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3152 finals > insulin > Flashcards

insulin Flashcards

1
Q

insulin MOA

A

○ Regulation of carbs (CHO), fat, aa
○ Glucose: facilitate uptake of glucose in muscle and adipose tissue
§ Inhibit hepatic glucose output (glycogenolysis, gluconeogenesis)
○ Fat: enhance fat storage (lipogenesis)
§ Inhibit mobilisation of fat for energy in adipose tissue (lipolysis, FFA oxidation)
○ Protein: incr protein synthesis
§ Inhibit proteolysis in muscle tissue
○ Acts on liver, pancreas muscle, adipocytes

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2
Q

benefits of insulin

A

MOST EFFECTIVE HbA1c: 2.5% lowering
* Indication
○ All types of DM
* Choice of therapy: PREG with DM

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3
Q

PD of insulin

A

○ Response to insulin is highly variable between individuals and within indiv
○ ROA rapid and shorter for: IV> IM > SC

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4
Q

PK of insulin

A

○ A: activity after SC admin from inj site rate limiting step
§ SC depot formed
○ D: enter bloodstream after SC depot directly

○ M/E:
§ Exogenous: by kidney
§ Endogenous: by liver

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5
Q

injection factors

A

needle length
gauge size
syringe size
site
insulin vial size
stability of insulin

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6
Q

Needle length

A

Pen: 4mm ~ 12.7 mm

Syringes: 6mm ~ 12.7 mm (account for vial stopper)
○ Average skin thickness of 2.4mm (not based on BMI, race, age)
○ No need long needle (may enter IM instead, affect absorption)
○No need > 8mm

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7
Q

Gauge size

A
  • 28,29,30,31,32 guages
    ○ Higher, more fine needle
    ○ Less pain
    ○ More weak needles – break
    ○Decr speed of inj
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8
Q

Syringe size:

A
  • 1 - 100 units
  • 1/2 - 50 units
  • 3/10 - 30 units
    Med safety: use smallest synringe possible for dose invovled
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9
Q

site of injection

A
  • Absorption speed (fastest is)
    ○ Abdomen > outer upper arms > top/ outer thighs > buttocks
  • Reduce lipohypertrophy by rotating sites
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10
Q

insulin vial size, amt

A
  • U100 = 100 units/ 1mL of insulin
  • 1 vial = 10mL
    ○ Each vial contains 1,000 units of insulin
    ~round up number of vials needed
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11
Q

Stability of insulin (shelf life vs expiration date)

A
  • Shelf life = unopened
    ○ Fridge = expiration date
    ○ Not fridge = 28 days
  • Opened insulin vials
    ○ Fridge/ no fridge = 28 days
    Other devices, pens, refills vary (package insert)
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12
Q

Injection technique

A

1) Pinch area to be injected
2) Insert needle 90* angle at center of pinched area
1. 45* if small children/ cachexic adults/ frail elderly
3) Release pinch/ continue to pinch
4) Press plunger to inject insulin
5) Hold syringe/ device at area for 5-10s
1. Insulin depot, not leak out
6) Remove syringe/ device

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13
Q

special considerations when inejcting

A

Angle of injection
* 45* if small children/ cachexic adults/ frail elderly

Pinching
* If use 6,8,12.7 mm
○ Don’t need pinch skinfold for meds to reach intended site
* 4-5mm needle
○ Don’t need pinch skinfold
○ Unless less SC fat (use arm, thighs for inj)

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14
Q

Factors affecting insulin absorption

A
  • Temp = Incr ab with HEAT
  • Massage = Incr ab
  • Exercise = Incr ab
  • Jet injectors
    • Incr ab via pressure (not use needles)
  • Lipodystrophy
    • lipoATROOPHY
    • lipoHYPERTROPHY
      inj sites
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15
Q

lipoatrophy vs lipohypertrophy

A
  • lipoATROOPHY
    ○ Incr ab
    ○ Concavity/ pitting of adipose tissue due to immune resp to porcine/ bovine insulin
  • lipoHYPERTROPHY
    ○ Decr ab
    ○Bulging of adipose tissue, from not rotating
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16
Q

Ultra-short acting
Rapid acting

A

Aspart
Lispro
Glulisine
——PPG

onset: 5-10min
1-2hr

duration of action: 3-5hr
One inj per meal (15min before)

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17
Q

Short acting

A

regular — PPG

30-60ming
2-4 hr

6-8hr
One inj per meal (30min before)

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18
Q

intermediate

A

NPH –FPG

onset: 1-2hr //6-12hr

duration of action: 10-16hr
2 inj for 24hcoverage

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19
Q

Long acting

A

Detemir —- FPG
Onset: 0.8-2hr

DOA:
12hrs for 0.2units/kg
20-24hrs for 0.4units/kg
2inj for 24hr coverage

Glargine U-100
1.5h
Peakless

24hr
1 inj for 24hr

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20
Q

Ultra long acting

A

Degludec —— FPG
Peakless
Duration of 42hr
Anytime of the day OD, sc inj

Glargine (U-300) ——FPG
36hr
OD, same time daily

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21
Q

stable mixed

A
  • Regular + NPH
  • Rapid + NPH
  • Rapid + degludec
    • Prior to admin
22
Q

unstable mixes to avoid

A
  • Glargine + other
    ○ Incompatible pH
  • Glulisine + (not NPH)
    ○ Incompatible
  • Detemir + other
    ○ Not recc
23
Q

EG OF MIXED (cover FPG + PPG)

A
  • Novomix 30
    • 30% aspart
    • 70% aspart protamine
  • Humalog mix 75/25
    • 25% lispro
    • 75% lispro protamine
  • Mixtard 70/30
    • 30% regular
    • 70% NPH
  • Mixtard 50/50
    • 50% regular
    • 50% NPH
24
Q

benefits of pre-mixed products

A
  • Covers for meal/snack & BASAL
  • Beneficial for pt difficulty measuring and mixing insulin
    ○ Retains indiv PD profile
  • Less inj
  • Expect multiple peaks (rapid + intermediate)
  • Challenging to titrate, adjust dose
  • Basal + prandial adjusted tgt
    ○ Need pt to SMBG: optimise drug therapy
25
Q

continue PO metformin?

A

YES

26
Q

continue TZD?

A

discontinue when initiate insulin
OR
reduce TZD dose

TZDL insulin sensitiser, incr risk of hypoglycemia

27
Q

continue SU

A

discontinue. reduce SU dose by 50% when BASAl insulin (pt risk of hypogly)

discontinue is mealtime insulin (PPG added)
- effectiveness of SU will wear off over time

SU: targets PPG

28
Q

continue SGLT2i?

A

YES

29
Q

insulin dosing conversions

A

Most insulin conversion 1: 1unit
□ Reduce dose 10-20% if pt high risk of hypoglycemia

Exceptions
□ BD NPH –> OD glargine/ detemir
* Reduce dose by 20%

	□ U300 glargine --> basal insulin (U-100 glargine/ detemir) 
		* Decr dose by 20%
30
Q

mixtard 30 (BD) —> glargine +aspart

A

Mixtard (70% NPH, 30% regular)
30units BD = 60 units

NPH = 0.70 x 60 = 42.0 —- FBG
42 x 0.80 = 33.6 (34) decr dose

Regular = 0.3 x 60 = 18.0 —- PPG
same

= 34units of glargine OD + 18/3 =6units aspart TDS during meals

31
Q

ADR of insulin

A

hypoglycemia (<4mmol/L)
Weight gain
Lipodystrophy (lipoatrophy, lipohypertrophy)
local allergic rxn
systemic allergic rxn (rare)
insulin resistance (rate)

32
Q

Management: 15-15-15 rule

A

15g fast acting carb
wait 15mins
check BG, still <4.0mmol/L, add another 15f of fasting cards

33
Q

Individual therapeutic interventions

A
  1. First line = metformin
    a. Continued as long as possible, start early also
    b. Combi can be considered if HbA1c really quite elevated
         c. If history of:
         1) ASCVD: GLP1 agonist/ SGLT2i 
         2) HF: SGLT2i
         3) CKD: SGLT2i
34
Q

after adding metformin still above target…

A

a. Need minimise hypoglycemia (elderly) = AVOID: SU, Insulin
b. Need promote weight loss = GLP1, SGLT2i
c. Financial difficulties = SU > TZDs > DPP4

35
Q

If need greater glucose lowering (despite PO drugs)

A

a. GLP1 agonist INJ
b. Insulin
□ Only first line INJ if:
Catabolism (weight loss)/ symp of Hypergly, A1c > 10%, BGL > 16.7 mmol/L

36
Q

how start insulin

A

a. Initiate with BASAL, FPG
□ Contributes most to HbA1c readings
□ 10 units or 0.1IU/Kg
□BEDTIME NPH
□ Or glargine/ determir/ degludec ($$$$$)

37
Q

A1c still uncontrolled with basal = STRAT TITRATE

A

Act on FPG (TITRATION)
- Incr insulin 2 units every 3 days (until FPG goal)
- Incr 4 units every 3 days (if FPG consistently >10 mmol/L)
◊ Must be out of control for 3 days then u titrate
*Decr insulin by 10-20% if hypogly with no reason

Target FPG 5-7mmol/L
- Higher end if pt needs

38
Q

Start prandial insulin when:

A

A1c still high, but
1) basal>0.5 IU/kg
2) FPG alr at goal

	- Change to pre-mixed insulin/ self-mixed to decr number of injections (Prandial + NPH)
39
Q

why cannot just keep incr basal

A
  • OVER-BASALISATION
    ◊ Basal insulin at ceiling effective dose
    ◊ Incr dose, less proportional decr FBG
    =Lead to weight gain, hypogly, Postpradial hypergly
40
Q

start prandial insulin by (2 methods)

A
  1. Add Prandial coverage (rapid / regular insulin)
    • Initiate 1 dose with largest meal
    • 4IU/ 10% of basal dose
      ◊ STOP SU (glipizide)
      -Decr BASAL by 4IU/ 10%
      ◊ If A1c <8%
  2. (or) Split dose of bedtime NPH
    • 2/3 for morning
      • 1/3 for evening
41
Q

insulin dosing when pt have multiple inj dose

A

1) full basal-bolus regimen
* 1 inj (basal, glargine)
+ 3 inj (regular/ rapid for each meal)
=4inj

2) or twice daily pre-mix regimen
*BD NPH+regular/ rapid insulin = 2inj

(basal consist >50% of total daily dose) – premix

42
Q

Diabetic emergencies;

A

Ketones are byproducts of fat metabolism
Type1 > type2

  • Absolute insulin deficiency
    Lipolysis + metabolism of FFA
    □ Form ketones (beta-hydroxybutyrate, acetoacetic acid, acetone) in liver
  • Stress
    Stimulates insulin counter regulatory hormones
    (glucagon, catecholamines, glucocorticoids, growth hormone)
    □ Excess glucagon: incr gluconeogenesis, decr peripheral ketone ultilisation
43
Q

Diabetic ketoacidosis (DKA)

A
  • Ketones formed
    ○ Found in blood, urine
    ○ Fruity breath odor
    ○ Acidosis
  • Still alert
  • BG > 14mmol/L
44
Q

DKA labs

A

Glucose
pH low Bicar low
Acetoacetate (ketones) high
Osmolarity (conc with blood) not too high
Anion gap (acidosis) HIGH
Sensorium = alert

45
Q

T2DM emergency = Hyperglycemic hyperosmolar state

A
  • Still residual insulin, usually no ketones
    ○ No acidosis
  • Extremely dehydrated BGL >33 mmol/L
  • Stupor
46
Q

T2DM hypergly labs

A

Glucose HIGH
pH neutral Bicar high
Acetoacetate (ketones) ABSENT
Osmolarity (conc with blood) HIGH
Anion gap (acidosis) NO <12
Sensorium = COMA

47
Q

Somogyi effect

A
  • BG drop at night
    • Too much insulin/ no snack
  • Body respond by release glucagon
    • Incr BGL

= SMBG at 3am
at night is high or LOW

48
Q

Dawn phenomenon

A

Release of cortisol in waking hrs causes BGL rise sharply

=SMBG at 3am
at night is normal

49
Q

Prevention and management of comorbidities

A

Aspirin admin// clopidogrel (if allergic to aspirin)

2nd prevention strategy if DM, ASCVD
1st prevention strategy if DM + incr risk of CV

50
Q

risk of CV (for aspirin therapy)

A

□ LDL cholesterol >2.6mmol/L
□ High BP
□ Smoke
□ CKD
□ Albuminuria
□ Fam hist/ premature ASCVD

51
Q

no need aspirin in

A

Not needed — Incr risk for bleeding events
□ Low/ no risk of ASCVD
□ Young <40 yrs
□ Old > 70 yrs

52
Q

limitations of HbA1c

A
  • fail to correlate with macro complications
  • pop A1c diff among race, ethnic grps
  • fail to reflect harms of hypogly
  • fails tp reflect glycemic variability
  • represent a target without providing guidance as to how to achieve

3152 finals (9 decks)

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