Dr. Kania's Insulin Lectures Flashcards
(102 cards)
1
Q
What are the three ultra short-acting insulins?
A
Aspart, lispro, and glulisine
2
Q
Approximate the time to onset for ultra short-acting insulins.
A
10-20 minutes
3
Q
Approximate the time to peak for ultra short-acting insulins.
A
30-90 minutes
4
Q
What is the average duration of action for ultra short-acting insulins?
A
3-5 hours
5
Q
Which insulin is short-acting?
A
Regular
6
Q
Approximate the time to onset for regular insulin.
A
30-60 minutes
7
Q
Approximate the time to peak for regular insulin.
A
2-4 hours
8
Q
What is the average duration of action for regular insulin?
A
5-8 hours
9
Q
Which insulin is intermediate-acting?
A
NPH
10
Q
Approximate the time to onset for NPH.
A
2-4 hours
11
Q
Approximate the time to peak for NPH.
A
4-10 hours
12
Q
What is the average duration of action for NPH?
A
8-12 hours
13
Q
Which two insulins are long-acting?
A
Glargine and detemir
14
Q
Approximate the time to onset for long-acting insulins.
A
1.5-4 hours
15
Q
Approximate the time to peak for detemir.
A
6-14 hours
16
Q
What is the average duration of action for long-acting insulins?
A
16-24 hours
17
Q
Which insulin is ultra long-acting?
A
Degludec
18
Q
Approximate the time to onset for degludec.
A
1 hour
19
Q
What is the average duration for degludec?
A
Over 24 hours (about 42)
20
Q
List the symptoms of hypoglycemia.
A
Shaking, sweating, anxiety, dizziness, hunger, tachycardia, impaired vision, weakness, fatigue, headache, irritability
21
Q
List the causes of hypoglycemia.
A
Too much insulin, too few calories, increased muscle utilization, excessive alcohol
22
Q
What drug class decreases responsiveness to hypoglycemia by blocking sympathetic warning symptoms?
A
Beta blockers
23
Q
What treatment options are available for severely hypoglycemic patients?
A
- 3 mg intranasal (Baqsimi)
- 1 mg SQ/IM/IV (Glucagen, Gvoke)
24
Q
A patient comes to your clinic showing signs of hypoglycemia. Upon further inspection, they have a blood sugar of 55 mg/dl. How would you treat this?
A
Start with 15 grams of carbohydrates and check in 15 minutes. If not >70 mg/dl, repeat with another 15 grams.
25
What are some common household foods that can be used to treat a hypoglycemic episode?
* 4 oz orange juice
* 6 oz cola
* 5-6 Lifesavers
* 2 tsp of sugar
* 1 tbsp of honey
26
How many glucose tabs would you give a hypoglycemic patient initially?
About 3 (there are 4-5 grams of CHO per tab)
27
Although aspart, glulisine, and lispro are all approved for IV use, why is regular insulin preferred?
The short-acting insulins are more expensive, with no real advantage over regular insulin
28
Which insulin type forms a crystal under the skin that may cause pain during injection?
Glargine
29
Which insulin type binds to albumin through its fatty acid chain?
Detemir
30
Which insulin type is a suspension?
NPH
31
When would insulin be used in a non-diabetic patient?
Hyperkalemia; insulin can push potassium back into cells
32
Rank these insulin routes of administration from fastest to slowest: IM, IV, SQ
IV\>IM\>SQ
33
Which site of injection is the fastest: stomach or buttocks/thigh?
Stomach
34
Why would you advise a patient to avoid going on a run after injecting insulin in the thigh?
Because it may absorb too quickly
35
When mixing insulins, which type must ALWAYS be drawn up first?
Regular insulin
36
How does the onset, peak and duration of action of U500 regular compare to U100?
U500 has a delayed onset and peak, and longer duration of action than U100
37
Will steroids increase or decrease blood sugar?
Increase
38
Does renal failure increase or decrease insulin clearance?
Decreases insulin clearance; increases insulin action and hypoglycemia risk
39
Does emotional/physical stress increase or decrease insulin clearance?
Increases insulin clearance (and therefore, blood sugar)
40
Although most insulin vials are stable at room temperature for 28 days, what is levemir's lifespan?
42 days
41
True or false: vials and pens not in use must be refrigerated.
True
42
How long are prefilled insulin syringes stable for at room temperature (range)?
10-28 days
43
If refrigerated, how long is a regular/NPH mix stable for?
7 days
44
How long is a short-acting/NPH mix stable for?
0 days; give IMMEDIATELY
45
What constitutes level 1 hypoglycemia?
Glucose \<70 mg/dl
46
What constitutes level 2 hypoglycemia?
Glucose \<54 mg/dl
47
What constitutes level 3 hypoglycemia?
Severe event with altered mental and/or physical function, needing another person for recovery
48
What is lipohypertrophy?
When tumorous-like fat pads develop from repeated insulin injections into the same site; inhibits absorption in the long term
49
What is lipoatrophy?
Concavities caused by destruction of fat from antibodies or allergic reactions; used to happen a lot with non-human insulins, but is rare now
50
List some advantages of the short-acting insulin analogs.
* Decreases pp hypoglycemia and has superior pp lowering of blood sugar
* Fewer overall hypoglycemic events + less noctural hypoglycemia
* Greater flexibility
51
List some disadvantages of the short-acting insulin analogs.
* Hypoglycemia risk if no meal is given within 15 minutes
* Must be combined with a long-acting insulin
* If mixed with another insulin, must be given immediately after mixing
* Hyperglycemia/ketosis may occur more rapidly if insulin delivery is interrupted
* More expensive than regular insulin
52
List some advantages of the long-acting insulin analogs.
* 24-hour coverage with constant absorption and no real peak
* Can benefit noctural hypoglycemic events
53
List some disadvantages of the long-acting insulin analogs.
* Risk of malignancy
* Cannot be mixed with other insulins
* More expensive than NPH
54
What were the major outcomes of the DEVOTE trial?
When compared to glargine, degludec insulin has a lower risk of CV death, nonftal MI, stroke, and severe hypoglycemia
55
If a patient is taking 30 units of NPH once daily and wants to switch to glargine, what total daily dose of glargine would you recommend?
30 units; when switching from daily NPH to a long-acting insulin, keep the dose the same!
56
If a patient is taking NPH twice daily for a total dose of 30 units, what is the appropriate amount of glargine to switch to?
24 units; when changing from BID NPH to a long-acting insulin, decrease the dose by 20%
57
At around how many units is it worth thinking about splitting insulin into 2 doses?
60 units
58
What should you do when switching a patient from BID NPH to U300 glargine?
Decrease dose by 20%
59
Which U100 to concentrated switches are a 1:1 conversion?
* Daily glargine/detemir to daily Toujeo/Toujeo Max (glargine)
* Basal insulin to U200 degludec
* U100 lispro to U200 lispro
* U100 basal-bolus to U500 when A1C is less than 8%
60
What should you do when switching a patient from U100 basal-bolus to U500 if their A1C is 8% or greater?
Reduce dose by 20%
61
True or false: U500 replaces both basal and bolus insulin types.
True
62
What is the average daily dose for insulin for T1DM in units/kg/day?
0.5-0.6 units/kg/day
63
What is the "honeymoon phase" insulin dosing for T1DM in units/kg/day?
0.1-0.4 units/kg/day
64
What is the optimal blood glucose testing frequency for type 1 diabetes?
Ideally, testing BG 4 times daily (before meals and at bedtime) and occassionally at 3AM to assess insulin dosages
65
What is the ultimate end goal for T1DM patients?
Insulin pump
66
What percentage of total insulin is given basally in T1DM?
50-70%
67
What carb ratio is a good starting point for adjusting prandial doses for T1DM?
1 unit for every 15 grams ingested (1:15)
68
What is the 2/3, 1/3 Rule?
When using 2 injections of an intermediate/short-acting mix, split the dose as 2/3 in the morning and 1/3 at night, with 2/3 of each dose being intermediate and 1/3 being short-acting (less common with new insulins)
69
What is the optimal insulin dosing if trying to move intermediate insulin to bedtime?
* Breakfast: short acting + NPH
* Lunch: none
* Dinner: short-acting
* Bedtime: NPH
70
What is the minimum age of eligibility for most insulin pumps?
14 years
71
What insulin type is used in pumps?
Rapid-acting insulin (for basal and prandial)
72
When first starting insulin in type 2 diabetics, what type will first be prescribed and when will it be given?
Long- or intermediate-acting insulin at bedtime
73
According to the ADA, what is the average starting dose in units/kg/day for T2DM?
0.1-0.2 units/kg/day OR 10 units/day
74
What is the ADA-recommended dose adjustment for T2DM?
Increase by 2 units every 3 days to reach FBS goal
75
How would you start a bolus insulin in T2DM?
* 0.1 units/kg
* 10% of basal dose
* 4-5 units of ultra-short/short-acting per meal
* Carb ratio: 1-2 units per 15 grams CHO
76
What are the two possible mix regimens for T2DM?
* N/R-o-N/R-o
* N/R-o-R-N
77
When correcting blood sugars, which should be targeted first: FBS or PPG?
FBS
78
If A1C is \>10%, what is the predominant problem: FBS or PPG?
FBS
79
If A1C is \<7.5%, what is the predominant problem: FBS or PPG?
PPG
80
What are the 2 options for calculating an insulin:CHO ratio?
1. Assess total CHO eaten daily for 3 days in order to establish an average intake per meal, and tehn divide by the amount og bolus insulin given
2. Take 500/total daily insulin
81
How do you calculate a correction factor for ultra short-acting insulins?
1800/total daily dose of insulin = how many mg/dl BG will drop for every 1 unit of insulin
82
How should you adjust the Rule of 1800 to dose regular insulin?
Use 1500
83
What should you do if a patient is on once-daily long-acting or intermediate insulin and experiencing fasting hyperglycemia?
Increase the dose or consider dividing into BID dosing
84
What should you do if a patient is on split dose insulin BID and experiencing fasting hyperglycemia?
Increase pre-supper or bedtime insulin dose
85
What should you do if a patient on basal-bolus insulin is experiencing fasting hyperglycemia?
Increase the basal PM dose depending upon bedtime readings
86
What should you do if a patient is experiencing fasting hypoglycemia?
Decrease evening insulin dose and check timing of the morning test and dose
87
What should you do if a patient is experiencing pre-lunch hypoglycemia?
Decrease/omit short-acting insulin dose in the morning
88
What should you do if a patient is experiencing pre-dinner hypoglycemia?
* Decrease lunch bolus
* Decrease mroning intermediate/long-acting dose
89
What should you do if a patient is experiencing bedtime hypoglycemia?
* Add a bedtime snack
* Decrease pre-dinner dose of short-acting insulin
* Decrease pre-dinner dose of intermediate insulin if given in the early afternooon
90
For adjusting insulin doses, what is a good empiric starting point for T1DM?
An increased insulin dose by 2 units decreases blood sugar by 50 mg/dl
91
For adjusting insulin doses, what is a good empiric starting point for T2DM?
An increased insulin dose by 4 units decreases blood sugar by 50 mg/dl
92
When decreasing an insulin dose for low readings, how many units is a decent empiric starting point?
Decrease by 2-4 units
93
What is the Somogyi Effect?
Nocturnal hypoglycemia with rebound hyperglycemia
94
What would you recommend for a patient experiencing the Somogyi Effect?
* Check blood sugar at 3 AM and ask about signs/symptoms
* Move NPH from dinner to bedtime or add a bedtime snack
95
What recommendations would you give a diabetic patient who is sick?
* Let someone know
* Continue insulin even if food intake is decreased; stress increases insulin need
* Maintain fluid intake
* Test BG every 4 hours to every hour
* Test urine for ketones every time
* Administer supplemental insulin doses
* Seek medical attention if ketones are present and BG \>250 mg/dl, breathing becomes difficult, mental status changes, or there is repeated vomiting
96
What are the 3 signs that a patient may want to change to a concentrated insulin?
1. Absorption problems
2. Increased pain
3. Leakage with large doses
97
At about how many total units of insulin should a concentrated insulin be considered?
200-300 units
98
How many units of Afrezza should be given to the insulin naive?
4 units at each meal
99
What is the dosing pattern/recommendation of Afrezza for the insulin experienced? This is a long one, sorry :(
* 0-4 units per meal → start 4 units per meal
* 5-8 units per meal → start 8 units per meal
* 9-12 units per meal → start 12 units per meal
* 13-16 units per meal → start 16 units per meal
* 17-20 units per meal → start 20 units per meal
* 21-24 units per meal → start 24 units per meal
100
List the possible adverse reactions to Afrezza.
* Hypoglycemia
* Cough
* Acute bronchospasm
* Upper respiratory infections
* Decline in pulmonary function (sprirometry tests at baseline, 6 months, and annually; if ≥20% reduction in FEV1, discontinue inhaled insulin)
* Lung cancer
* Throat pain/irritation
* Hypersensitivity reactions
101
How fast-acting is Afrezza?
Ultra rapid-acting
102
List the three future dosage forms of insulin.
1. Oral tablets
2. Sprays
3. Transdermal patches
