Insulin Types and A1c impact

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Questions and Answers

A patient with type 2 diabetes is prescribed insulin therapy. If the therapy is appropriately titrated, what approximate percentage range of A1c reduction can be expected?

  • 1 - 2% (correct)
  • 3 - 4%
  • 2 - 3%
  • 0.5 - 1%

Which of the following ultra-rapid acting insulins is formulated with niacinamide to enhance its absorption rate?

  • Apidra
  • Lyumjev
  • NovoLog
  • Fiasp (correct)

A patient requires rapid-acting insulin to manage postprandial glucose spikes. Which of the following insulins would be MOST appropriate?

  • Insulin lispro (correct)
  • NPH insulin
  • Insulin glargine
  • Regular insulin

Which type of insulin is MOST likely to be prescribed for a patient who requires a concentrated form due to high insulin requirements?

<p>Humulin R U-500 (A)</p> Signup and view all the answers

Which of the following insulin types has the LONGEST duration of action, offering flexible dosing due to its extended duration?

<p>Insulin degludec (D)</p> Signup and view all the answers

A patient is prescribed an insulin that provides stable basal insulin coverage with an onset around 1.5 hours and lasts approximately 24 hours. Which insulin is the patient MOST likely taking?

<p>Insulin glargine (A)</p> Signup and view all the answers

Which non-insulin antidiabetic agent is typically considered first-line therapy for type 2 diabetes due to its efficacy, weight neutrality, and low risk of hypoglycemia?

<p>Metformin (B)</p> Signup and view all the answers

An overweight patient with type 2 diabetes is prescribed an antidiabetic medication that not only helps lower blood glucose but also offers cardiovascular and renal benefits. Which class of medication is MOST likely prescribed?

<p>SGLT2 Inhibitors (A)</p> Signup and view all the answers

Which of the following antidiabetic medications uniquely targets both SGLT1 and SGLT2 receptors, leading to reduced renal glucose reabsorption and intestinal glucose absorption?

<p>Sotagliflozin (A)</p> Signup and view all the answers

A patient with type 2 diabetes is prescribed a DPP-4 inhibitor. What is the PRIMARY mechanism of action of this class of drugs?

<p>Prolonging the activity of incretin hormones (B)</p> Signup and view all the answers

A patient with type 2 diabetes has a history of heart failure. Which DPP-4 inhibitor should be avoided, or used with caution, due to potential increased risk of heart failure?

<p>Saxagliptin (C)</p> Signup and view all the answers

Which of the following mechanisms is NOT typically associated with GLP-1 receptor agonists (GLP-1 RAs)?

<p>Stimulating insulin release regardless of blood glucose levels (D)</p> Signup and view all the answers

A patient with type 2 diabetes is prescribed liraglutide. What additional benefit, beyond glycemic control, makes this medication a favorable choice?

<p>Cardiovascular benefits (A)</p> Signup and view all the answers

A patient is started on Tirzepatide for the management of their type 2 diabetes. What is the PRIMARY mechanism of action that differentiates Tirzepatide from other GLP-1 receptor agonists?

<p>It is a dual agonist for both GLP-1 and GIP receptors (C)</p> Signup and view all the answers

Which class of antidiabetic drugs is known to stimulate insulin release from pancreatic β-cells, but carries a risk of hypoglycemia and weight gain?

<p>Sulfonylureas (C)</p> Signup and view all the answers

A patient with type 2 diabetes is prescribed pioglitazone. What is the MAIN mechanism by which this medication improves glycemic control?

<p>Activating PPAR-γ to improve insulin sensitivity (D)</p> Signup and view all the answers

Which of the following is NOT a notable point regarding Metformin (Glucophage)?

<p>Often leads to significant weight gain (C)</p> Signup and view all the answers

Which class of medications has demonstrated cardiovascular and renal benefits in clinical trials?

<p>SGLT2 Inhibitors (D)</p> Signup and view all the answers

Which of the following statements BEST describes the action of Afrezza?

<p>A rapid, non-injection option for mealtime insulin delivery (C)</p> Signup and view all the answers

Which factor differentiates Tresiba from Lantus?

<p>Duration of action (C)</p> Signup and view all the answers

Which insulin is MOST appropriate for basal coverage and exhibits a peak and shorter duration than long-acting insulins?

<p>Humulin N (C)</p> Signup and view all the answers

Which of the following drugs does NOT belong to the SGLT2 inhibitor class?

<p>Sitagliptin (B)</p> Signup and view all the answers

A patient is prescribed Exenatide (Byetta). Which of the following side effects is MOST commonly associated with this medication:

<p>Weight loss (C)</p> Signup and view all the answers

Which medication is available in both injectable and oral formulations?

<p>Semaglutide (A)</p> Signup and view all the answers

What is the generic name for Admelog?

<p>Insulin lispro (D)</p> Signup and view all the answers

A patient who recently started on Pioglitazone reports swelling in their ankles. Which side effect is MOST likely?

<p>Fluid retention (A)</p> Signup and view all the answers

Which of the following insulin preparations is the MOST rapid-acting?

<p>Fiasp (C)</p> Signup and view all the answers

Which of the following insulins is MOST appropriate to administer prior to a meal in order to cover the expected rise in blood glucose?

<p>Humulin R U-100 (B)</p> Signup and view all the answers

Which of the following non-insulin antidiabetic medications carries the HIGHEST risk of causing hypoglycemia as a side effect?

<p>Glipizide (A)</p> Signup and view all the answers

According to the information provided, overall, appropriately titrated insulin therapy can reduce A1c by approximately:

<p>1 - 2% (D)</p> Signup and view all the answers

A patient with type 2 diabetes is on Metformin but still requires additional glycemic control. Which of the following medications would be MOST appropriate to add, considering the patient's history of cardiovascular disease?

<p>Empagliflozin (A)</p> Signup and view all the answers

A patient asks about the primary difference between Humalog and NovoLog. What is the MOST accurate comparison?

<p>The onsets and durations of action are slightly different (A)</p> Signup and view all the answers

A patient taking insulin reports experiencing hypoglycemia more frequently at night. If their insulin regimen includes NPH insulin, what would be the MOST likely cause?

<p>NPH insulin has a peak effect, increasing the risk of nocturnal hypoglycemia (D)</p> Signup and view all the answers

A patient is interested in an oral medication that has a lower risk of hypoglycemia than sulfonylureas. Which of the following is the MOST appropriate choice?

<p>Sitagliptin (C)</p> Signup and view all the answers

How does the mechanism of action of SGLT2 inhibitors differ from that of Metformin in managing type 2 diabetes?

<p>SGLT2 inhibitors reduce renal glucose reabsorption, whereas Metformin inhibits hepatic gluconeogenesis (C)</p> Signup and view all the answers

Which of the following drugs improves insulin sensitivity in adipose tissue, muscle, and liver?

<p>Pioglitazone (C)</p> Signup and view all the answers

A patient newly diagnosed with type 2 diabetes is prescribed Metformin. What is the typical A1c reduction expected with Metformin?

<p>1 - 2% (C)</p> Signup and view all the answers

A patient is prescribed Afrezza to manage post-meal blood glucose levels. Which of the following administration instructions is MOST important for the patient to know?

<p>Afrezza is an inhaled insulin taken at the start of a meal (B)</p> Signup and view all the answers

A patient is prescribed Fiasp for mealtime coverage. What is the MOST important counseling point regarding its administration?

<p>It must be injected subcutaneously near mealtime. (D)</p> Signup and view all the answers

Which of the following BEST describes the distinguishing feature of Lyumjev compared to other rapid-acting insulins?

<p>Lyumjev is specifically designed for faster absorption into the bloodstream. (D)</p> Signup and view all the answers

A patient using Humalog consistently experiences postprandial hyperglycemia. What adjustment to their insulin regimen is MOST appropriate?

<p>Ensure Humalog is administered 15 minutes before or immediately after meals. (C)</p> Signup and view all the answers

A patient is starting on NovoLog. What is the MOST important instruction to provide regarding when to take this medication?

<p>Inject it 5–10 minutes before a meal is typical. (D)</p> Signup and view all the answers

What is the MOST appropriate timing for administering Apidra relative to meals?

<p>Within 15 minutes before or 20 minutes after a meal. (C)</p> Signup and view all the answers

Which consideration is MOST critical when switching a patient from Humulin R U-100 to Humulin R U-500?

<p>The patient must be closely monitored for hypoglycemia due to increased potency and prolonged action. (C)</p> Signup and view all the answers

When should Afrezza be administered in relation to meals?

<p>At the beginning of a meal. (B)</p> Signup and view all the answers

What is the PRIMARY reason Humulin R U-500 is prescribed over standard U-100 insulin?

<p>To manage patients with significant insulin resistance requiring high doses. (C)</p> Signup and view all the answers

A patient on Humulin N is experiencing early morning hyperglycemia. What is the MOST likely cause?

<p>The pronounced peak of NPH insulin is causing nocturnal hypoglycemia, followed by rebound hyperglycemia. (C)</p> Signup and view all the answers

What is a key counseling point for patients who are prescribed Humulin N?

<p>Expect a peak effect that may require monitoring for nocturnal hypoglycemia. (D)</p> Signup and view all the answers

What is the PRIMARY advantage of Lantus (insulin glargine) over NPH insulin for basal coverage?

<p>Lantus has a peakless profile, providing more consistent basal insulin levels. (B)</p> Signup and view all the answers

A patient on Lantus reports experiencing fasting hyperglycemia despite consistent dosing. What should be considered?

<p>The Lantus dose may need to be divided into twice-daily injections. (D)</p> Signup and view all the answers

What is the MOST significant advantage of Toujeo over other long-acting insulin preparations?

<p>Toujeo offers an extended duration of action, allowing for more flexible dosing times. (B)</p> Signup and view all the answers

A patient on Tresiba is traveling internationally and will be shifting time zones. What advice should they receive regarding their insulin dosing?

<p>They can adjust the timing of their Tresiba dose, taking it at a different time of day without significant impact on glycemic control. (C)</p> Signup and view all the answers

What is the PRIMARY mechanism of action of Metformin?

<p>Inhibits hepatic glucose production and improves insulin sensitivity. (A)</p> Signup and view all the answers

A patient newly diagnosed with type 2 diabetes also has stage 3 chronic kidney disease. Which factor is MOST important when considering metformin?

<p>The dose of metformin should be adjusted based on the patient's eGFR. (A)</p> Signup and view all the answers

Which of the following is MOST accurate regarding the expected A1c reduction with Metformin?

<p>Metformin typically reduces A1c by 1-2%. (B)</p> Signup and view all the answers

A patient with type 2 diabetes is prescribed Fiasp. Which of the following is the MOST important counseling point regarding its mechanism of action:

<p>It enhances insulin absorption through the addition of niacinamide. (B)</p> Signup and view all the answers

A patient with type 2 diabetes is prescribed Lyumjev. Which of the following is the MOST important counseling point?

<p>This medication is designed for fast absorption. (A)</p> Signup and view all the answers

A patient using Humalog consistently experiences postprandial hyperglycemia. What is the MOST likely reason for this? (Select the BEST option)

<p>They are not taking enough Humalog. (B)</p> Signup and view all the answers

A patient is prescribed NovoLog for their type 2 diabetes. Which of the following is the appropriate timing of medication administration?

<p>Take it 5-10 minutes before a meal. (A)</p> Signup and view all the answers

A patient with type 2 diabetes is prescribed Humulin R U-100 / Novolin R U-100. Which of the following is MOST important regarding timing?

<p>Administer this medication 30 minutes prior to meals. (C)</p> Signup and view all the answers

A patient with a history of chronic obstructive pulmonary disease (COPD) and type 2 diabetes requires mealtime insulin. What is the BEST option?

<p>Humalog (D)</p> Signup and view all the answers

A patient with extreme insulin resistance requires high doses of insulin. What is the best insulin?

<p>Humulin R U-500 (B)</p> Signup and view all the answers

What would be the MOST accurate counseling point with Lantus?

<p>This medication provides steady basal levels (A)</p> Signup and view all the answers

Which of the following is an example of a Long-Acting Insulin?

<p>Toujeo (C)</p> Signup and view all the answers

What is the MOST accurate mechanism of action of Metformin?

<p>Enhances glucose uptake (D)</p> Signup and view all the answers

A patient is prescribed Humulin R U-500. What is the MOST important risk of this prescription?

<p>Dosing errors (D)</p> Signup and view all the answers

A patient is experiencing nocturnal hypoglycemia on Humulin N. What risk is this associated with?

<p>There is a risk of nocturnal hypoglycemia due to the peak effect. (B)</p> Signup and view all the answers

What is MOST likely to be important regarding the long duration of Toujeo?

<p>Flexible dosing times (A)</p> Signup and view all the answers

What is the most appropriate instruction regarding Afrezza?

<p>Inhalation is performed at the beginning of a meal. (A)</p> Signup and view all the answers

Who is most likely NOT a candidate for Afrezza?

<p>A patient with chronic lung disease (B)</p> Signup and view all the answers

What is the most accurate duration of time to expect with Tresiba?

<p>36-42 hours (C)</p> Signup and view all the answers

What is the BEST counseling point for Tresiba?

<p>It offers dosing flexibility. (C)</p> Signup and view all the answers

Why is knowing the onset of insulins important for patients?

<p>The onset assists when administering the medication at the appropriate time to affect a meal or a sugar spike. (B)</p> Signup and view all the answers

What is the BEST description of Humulin N?

<p>Intermediate acting insulin (B)</p> Signup and view all the answers

What is the BEST description of Humulin R U-500?

<p>It useful in patients with high insulin requirements (B)</p> Signup and view all the answers

A1c can be lowered by how much with proper insulin titration?

<p>Roughly 1–2% or more (D)</p> Signup and view all the answers

A patient on Tresiba wants to change the time they take the medication. Select the correct response:

<p>They can adjust the timing of their Tresiba dose, taking it at a different time of day without significant impact on glycemic control. (A)</p> Signup and view all the answers

A patient is started on Metformin. What is essential to discuss with this patient?

<p>Side effects should lessen, they may take up to two weeks. (B)</p> Signup and view all the answers

Flashcards

Fiasp Mechanism

Insulin aspart, formulated with niacinamide for faster absorption, acts rapidly at mealtimes.

Lyumjev Mechanism

Rapid-acting formulation with accelerated absorption for mealtime control.

Admelog and Humalog Mechanism

Rapid onset to cover mealtime glucose spikes.

NovoLog Mechanism

Rapid-acting with a quick onset and short duration to match postprandial needs.

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Apidra Mechanism

Rapid-acting insulin for meal coverage.

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Humulin R U-100 and Novolin R U-100 Mechanism

Slightly slower onset than rapid-acting insulins, used preprandially.

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Afrezza (inhaled) Mechanism

Provides a rapid, non‑injection option for mealtime insulin delivery.

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Humulin R U-500 Mechanism

Due to its concentration, it has a prolonged duration; used for patients with high insulin requirements.

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Humulin N and Novolin N Mechanism

Intermediate-acting insulin providing basal coverage; exhibits a peak and shorter duration than long‑acting insulins.

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Lantus, Basaglar, Semglee, Rezvoglar Mechanism

Provides peakless, stable basal insulin coverage with an onset around 1.5 hours and ~24‑hour duration.

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Toujeo Mechanism

Extended duration (24–36 hours) allows for a more stable basal level.

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Tresiba Mechanism

Ultra-long acting insulin with a duration of 36–42 hours offering flexible dosing.

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Metformin (Glucophage) Mechanism

Inhibits hepatic gluconeogenesis, enhances insulin sensitivity, and improves peripheral glucose uptake.

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Canagliflozin, Dapagliflozin, Empagliflozin, Ertugliflozin Mechanism

Inhibit SGLT2, reducing renal glucose reabsorption and promoting glycosuria.

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Sotagliflozin (Zynquista) Mechanism

Dual SGLT2 and SGLT1 inhibitor; reduces both renal glucose reabsorption and intestinal glucose absorption.

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Sitagliptin, Saxagliptin, Linagliptin, Alogliptin Mechanism

Inhibit the DPP‑4 enzyme, prolonging the activity of incretin hormones to enhance glucose-dependent insulin secretion and suppress glucagon release.

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Exenatide (Byetta and Bydureon) MOA

Mimics GLP‑1 to enhance insulin secretion in a glucose‑dependent manner, suppress glucagon, slow gastric emptying, and promote satiety.

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Liraglutide (Victoza) Mechanism

GLP‑1 receptor agonist with similar actions.

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Dulaglutide (Trulicity) Mechanism

Long‑acting GLP‑1 RA for once‑weekly dosing.

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Semaglutide (Ozempic and Rybelsus) MOA

Potent GLP‑1 receptor agonist.

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Lixisenatide (Adlyxin) Mechanism

GLP‑1 receptor agonist with a shorter duration of action, administered once daily.

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Tirzepatide (Mounjaro) Mechanism

Dual agonist for both GLP‑1 and GIP receptors.

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Glipizide, Glyburide, Glimepiride Mechanism

Stimulate insulin release by binding to and closing the ATP‑sensitive K⁺ channels on pancreatic β‑cells.

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Pioglitazone Mechanism

Activates PPAR‑γ to improve insulin sensitivity in adipose tissue, muscle, and liver.

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Fiasp

Ultra-rapid acting insulin analog; absorption accelerated using niacinamide.

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Common Insulin Risks

Hypoglycemia, weight gain, and injection site reactions.

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Lyumjev

Rapid-acting insulin analog for fast absorption at meal times.

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NovoLog Timing

Administer 5-10 minutes before a meal due to rapid onset.

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Apidra timing

Administer within 15 minutes before or 20 minutes after a meal.

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Humulin R/Novolin R Timing

Onset ~30 minutes; duration ~8 hours; inject 30 minutes prior to meals.

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Afrezza Contraindications

Inhaled, rapid-acting, contraindicated in lung disease/smokers.

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Humulin R U-500 Risks

Onset ~30 minutes; duration mean ~21 hours. Increased risk for dosing errors and prolonged hypoglycemia.

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NPH Insulin considerations

Onset ~1.5 hours; duration 12–24 hours. Risk of nocturnal hypoglycemia.

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Insulin Glargine Duration

Onset ~1.5 hours; duration ~24 hours. Can be dosed once or twice daily.

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Toujeo Dosing

Once daily, allows for flexible dosing times. Monitor for hypoglycemia!

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Tresiba flexibility

Offers flexible dosing (different times of day).

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Study Notes

  • Insulin therapy, when properly adjusted, can lower A1c by about 1–2%.
  • Insulin is used to replace or supplement endogenous insulin.
  • Insulin regimens (basal, bolus, or basal‑bolus), when titrated properly, may reduce A1c by roughly 1–2% or more depending on baseline hyperglycemia.
  • Hypoglycemia, weight gain, and injection site reactions are common risks of insulin therapy.

Ultra‑Rapid Acting Insulins

  • Act quickly at meal times.
  • Used as part of an intensive insulin regimen, typically contributes to a ~1–2% reduction when combined with basal insulin.
  • Fiasp and Lyumjev are both used at meal times.
  • Both Fiasp and Lyumjev contribute to an overall ~1–2% reduction when used in combination therapy.
  • Fiasp (Insulin aspart): formulated with niacinamide for faster absorption.
    • Contraindicated in patients with known hypersensitivity to insulin aspart or its excipients.
    • Use cautiously in patients at risk for hypoglycemia.
    • Onset 5–10 minutes, duration 3–5 hours.
    • Injected subcutaneously near meal time.
  • Lyumjev (Insulin lispro‐aabc): rapid-acting formulation with accelerated absorption for mealtime control.
    • Avoid in patients with allergy to lispro or formulation components.
    • Monitor closely to minimize hypoglycemia.
    • Onset ~15 minutes; duration ~3–5 hours.

Rapid-Acting Insulins

  • Used to cover mealtime glucose spikes integrated in basal-bolus regimens, contributing to an overall reduction of ~1–2%.
  • Admelog and Humalog, NovoLog, and Apidra all contribute to an overall ~1–2% reduction when used in basal-bolus regimens.
  • Admelog and Humalog (Insulin lispro): rapid onset to cover mealtime glucose spikes.
    • Contraindicated in patients with known hypersensitivity.
    • Caution in patients with erratic meal patterns or renal impairment due to hypoglycemia risk.
    • Onset 15–30 minutes, duration 3–5 hours.
    • Administer 15 minutes before or immediately after meals.
  • NovoLog (Insulin aspart): quick onset and short duration to match postprandial needs.
    • Watch for hypoglycemia.
    • Onset 10–20 minutes, duration ~3–5 hours.
    • Injection 5–10 minutes before a meal is typical.
  • Apidra (Insulin glulisine): for meal coverage.
    • Contraindicated in patients with hypersensitivity to insulin glulisine.
    • Hypoglycemia is a risk if dosing/timing is not optimal.
    • Onset ~20 minutes; duration ~3–5 hours.
    • Administer within 15 minutes before or 20 minutes after a meal.

Short-Acting (Regular) Insulins

  • Used preprandially, integrated into therapy, contribute to an overall reduction of ~1–2%.
  • Humulin R U‑100, Novolin R U‑100 and Afrezza contribute to overall ~1–2% A1c reduction.
  • Humulin R U‑100 and Novolin R U‑100 (Regular insulin): Slightly slower onset than rapid-acting insulins.
    • Contraindicated in patients with hypersensitivity to regular insulin.
    • Increased risk of hypoglycemia if timing or dosing is off.
    • Onset ~30 minutes; duration ~8 hours.
    • Typically injected 30 minutes prior to meals.
  • Afrezza (inhaled regular insulin): Provides a rapid, non‑injection option for mealtime insulin delivery.
    • Contraindicated in patients with chronic lung disease (e.g., asthma, COPD) or smokers.
    • Monitor lung function.
    • Onset 12–20 minutes; duration ~2.5–3 hours.
    • Inhalation is performed at the beginning of a meal.
  • Humulin R U‑500 (Concentrated regular insulin (500 U/mL)): prolonged duration; used for patients with high insulin requirements.
    • Increased risk for dosing errors and prolonged hypoglycemia if not managed carefully.
    • Contraindicated in patients with known hypersensitivity.
    • Onset ~30 minutes; duration mean ~21 hours (range 13–24 hours).
    • Requires careful monitoring of blood glucose to prevent insulin stacking.

Intermediate-Acting Insulins

  • Exhibits a peak and shorter duration than long‑acting insulins, contributes as part of a basal regimen to achieve a ~1–2% reduction overall.
  • Humulin N and Novolin N (NPH insulin): Provides basal coverage
    • Contraindicated in patients with known hypersensitivity to NPH insulin.
    • Risk of nocturnal hypoglycemia due to the peak effect.
    • Onset ~1.5 hours; duration 12–24 hours.
    • Often requires twice-daily dosing to maintain 24‑hour coverage.

Long-Acting Insulins

  • Typically used once daily as the basal component in a regimen that can lower A1c by ~1–2%.
  • Lantus, Basaglar, Semglee, Rezvoglar (Insulin glargine): peakless, stable basal insulin coverage with an onset around 1.5 hours and ~24‑hour duration.
    • Contraindicated in patients with hypersensitivity to insulin glargine.
    • Overdosage may cause prolonged hypoglycemia.
    • Onset ~1.5 hours; duration ~24 hours (may be used once daily, although some patients might benefit from twice-daily dosing).

Ultra-Long Acting Insulins

  • Part of a regimen targeting overall glycemic control with a similar 1–2% reduction potential.
  • Toujeo (Insulin glargine): Extended duration (24–36 hours) allows for a more stable basal level.
    • Contraindicated in patients with hypersensitivity.
    • Monitor for hypoglycemia, especially during transitions.
    • Onset ~1 hour; duration 24–36 hours.
    • Allows for flexible dosing times.
  • Tresiba (Insulin degludec): duration of 36–42 hours offering flexible dosing.
    • Contraindicated in individuals with known hypersensitivity.
    • Like all insulins, careful monitoring to avoid hypoglycemia is essential.
    • Onset ~1.5 hours; duration 36–42 hours.
    • Offers dosing flexibility (different times of day).

Non‑Insulin Antidiabetic Agents

Biguanides

  • Metformin (Glucophage): Inhibits hepatic gluconeogenesis, enhances insulin sensitivity, and improves peripheral glucose uptake, reduces A1c by about 1–2%.
  • First‑line therapy in type 2 diabetes; weight-neutral or modest weight loss; low risk of hypoglycemia.
  • Contraindicated in patients with severe renal impairment (e.g., eGFR

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