Insulin and Diabetic Emergencies

Question 1

What are the broad types of insulin?

Answer 1

Rapid Acting
Short Acting
Intermediate Acting
Long Acting
Ultra long acting insulin

Question 2

What are the factors affecting insulin absorption?

Answer 2

Temperature
Massage
Exercise
Jet injectors
Lipodystrophy

Question 3

Name the Rapid Acting insulin and what is the target blood glucose

Answer 3

Aspart
Lispro
Glulisine

Targets PPG; inject 15 mins before meal

Question 4

Name the Short Acting insulin and what is the target blood glucose. When should it be injected?

Answer 4

Regular insulin

Targets PPG; inject 30mins before meal

Question 5

Name the Intermediate acting insulin and what is the target blood glucose. When should it be injected?

Answer 5

NPH

Targets FPG; Inject at same time everyday.

Question 6

Name the Long Acting insulin and what is the target blood glucose. When should it be injected?

Answer 6

Detemir
Glargine (U-100)

Target FPG. Inject regardless of meal at same time everyday

Question 7

Name the Ultra Long Acting Insulin

Answer 7

Insulin Degludec

Insulin Glargine (U-300)

Question 8

What insulin regimens are safe to be mixed?

Answer 8

Regular + NPH
Rapid acting + NPH
Rapid Acting + Degludec (ultra long acting)

Question 9

What insulin regimens are unstable to be mixed? Why is that so?

Answer 9

Glargine/ Detemir with other insulin
- Not compatible

Question 10

Name the premixed Rapid Acting + Intermediate Acting and their proportion.

Answer 10

Novomix: 30% insulin aspart; 70% insulin aspart protamine

Humalog: 25% insulin lispro + 75% insulin lispro protamine

Question 11

Name the premixed regular + NPH insulin and their proportion

Answer 11

Mixtard 70/30: 70% NPH + 30% regular

Mixtard 50/50 : 50% NPH + 50% regular

Question 12

How often should premixed insulin be given?

Answer 12

Twice a day

Question 13

What is the place in therapy for the use of premixed insulin?

Answer 13

Provides meal / snack and basal coverage

Beneficial for patients who have difficulty measuring and mixing

Retains individual pharmacodynamic profiles

Lesser injections needed

Question 14

What is a potential challenge upon using premixed insulin?

Answer 14

Basal and prandial coverage must be adjusted together and is not possible without knowing patients and their lifestyle

Multiple peaks in glucose level may also make it tougher for it to adjust

Question 15

What are some considerations about oral therapies upon starting patient on insulin?
Metformin
SGLT2i
TZD
SU

Answer 15

Metformin and SGLT2i: Continue
TZD: Discontinue when initiating insulin/ reduce dose
SU: Depends on type of insulin
- Basal insulin: discontinue / reduce dose by 50%
- Mealtime insulin: discontinue

Question 16

What is the general rule of thumb for insulin dose conversion?

Answer 16

1:1
(e.g. regular + NPH –> rapid acting + NPH)

Question 17

What should you do if patient is at risk of hypoglycemic while conducting the insulin dose conversion?

Answer 17

Reduce dose by 10-20%

Question 18

What are some exceptions in terms of insulin conversion and what should be done?

Answer 18

Switching from twice daily NPH to once daily glargine/ detemir
- Decrease dose by 20% (NOTE: Need to consider one full day’s dose)

Question 19

FG is a 65 year old female who has been on insulin Mixtard 30. She injects 30 units twice daily. As FG is getting older, her physician wants to switch her to Glargine and Aspart to reduce risk of hypoglycemia. Her current Hba1c hovers around 8% How do we do her new insulin regimen?

Answer 19

34 units of glargine once daily

6 units of aspart three times daily before meals

Question 20

What are the adverse effects of insulin?

Answer 20

Hypoglycemia
Weight gain
Lipodystrophy (more common lipohypertrophy)

Rare: Local allergic reaction, systemic allergic reaction and insulin resistance

Question 21

What are the hypoglycemia symptoms and how should a patient manage them?

Answer 21

Blurry vision, sweating, tremor, hunger, confusion, shaking, irregular HR

Question 22

What is the first line of therapy for T2DM?

Answer 22

Metformin

Question 23

Should patient’s Hba1c be uncontrolled and patient is suffering from other comorbidities such as ASCVD, CKD and HF, what can be added?

Answer 23

ASCVD: GLP-1 agonist and SGLT2i

CKD and HF: SGLT2i

Question 24

What can we consider prioritizing if patient’s A1C level is above goal after using 2 agents?

Answer 24

Weight loss
Financial difficulties

Question 25

What BG is prioritized if we start patient on insulin and how should insulin be started ?

Answer 25

FPG NPH < 10 units at bedtime

Question 26

Insulin: If A1c level of patient remains uncontrolled, what must we consider first and what can we consider doing?

Answer 26

FPG high for 3 consecutive days Increase insulin by 2 units every 3 days until FPG is at goal

Question 27

If A1c level of patient remains uncontrolled at >10mmol/L, what can we consider doing?

Answer 27

Increase insulin by 4 units every 3 days until goal

Question 28

What should we consider next once FPG is at goal while A1c remains high?

Answer 28

Addition of prandial coverage such as rapid/ regular acting insulin Split the bedtime NPH dose in 2, 2/3 in the AM and 1/3 in the evening

Question 29

If prandial coverage was added to cover PPG, what dose should be initiated?

Answer 29

4 IU OR 10% of basal with largest meal

Question 30

If prandial coverage was added, however patient's A1c level < 8%, what should be done?

Answer 30

Decrease by 4 IU OR 10% of basal with largest meal

Question 31

TSL is a 60 year old Chinese female who has been on insulin glargine 20 units ON for the past 3 months. Her average FPG is 5.7 mmol/L but her Hba1c level hovers around 8%. Her average PG for past 2 weeks is 13.2 mmol/L. Her largest meal is lunch. What should be done?

Answer 31

Add one rapid acting insulin for lunch. Give rapid acting 2-4 units before lunch and give glargine 16-18 units ON (consider decreasing dose due to hypoglycemia)

Question 32

What is the usual final regimen for those on insulin?

Answer 32

Full basal bolus: injection of basal insulin + rapid acting/ regular for each meal Twice daily pre mix: NPH + regular/ rapid

Question 33

Why do diabetic emergencies occur more in Type 1 than in Type 2?

Answer 33

T1DM have absolute insulin deficiency while T2DM have residual insulin production and therefore are protected against excessive lipolysis and ketone production

Question 34

Why do diabetic emergencies occur?

Answer 34

Happens when ketones are formed as a by-product of fat metabolism

Question 35

What is the difference between DKA and Hyperglycemic hyperosmolar state?

Answer 35

Presence of ketones - DKA: yes, acidic pH, fruity breath and ketones in blood and urine - HSS: no, neutral pH Is patient awake? - DKA: Yes in less severe cases - HSS: Stupor/coma Blood glucose - DKA: Not as high, BG > 14 mmol/L - HSS: High. BG > 33mmol/L

Question 36

Why does HSS have no ketones or acidic pH?

Answer 36

Residual insulin still present and hence no ketones form

Question 37

How can DM complications be prevented and managed?

Answer 37

Aspirin administration (debatable) Smoking cessation BP Lipid profile

Question 38

Why is Aspirin considered?

Answer 38

Acts as a secondary prevention strategy for DM and ASCVD patients

Question 39

Who are suitable candidates for aspirin initiation?

Answer 39

Young patients with > 1 risk factor Old patients with no risk factors

Question 40

Who are unsuitable candidates for aspirin management?

Answer 40

Olde patients > 70 y Low risk ASCVD diabetic patients

Question 41

Define the somogyi effect

Answer 41

Happens when blood glucose drops sharply Body then responds by increasing glucagon and hence causing blood glucose to increase

Question 42

Define the dawn phenomenon

Answer 42

Release of cortisol (due to stress) in waking hours cause blood glucose to rise sharply