Stimulates glycolysis in the peripheral tissues (skeletal muscle)
2. Reduces carbohydrate absorption
3. Reduces circulating LDLs and triglycerides
4. Increases fatty acid oxidation
5. Increases insulin binding to its receptor
6. Modest weight loss


What is a major advantage of using metformin?

Does NOT cause hypoglycemia


Describe the dosing of Metformin.

Before breakfast and dinner
(SL tablets now available)


List 3 ADRs associated with the use of metformin.

1. Nausea
2. Diarrhea
3. Rarely lactic acidosis


____ are insulin sensitizers



List 4 MOAs of Glitizones (Thiazolidinedione).

1. Increase insulin sensitivity in muscle, liver, and adipose tissue
2. Improves insulin resistance
3. Improves lipid and cholesterol levels
4. May also delay progression of the disease


List 4 ADRs associated with the use of Glitizones.

1. Fluid retention
2. Weight gain
3. Increased risk of fractures
4. Possible risk of bladder cancer with Actos


Where is insulin produced?

Produced in the pancreatic beta cell


Describe the synthesis of insulin.

Preproinsulin becomes proinsulin which becomes insulin.


What triggers the release of insulin from the beta cells on a cellular level?

Calcium entry


____ and ____ are the transporters responsible for allowing glucose to enter the beta cell. It can be further stimulated by ___.

Glut 2 and Glut 4 (skeletal muscle) transporter



List 8 instances when blood glucose levels should be monitored.

1. Check frequently (6-10x daily)
2. Before meals
3. Before exercise
4. Before bed (2am- night monitor 1x/moth)
5. Before a critical tasks (driving)
6. 2 hrs after meal
7. After treatment
8. When low blood glucose is suspected


Rate of insulin absorption is greater in the ____ than in the ____.

Greater in the abdomen than in the leg


Glucose utilization ____ during moderate exercise and _____ during maximal 10 sec sprint.

Increases with moderate exercise

Decreases with maximal 10 sec sprint


Blood glucose levels will ____ during moderate exercise and ____ during maximal 10 sec sprint.

Decrease with mod exercise

Increase with max 10 sec sprint


True or False: Insulin should be injected into the extremities prior to exercise.



What must a diabetic patient reduce prior to exercise? Why?

Pre-meal insulin dose (up to 75% but depends on patient)

Why? Because exercise increases the absorption of the insulin, so too much insulin can make the patient hypoglycemic


What are 3 recommendations for the end of an exercise session to keep in mind with diabetic patients?

1. May end session with 10 sec sprint to reduce post exercise hypoglycemia
2. Try to end session with pre-exercise glucose reading
3. Have a snack at end of exercise if exercising later in the day to prevent nocturnal hyperglycemia