29 Questions
What triggers the release of insulin?
Increased blood glucose levels
In type 1 diabetes management, what is the role of insulin?
Replacing endogenous insulin
What does basal insulin do?
Regulates blood glucose between meals
When is bolus insulin released and delivered exogenously?
After meals to manage the rise in blood glucose
What is the most common adverse effect associated with insulin therapy?
Hypoglycemia
What is the primary function of rapid-acting insulin in diabetes management?
To provide a bolus of insulin at mealtime
What medication would be recommended to improve PJ's diabetes control based on his current regimen?
Liraglutide injected once daily
Which of the following medications is not recommended in renal impairment due to unknown effects?
Exenatide injected subcutaneously twice weekly
What medication does Mr. Jones pick up at the community pharmacy counter according to the prescription details provided?
Trulicity (Dulaglutide) 0.75 mg, Inject into the skin once weekly
Which medication is administered by injection once every week?
Trulicity (Dulaglutide) 0.75 mg, Inject into the skin once weekly
What side effects is Mr. Jones likely to experience with the prescribed medication?
Nausea and diarrhea
What medication did Ned start taking a year later to help with his glucose levels?
Lantus insulin
What medication did Ned stop taking about 6 months ago due to cost?
Dulaglutide
What is Ned's current weight a year later?
112 kg
What is Ned's current A1c level a year later?
7.8%
What type of insulin did Ned start with before managing his glucose elevations prior to meals a month later?
Insulin lispro
Where is the recommended site for administering insulin?
Subcutaneously
How many pens are needed to fulfill a 30-day supply of Continuous Glucose Monitors (CGMs)?
2 pens
What is the purpose of High and low alerts on CGMs?
To alert the patient to rapid changes in glucose levels
Why may a Continuous Glucose Monitor require calibration with fingerstick readings?
To ensure accurate readings
Which Insulin Pump integrates with the Dexcom G6 or G7 CGM?
Tandem T:slim X2 with Control IQ Technology
What is the estimated starting total daily dose of insulin for Jessie, a 65-pound 10-year-old female newly diagnosed with Type 1 Diabetes?
32.5 units/day
Which sensor provides 'Real-time' glucose monitoring among the available CGM products mentioned?
Dexcom G6
What is the purpose of adjusting or discontinuing sulfonylureas with initiation of insulin therapy?
To lower the risk of hypoglycemia
When should NPH insulin be converted to twice daily dosing?
If the A1c remains above target
Which of the following medications is an insulin sensitizer and may be continued with insulin therapy despite common weight gain?
Thiazolidinediones (TZDs)
Why is it recommended to balance the injection burden when combining GLP-1 receptor agonists with prandial insulin?
To avoid excessive injections
What adjustment should be made if fasting blood sugars remain consistently high despite the initiation of NPH insulin therapy?
Increase the evening dose of NPH insulin
Why are DPP-4 inhibitors usually weaned or discontinued when initiating insulin therapy?
Because of limited effectiveness in reducing glycated hemoglobin
Study Notes
Non-Invasive Glucose Monitoring
- Continuous Glucose Monitors (CGMs) measure interstitial glucose through a sensor placed below the skin, replaced every 7-10 days, and read on a receiving device.
- CGMs require calibration with fingerstick and have high and low alerts for rapid rises and falls in blood glucose and when values cross programmed thresholds.
- They integrate with insulin pumps to provide closed-loop artificial pancreas technology.
- Best results are achieved with consistent (daily) use.
Insulin Initiation and Titration
- Insulin initiation for T1DM involves both long-acting and rapid-acting insulin, based on weight, with a total daily dose of 0.5 units/kg/day.
- The amount is split 50% between long-acting insulin and 50% rapid-acting insulin analog.
- Insulin dosing for T2DM involves long-acting insulin to suppress hepatic glucose production, leading to improved glucose utilization overnight and in between meals, and rapid-acting insulin to improve glucose utilization at mealtime.
Insulin Overview
- Insulin is released in response to increased blood glucose levels.
- Glucagon is released in response to decreased blood glucose levels.
- Insulin's physiologic actions include facilitating glucose uptake in cells, inhibiting glucose production in the liver, and promoting glycogen synthesis.
- Insulin replacement in T1DM and long-acting insulin in T2DM suppresses hepatic glucose production, leading to improved glucose utilization overnight and in between meals.
- Adverse effects of insulin include injection site reactions, hypoglycemia, and weight gain.
Basal and Bolus Insulin
- Basal insulin, also referred to as background insulin, regulates blood glucose between meals and is released 24 hours a day.
- Bolus insulin is released in response to food ingestion and manages the rise in blood glucose that occurs with absorption of carbohydrates and other mixed foods.
- When delivered exogenously, basal insulin is injected once or twice a day, and bolus insulin is delivered prior to meals and/or snacks or in between meals to correct elevated blood glucose.
Adjusting Oral Diabetes Medications with Insulin Initiation
- Metformin should be continued.
- SGLT-2 inhibitors are usually continued with insulin therapy.
- Thiazolidinediones (TZDs) may be continued, although weight gain is common.
- Sulfonylureas and DPP-4 inhibitors are typically weaned or discontinued.
- Glinides should typically not be used, especially as you progress to prandial/bolus insulin.
- GLP-1 receptor agonists are often used with basal insulin, with prandial insulin, must balance injection burden.
NPH Insulin Initiation and Titration
- NPH insulin is intermediate-acting insulin, initially dosed once a day at bedtime, 10 units or 0.1 to 0.2 units/kg/day.
- If A1c remains above target, NPH insulin can be converted to twice daily, 2/3 of total daily dose (TDD) before breakfast, and 1/3 of TDD in the evening (usually at bedtime).
- Titration: 2 units every 2 to 3 days based on FASTING blood sugars.
Test your knowledge on diabetes management by selecting the best agent to add to a patient's regimen for improved diabetes control. The scenario involves a patient with type 2 diabetes, previous myocardial infarction, and hypertension.
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