Insulin Regimens and Effects

Insulin Regimens and Adverse Effects

• Insulin regimens, such as basal-bolus and intensive insulin replacement, can improve long-term outcomes by lowering HgA1c.
• Intensive regimens involve multiple daily injections or continuous subcutaneous administration via a pump.
• Lack of insulin can lead to adverse effects like hyperglycemia, ketoacidosis (acidic blood, fruity breath, weight loss, high triglycerides), and tissue catabolism.

Basal Insulin

• Basal insulin suppresses hepatic glucose production, maintaining near-normal blood sugar levels during fasting.
• Appropriate doses of basal insulin are crucial for managing blood glucose levels.

Bolus Insulin

• Bolus insulin (prandial/premeal) is used to cover extra glucose requirements after meals, minimizing post-meal blood sugar fluctuations.

Long-Acting Insulins

• Long-acting insulin analogs, such as glargine, detemir, and degludec, provide a flatter, more consistent plasma level over a longer duration.

Short-Acting Insulins

• Short-acting insulin analogs, like lispro, aspart, and glulisine, have a quicker onset, peak, and shorter duration of action, and are usually associated with less weight gain and lower hypoglycemia risk.

Insulin Onset and Duration

• Lispro insulin has an onset of 15-30 minutes.
• Insulin glargine has a duration of action of 20 to more than 24 hours.

Type 1 Diabetes Basal Insulin/Bolus Percentage

• 50% basal and 50% bolus is the general percentage of basal and bolus insulin for newly diagnosed Type 1 diabetics.

Factors Affecting Insulin Dosing

• Carbohydrate intake, pregnancy, puberty, and illness can affect insulin dosing requirements. These factors need to be considered when adjusting insulin dosage.

Total Daily Insulin Dose

• Initial total daily insulin dose when starting is 0.5 U/kg. While stabilized, typical doses are between 0.4-1 U/kg.

Bolus Insulin Considerations

• Factors like pre-meal glucose levels, carbohydrate consumption, and anticipated activity (e.g., exercise) should be considered when determining bolus insulin doses

Insulin Injection Sites

• Insulin is injected subcutaneously. Rotating injection sites helps prevent lipohypertrophy. Intramuscular (IM) injection is generally avoided.

Type 2 Diabetes Risk Factors

• Insulin resistance, impaired insulin secretion, elevated liver glucose production, reduced effectiveness of insulin on target cells, and overweight/obesity are all factors associated with Type 2 diabetes.
• Lean individuals can also develop Type 2 diabetes.

Metformin Mechanism of Action

• Metformin reduces hepatic glucose production, decreases intestinal glucose absorption, and improves insulin sensitivity.

Metformin Adverse Effects

• Gastrointestinal issues (nausea, vomiting, diarrhea) and lactic acidosis are potential side effects, especially with kidney problems, high doses, or severe illness.

SGLT2 Inhibitors Mechanism and Adverse Effects

• SGLT2 inhibitors increase glucose excretion in the urine.
• Potential adverse effects include volume depletion (leading to hypotension) and increased risk of urinary tract infections, especially in individuals with uncontrolled blood sugar.

GLP-1 Receptor Agonists (RAs)

• Enhance glucose-dependent insulin secretion.
• Slow gastric emptying, decreasing food intake.
• Reduce postprandial glucagon.

Glucagon and Liver Glucose Production

• Decreased glucagon production results in decreased liver glucose production.

Thiazolidinediones (TZDs)

• Insulin sensitizers in fat, muscle, and the liver.

Sulfonylureas Adverse Effect

• Hypoglycemia is a serious adverse effect associated with sulfonylureas

GERD Treatment

• Antacids provide faster relief, while PPIs provide longer-lasting effects. H2 antagonists are an intermediary option.

PPI Use in Elderly

• Prolonged PPI use in the elderly can lead to osteoporosis.

Sucralfate Mechanism of Action

• Sucralfate forms a paste that protects ulcers and the stomach lining from peptic acid, pepsin, and bile.

Topical Corticosteroids Potency

• Topical corticosteroid potency varies greatly. It is important to understand the potency scale and choose appropriate strength based on the area being treated.

Topical Corticosteroid Contraindications

• Infections, pre-existing skin conditions, areas of impaired wound healing etc . should be considered during topical corticosteroid use.

Oral Acne Medication

• Oral antibiotics like tetracycline, used as treatment for severe acne.

Thyroid Hormone Levels and Hypo/Hyperthyroidism

• Understanding normal Thyroid-Stimulating Hormone (TSH), thyroxine (T4), free T4 (FT4), triiodothyronine (T3) levels is important in assessing and managing hypo- and hyperthyroidism.

Levothyroxine MOA

• Levothyroxine is a synthetic form of T4, used to replace deficient thyroid hormones

Hypothyroidism Treatment

• Levothyroxine is often the first-line treatment of hypothyroidism.

Hyperthyroidism Treatment

• Treatments include antithyroid medications (methimazole, propylthiouracil) and in some cases ablation of thyroid tissue

Thyroid Storm

• Thyroid storm is a life-threatening condition characterized by extreme thyrotoxicosis. Treatments are aggressive and involve hospitalization.

Common ADEs with Topical Corticosteroids

• Purpura, striae, telangiectasia, and focal hypertrichosis can be common side effects.

Topical Corticosteroid Potency

• Topical corticosteroid potency varies widely. Choosing the appropriate strength is crucial to minimizing potential side effects, while managing the condition effectively.

Isotretinoin Monitoring

• Isotretinoin treatment involves rigorous monitoring of pregnancy, liver function, and other potential side effects.

Hypothyroidism Lab Values

• High TSH and low T4 values indicate hypothyroidism.

Levothyroxine Mechanism of Action

• Synthetic T4 hormone replacement is a mechanism of action for treating hypothyroidism.

Special Populations and Hypothyroidism Dosing

• Elderly and pregnant women require close monitoring and adjustments to their hypothyroidism dose.