Flashcards in Insulin therapy Deck (39):
Major adverse effects of insulin?
- local or systemic allergic reaction
- somogyi effect
What is the somogyi effect?
- if blood sugar drops too low in early morning hours (3-4 am): hormones 9GH, cortisol, and catecholamines) are released -> blood sugar rebounds
- these help reverse low blood sugar level but may lead to elevated blood sugar levels in the morning
- this may occur if pt who takes insulin doesn't eat a regular bedtime snack resulting in decreased blood sugar in early AM
What is the Dawm phenomenon?
- normal rise in blood sugar as person's body prepares to wake up
- in early morning hours, GH, cortisol, and catecholamines cause liver to release large amounts of glucose into bloodstream
- if there isn't enough insulin to cover this than AM glucose will be high
Smogyi vs. Dawn?
- check blood sugar levels at bedtime, around 2-3 am, and at normal wake up time for several nights. A continuous glucose monitor could also be used throughout the night (happens in type 1)
- if blood sugar level low at 2 am to 3 - suspect somogyi effect
- if blood sugar level normal or high at 2-3 am than likely it is the dawn phenomenon
Main problem and solution in smogyi effect?
- taking too much insulin and not eating enough before bed
- eat bedtime snack or cut back on insulin
Main problem and solution in dawn phenomenon?
- going to have that normal rise of blood sugar in the morning so need enough insulin to cover rise
What are the rapid acting analogs of insulin?
- just used to cover meals
- Lispro (humalog)
- Aspart (Novolog)
- Glulisine (Apidra)
What are the short acting insulins?
- human insulin
- human Regular (Humulin R and Novolin R)
What are the intermediate acting (basal) insulins?
- human NPH
- Lente (Humulin L and Novolin L)
What are the basal insulin analogs?
- Glargine (Lantus)
- Detemir (Levemir)
- Degludec (Tresiba): not out yet
What has better effect, human insulin or non-human insulin?
- human insulin doesn't stick around in the body as long, so you want to prescribe analogs for better effect
What is the difference between human insulin and insulin analogs?
- human insulin (NPH and Regular) don't replicate the time to peak concentration or duration of action of endogenous insulin secretion
- rapid acting insulin analog preps have: faster onset and shorter DOA than regular insulin
- long acting insulin analog preps have: longer onset of action and a flatter serum concentration than NPH for basal coverage
- analogs resemble endogenous insulin
Human insulin action profile?
- give NPH human: get rapid rise and peak but then drops (this is basal - intermediate acting)
- give glargine and its more even of an effect, doesn't really peak, just stays constant
What is conventional insulin therapy?
- either single daily injections, or 2 injections per day of regular and NPH insulin, mixed together in the same syringe and given in fixed amounts before breakfast and dinner
What is intensive insulin therapy?
more complex regimens that:
- basal insulin delviery ( given as 1 to 2 daily injections of intermediate or long acting insulin)
- with superimposed doses of short-acting or rapid-acting insulins 3 or more times daily (bolus every time they eat)
What is basal insulin?
- controls glucose production between meals and overnight
- near-constant levels
- usually around 50% of daily needs
What is bolus insulin?
- given at mealtime or prandial
- limits hyperglycemia after meals
- immediate rise and sharp peak at 1 hr post meal
- 10-20% of total daily insulin requirement at each meal
components of ideal insulin replacement therapy?
- each component should come from a different insulin with a specific profile via an insulin pump (with 1 insulin)
Who uses intensive insulin tx?
- both type 1 and type 2 (initially intensive regimens initially used for type 1)
Will conventional insulin therapy achieve target A1C levels?
- no conventional therapy is unlikely to achieve target A1C levels in pts with type 1 diabetes, and may provide suboptimal glycemic control for pts with type 2 diabetes as beta cell function declines
Benefits of intensive insulin therapy?
- prevent or slow progression of long-term diabetes complication
- reduces diabetes related heart attacks and strokes by more than 50%
- reduce risk of eye damage by more than 75%
- reduce risk of nerve damge by 60%
- prevent or slow the progression of kidney disease by 50%
What are goals for intensive insulin therapy?
- blood sugar level before meals: 90-130
- blood sugar 2 hours after meals: less than 180
- hemoglobin A1C: less than 7%
onset of actions for insulins?
- humalog (lispro), aspart (novolog), glusisine (apidra): 5 to 15 minutes
regular: 30 minutes
NPH, glargine (lantus), detemir (levemir): 2 hours
Time to peak effect:
- Humalog, Novolog, and Apidra: 45-75 minutes
- regular: 2 to 4 hours
- NPH: 6-10 hours
- glargine: no peak
- detemir (levemir): no peak
- Degludec: unknown
Duration of action?
- Humalog, Novolog, Apidra: 2 to 4 hours
- Regular: 5-8 hours
- NPH: 14-26 hours
- Glargine (lantus): 20 to 24 hours
- detemir (levemir): 20 hours
- degludec: 42 hours!!
Insulin therapy basics?
- basal insulin: 1-2 doses a day + bolus therapy (rapid vs. short acting) 15 minutes before each meal
- OR premixed intermediate and short acting taking basal and bolus at same time:
Humulin 50/50, Humulin 70/30
- usually dosed 2x daily and not adjusted for current BG and carb intake
1 ml =? .5 ml =?
- 1 ml = 100 U
- .5 ml = 50 U
- .3 ml = 30 U
- 2 lengths of needles: 8 mm and 12.7 mm
Where is insulin injected? Absorptive differences?
- insulin is absorbed fastest from abdominal wall, slowest from leg and buttock, and at intermediate rate from arm, at any of these sites the rapidity of insuln absorption varies inversely with subq fat thickness
How should insulin be stored?
- insulin remains stable for 1 mo at room temp or 3 mo under refrigeration. Store extra bottle of insulin in refrigerator
- refrigerate pre-filled plastic and gass syringes, which can be stored under refrigeration for up to 14 days
- don't freeze and don't expose to extreme temps or sunlight
How should you start type 2 diabetics on insulin?
- 10 U/ day or 0.1-0.2 U/kg/day of basal insulin given at night : glargine 10 U
- continue other oral non-insulin meds
- self blood glucose monitoring is important!!
- focus on AM FPG for goals near normal
- titrate up by 2U every 3 days or so
- consider adding bolus dosing to cover meals if not to A1C goal after FPG goal is met
- start low and slow
What is the 3, 2, 1 countdown?
- every 3 days, increase by 2 units, until fasting plasma glucose of 100
- then comes critical thinking and adjustment of dose based in pt response
How does the twice-daily split mixed regimen or 70/30 conventional insulins work?
- insulin dosing is based on pts wt
- give 2 injections that contain a combo of short or rapid acting and intermediate acting insulin
- doses are given before breakfast and before the evening meal
- 2/3 of dose with breakfast
- 1/3 of dose with evening meal
(either mix yourself or use premix)
- so Regular (bolus) covers meals, and NPH is intermediate acting (basal)
Purpose of basal/bolus insulin?
- basal: suppress glucose production between meals and overnight
- nearly constant levels
- 50% of daily insulin dose
- bolus: mealtime or prandial
limits hyperglycemia after meals, immediate rise and sharp peak at 1 hr, 10-20% of total daily insulin dose at each meal
General rulse of thumb for Type 1 DM insulin therapy?
- need intensive therapy with combo of rapid/bolus doses of insulin daily (usually 4 doses)
- wt based dosing: 0.5-0.6 U/kg/day
- example 200 lbs
- 200/2.2 = 91 U day x.5 = 45.5
- give 25-50% in basal insulin and rest to cover meals
What is continuous subq insulin infusion?
- small battery operated programmable pump
- provides continuous SQ infusion of rapid-acting insulin along with manually administerd bolus dose before each meal.
- pt self monitors preprandial glucose levels to adjust bolus doses
- encouraged for those who are unable to obtain target control while on multiple injection regimens
- good for glycemic control with pregnancy
- use requires involvement and commitment by pt
- monitors blood glucose and can alarm and awaken a pt with nocturnal hypoglycemia
- pump: short acting insulin, given at slow infusion rate
Why wasn't exubera successful (inhaled insulin)?
- dosing inflexibility
- CI or must be used with caution in smokers or pts with underlying lung disease
- cumbersome because PFTs reqd at baseline, 6 months and then annually thereafter
- only available as rapid acting agent and therefore most pts still had to inject a long-acting insulin 1-2x a day
ADA guidelines for management of type 1 diabetes?
- tx with mult. dose insulin injections (3-4 injections/day of basal and prandial insulin) or continuous subq infusion
- match prandial insulin dose to carb intake, premeal blood glucose, and anticipated activity
- use insulin analogs to reduce risk of hypoglycemia
- consider using sensor augmented low glucose suspended threshold pump in pts with frequent nocturnal hypoglycemia and/or hypoglycemia unawareness
What other agent is used in type 1 DM management?
- pramlinitide (amylin analog):
delays gastric emptying
blunts pancreatic secretion of glucagon
induces wt loss
lowers insulin dose
use oly in adults