T1DM Therapeutics Flashcards by Alanna Parker

What is T1DM/ what causes it

it happens when you have an absolute insulin deficiency due to beta cell destruction
——- need exogenous insulin to survive

— can be caused by a lot of shit: genetics, immune triggered etc

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Ratio to determine total daily insulin dose

0.5units/kg/day

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What is our main goal when designing an insulin regimen

To try and mimic endogenous insulin as much as possible
—- basal insulin secretion: background, keeps at set level
— bolus: rapidly released with meals

** normally separated 50% Basal + 50% bolus

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What are the 2 phases of exogenous bolus insulin secretions

phase 1: initial peak released in response to food, release of preformed insulin (normally within 5 mins of eating; lasts 10)

phase 2: delayed, smaller peak after eat; normally from newly made insulin (happens about 30 mins after eat)

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What phase of bolus insulin secretion is impaired in T1 vs T2

T1: all insulin secretion impaired
T2: P1 is gone, P2 is lower than normal; higher baseline insulin levels present though before eating

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What type of insulin undergoes hepatic metabolism first: exogenous or endogenous

endogenous; released by pancreas + undergoes metabolism before going to SoA

—- exogenous: given SC so goes to body 1st before metabolism (insulin release then predetermined based on time-action profile)

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Average onset + peak of RA insulin

onset - 10-15mins
peak: 1 hour
duration: 3-5hours

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What insulins are all rapid acting

aspart (novorapid), glulisine (apidra), lispro (humalog)
—- U100s

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T or F: Fiasp has a quicker onset but later peak that insulin aspart

F- quicker onset + peak
—— onset: 5 mins; peak: 0.5-1hr
— same duration though

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What are the short acting insulins

regular human insulins (Humulin-R, Novolin ge Toronto, and Eztunzity)
——Eztunzity: different as it is a U500 (longer duration + faster onset)

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Average onset+ duration of normal regular human insulin (not Eztunzity)

onset- 30 mins (little later than RA)
peak: 2-3 hours (later than RA)
—— why not as good as RA, delay in onset + peak
—- duration is slightly longer (6.5)

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How does Eztunzity differ from other regular human insulin

onset- similar to RA (15mins)
- peak: later than other SA (4-8 hours)
duration —- longer (24hours vs 6hr)

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What is NPH and its dosing

Neutral protamine Hagedorn —- regular human insulin onset+ protamine —- slower onset than regular

— duration: up to 18hours (dose BID: am +HS)

onset: 1-3 hours (later then regular)
peak: 5-8 (why dose at an +HS)

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What are the long acting insulins

glargine (Lantus + Basaglar U100, Toujeo U300)
- U100 + U300 not bio similar (different
- toujeo longer duration (30 vs 24)

detemir - dose dependent conc one
- dosed BID to QD

degludec (Tresiba 100+ 200): 42 hour duration (QD dosing)

icodec: weekly dosing
- peak: 6 hours

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What are the different types of premixes

1) Premixes that include Regular + NPH (Humulin 30/70)
— these ones have 2 numbers in their name
- ratio is SA/NPH

2) Premixed insulin analogues (ex// Novomix 30)
- one # in their name —- RA amount compared to intermediate (NPH)
- longer duration that regular+NPH mix; faster onset

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How many days does it take to get to the max effect of toujeo

5 days
— not bioequivalent to insulin glargine U100

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T or F: Degludec U100 is bioequivalent to the U200

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When would you use Eztunzity regular insulin as the bolus

if people need more than 200 units/day/ high insulin R

—- different PK than other regular human insulins

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When is the max hypo effect seen in icodec U700

2-4 days after injection

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T or F: RA insulins have faster onset + peak than regular

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Which is more likely to cause hypoglycemia: RA or regular

regular

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When can you inject RA insulin in comparison to your meal

inject before, at or up to 15 mins after

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T or F: glargine has a dose dependent duration; higher dose—- drug will work longer

F- only detemir has that

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How many injections of insulin are needed daily to prevent metabolic decompensation generally

1-2 injections daily

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At what BG level is hyperglycemia normally in T1DM

12 mmol/L - once hit this; we start peeing out glucose

What are the 3 goals of T1DM therapy

1) prevent metabolic decompensation 2) prevent symptoms of hyperglycaemia 3) prevent complications of chronic hyperglycemia

AEs of insulin

hypo risk weight gain allergic rxn lipohypotrophy: if don’t route sites —— can impair insulin absorption

What are the 3 main methods of insulin administration

pen syringe pump: uses rapid or regular insulin (no LA or Intermediate) —- delivers insulin via CSII where secretes basal level of RA all the time then boluses with meals

What type of needle do we use to inject

4mm

Why do we normally inject into the abdomen

most consistent insulin absorption - move through the quadrants; avoid belly button

What has the fasted absorption : IV, IM or SC

IV- fastest IM - a lot of variability (may be faster than SC) SC - slowest

T or F: thyroid fxn can impact insulin action

What site of injection has the fastest vs slowest absorption

fastest- stomach slowest. thigh (but again varies based on PA etc)

T or F: exercise increases insulin absorption

T - along with high temps and massaging injection site

How do we prep cloudy insulin

roll + tip — pre mixed insulins and NPH

What is conventional insulin therapy

Not preferred: consisted of premixed or self mixed regular insulin/ RA + NPH —- fixed BID dosing all the time — less BG control

What is intensive insulin therapy

multiple daily injections/ basal bolus or pump —- system of matching dose to pt (food, activity etc)

What is the preferred agents for intensive / basal bolus therapy

Analogues (less hypo) - basal: LA bolus: RA or SA (prefer RA) TID with meals

T or F: we can use NPH insulin in intensive/ basal bolus therapy

T- NPH can act as the basal insulin basal: NPH at am + HS bolus: SA/RA TID with meals

Why do we prefer RA over SA

RA- better mimics endogenous insulin; less hypo risk —- faster onset + peak like our normal insulin

T or F: if using conventional therapy, you need to ensure you eat lunch at time

T- use NPH insulin in conventional —- am dose will peak at lunch therefore need to ensure you eat —- not good mimic of our normal insulin

What percentage of TDI dose is basal and bolus doses

basal: 40-50 bolus: 50-60 (split bw 3 meals evenly or based on CHO intake)

What is the honeymoon phase

right after starting insulin —- will have a decrease need for insulin during the first start of therapy

T or F: we use the calculation for TDI (0.5 units/kd/day) to modify someone’s current insulin regimen

F- just used to help with new therapy/ initial dosing

What do we use to adjust basal insulin dose

Fasting glucose patterns first thing in the am (before eat)

What is our FPG target

4-7

What do we do if pattern of hyper is seen in am FPG

increase basal dose by 1 unit/day

What do we do if we see a pattern of hypos in the am FPG

Decrease basal by 10-20% —- hypo <4

What measurements do we use to determine efficacy of bolus dosing

2hPPG — if measuring right after they eat (2 hours)—- 5-10 FPG — BG right before eat (4-7)

What are the 2 options for bolus dosing / how to divide bolus dose for the day

1) Fixed bolus dose + consistent carb consumption (try to eat the same each meal) —— 15g— 1 serving of carbs 2) Variable bolus dose+ carb counting (I:CHO ratio)

What does the I:CHO ratio tell us

-tells us how many g of carbs 1 unit of insulin covers

What rule do we use to calculate the I:C ratio

Rule of 500 (RA): 500/TDI —- # of carbs covered by 1 insulin unit —- rule of 450 (SA) ** only works for T1DM

What is the dawn phenomenon

Natural increase in BG in am — lowest BG normally bw 12-3; body release counter-regulatory hormones in response to increase glucose

What is ISF

correction factor: approximately glucose lowering ability of 1 unit of insulin — used to estimate how much to ADD to bolus insulin dose if hyperglycemia before meal

What is the rule of 100

- used to determine the ISF/correction dose

What are the 3 factors that determine mealtime bolus doses

1) CHO intake - use I:C ratio (total carbs - fiber —- carbs of meal) 2) Premeal glucose - if above target, correct with ISF 3) Physical activity happening within 2 hours after meal —- depending on type + duration; may need to reduce mealtime dose (if over 90 mins —- may need to also adjust basal dose)

What are autonomic Hypo symptoms

trembling, sweating, palpitations, hunger, nausea

What are neuroglycopenic symptoms

confusion, weakness, vision changes, drowsy

RF for severe hypoglycemia

prior episodes current A1c < 6 hypoglycemia unawareness autonomic neuropathy CKD pregnant elderly preschool kids cognitive impairment

When is the only time you can modify an insulin dose W/OUT a 3 day pattern of BG

if HS hypoglycemic event + symptoms —- change basal the next day

What is the approach to pattern management/fixing someone’s insulin regimen

1) target hypos first 2) look at fasting hyper — start with the 1st high one of the day ** change one thing at a time **

What else can impact BG levels

CHO, illness, PA, stress, drugs, hormones, period

How often should people with T1DM monitor their BG

- SMBG as much as they use insulin —- basal +bolus : QID

What can alcohol do to BG

lower it

T1DM Therapeutics Flashcards

(64 cards)