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Questions and Answers
What triggers the release of insulin?
What triggers the release of insulin?
- Decreased blood glucose levels
- Increased blood glucose levels (correct)
- Low calcium levels
- High blood pressure
In type 1 diabetes management, what is the role of insulin?
In type 1 diabetes management, what is the role of insulin?
- Suppressing hepatic glucose production
- Causing weight loss
- Increasing blood glucose levels
- Replacing endogenous insulin (correct)
What does basal insulin do?
What does basal insulin do?
- Increases hepatic glucose production
- Promotes weight loss
- Causes hypoglycemia
- Regulates blood glucose between meals (correct)
When is bolus insulin released and delivered exogenously?
When is bolus insulin released and delivered exogenously?
What is the most common adverse effect associated with insulin therapy?
What is the most common adverse effect associated with insulin therapy?
What is the primary function of rapid-acting insulin in diabetes management?
What is the primary function of rapid-acting insulin in diabetes management?
What medication would be recommended to improve PJ's diabetes control based on his current regimen?
What medication would be recommended to improve PJ's diabetes control based on his current regimen?
Which of the following medications is not recommended in renal impairment due to unknown effects?
Which of the following medications is not recommended in renal impairment due to unknown effects?
What medication does Mr. Jones pick up at the community pharmacy counter according to the prescription details provided?
What medication does Mr. Jones pick up at the community pharmacy counter according to the prescription details provided?
Which medication is administered by injection once every week?
Which medication is administered by injection once every week?
What side effects is Mr. Jones likely to experience with the prescribed medication?
What side effects is Mr. Jones likely to experience with the prescribed medication?
What medication did Ned start taking a year later to help with his glucose levels?
What medication did Ned start taking a year later to help with his glucose levels?
What medication did Ned stop taking about 6 months ago due to cost?
What medication did Ned stop taking about 6 months ago due to cost?
What is Ned's current weight a year later?
What is Ned's current weight a year later?
What is Ned's current A1c level a year later?
What is Ned's current A1c level a year later?
What type of insulin did Ned start with before managing his glucose elevations prior to meals a month later?
What type of insulin did Ned start with before managing his glucose elevations prior to meals a month later?
Where is the recommended site for administering insulin?
Where is the recommended site for administering insulin?
How many pens are needed to fulfill a 30-day supply of Continuous Glucose Monitors (CGMs)?
How many pens are needed to fulfill a 30-day supply of Continuous Glucose Monitors (CGMs)?
What is the purpose of High and low alerts on CGMs?
What is the purpose of High and low alerts on CGMs?
Why may a Continuous Glucose Monitor require calibration with fingerstick readings?
Why may a Continuous Glucose Monitor require calibration with fingerstick readings?
Which Insulin Pump integrates with the Dexcom G6 or G7 CGM?
Which Insulin Pump integrates with the Dexcom G6 or G7 CGM?
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?
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?
Which sensor provides 'Real-time' glucose monitoring among the available CGM products mentioned?
Which sensor provides 'Real-time' glucose monitoring among the available CGM products mentioned?
What is the purpose of adjusting or discontinuing sulfonylureas with initiation of insulin therapy?
What is the purpose of adjusting or discontinuing sulfonylureas with initiation of insulin therapy?
When should NPH insulin be converted to twice daily dosing?
When should NPH insulin be converted to twice daily dosing?
Which of the following medications is an insulin sensitizer and may be continued with insulin therapy despite common weight gain?
Which of the following medications is an insulin sensitizer and may be continued with insulin therapy despite common weight gain?
Why is it recommended to balance the injection burden when combining GLP-1 receptor agonists with prandial insulin?
Why is it recommended to balance the injection burden when combining GLP-1 receptor agonists with prandial insulin?
What adjustment should be made if fasting blood sugars remain consistently high despite the initiation of NPH insulin therapy?
What adjustment should be made if fasting blood sugars remain consistently high despite the initiation of NPH insulin therapy?
Why are DPP-4 inhibitors usually weaned or discontinued when initiating insulin therapy?
Why are DPP-4 inhibitors usually weaned or discontinued when initiating insulin therapy?
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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.
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