40 Questions
Match the A1C goal with the population
Child with T2DM = <7% Child with T1DM = <7-7.5%
65 yo & healthy (can have few chronic illnesses) = <7-7.5% 65 yo with multiple coexisting chronic illnesses = <8%
What is the normal/acceptable fast blood glucose range for a child with type one diabetes?
80-130
What injection site has the fastest to slowest rate of absorption of insulin? 1 = fastest, 3 = slowest
abdomen = 1 arms = 2 thighs = 3 buttocks = 3
What is the major site of insulin clearance?
kidney
A T1D that take insulin presents with c/o weight gain, headache, nasopharyngitis, pharyngitis, rhinitis, nausea, and edema. What is the likely cause for the patient?
insulin
Levels of hypoglycemia
A patient has a blood glucose level of 54-70 mg/dL = Level 1 A patient has a BGL that is less than 54 mg/dL = Level 2 A patient is having a severe hypoglycemic event with a BGL less than 54 mg/dL with signs of AMS and requires assistance = Level 3 a = a
What are NOT signs of HYPOGLYCEMIA
High energy with rapid speaking
If you are caring for a patient in a Level 3 hypoglycemic event, what is NOT a recommended management option for a patient unable to take anything by mouth, and/or unconscious in this emergency situation?
Chocolate bars until EMS arrives
What drug interactions should you be aware of when caring for a diabetic patient?
Antidiabetic agents = enhance hypoglycemic effects Beta-blockers = increases tissue uptake of glucose and mask hypoglycemia Antibiotics (quinolones, sulfa = increase insulin release SSRI and Aspirin (>3g/daily) = increase insulin release
Where should unopened insulin be stored?
Fridge
What patient education should you offer when teaching someone how to inject insulin?
Hold for 5-10 seconds before withdrawing needle
What is a inhaled delivery of ultra-rapid acting insulin that is contraindicated in smokers and COPD?
Afrezza
What are adverse effects of insulin that you should advise your patient of?
Weight gain, headache, pharyngitis
What is the time of onset for different type of insulin?
intermediate-acting NPH = 2 hours ultra-rapid-acting = 5-20 minutes rapid-acting = 15-30 minutes Long-acting = 2-4 hours
The peak for long-acting and ultra-long-acting is around 14 hours.
False
Insulin Terminology
Basal Dose = Background insulin supply, between meals and overnight; Intermediate, long or ultra-long acting Bolus Prandial = Given just prior, during or up to 20 min after starting a meal; Controls rise in glucose following a meal; Rapid or regular Bolus Correction = Additional units added to prandial insulin dose or in between meals; Given to correct high levels of glucose; Rapid or regular Mixed = Mixture of rapid or regular insulin with intermediate; Given twice daily before meals
What are rapid and ultra-rapid acting insulin used for?
bolus for prandial or correction
What are examples of short acting bolus insulin that is available OTC? This is NOT the preferred prandial/correction insulin (esp. for Type 1 DM due to hypoglycemia).
Regular insulin (Novolin R, Humulin R)
What is the concentration of the prescription short acting regular insulin that requires its own syringes, and must be given in 2-3 injections per day?
Regular Insulin U500
Once regular insulin U-500 is initiated, basal (the background or long acting) insulin is discontinued
True
What are the available intermediate NPH insulin products that are doses QD/BID as basal insulin?
Novolin N, Humulin N
What is the preferred basal option, especially for T1DM?
Long-acting Insulin (Levemir, Lantus, Basaglar, Semglee)
What can be added to oral and non-insulin therapies for T2DM?
Long-acting & Ultra-long-acting Insulin
Toujeo and Tresiba are ULTRA long acting human insulin analogs (rDNA)
True
A patient is currently taking (column A) and is being changes to a long-acting basal insulin (Levemir, Lantus, Basaglar, Semglee). What is the basal insulin conversion?
Toujeo = 80% of Toujeo dose once daily NPH twice daily = 80% total daily dose once daily Premix = 80% of the “basal” component once daily Lantus, Basaglar, Semglee, Levemir, NPH once daily or Tresiba = unit to unit (1:1)
Combination rapid- OR short-acting insulin PLUS intermediate acting insulin that allows of cheaper and less injections per day for the patient, is called?
pre-mixed insulin
What medication is a combination of insulin and liraglutide?
Xultophy
When should the patient administer their insulin?
rapid acting insulin = 10-15 minutes before a meal ultra-rapid-acting insulin = at start of the meal regular insulin = 30 minutes before meal I am not wanting to eat = skip insulin
T1DM will required BID dosing for their basal insulin.
True
Higher amount of insulin is needed during puberty, pregnancy and medical illness
True
What type of insulin is used in a continuous subcutaneous insulin infusion device for T1DM and T2DM?
rapid-acting
What is the standard dose range for T1DM? __ to ____ units/kg/day with 50% basal and 50% prandial (divided into meals)
0.4 to 1.0
What is the usual starting dose for initiating insulin in T1DM? ___ units/kg/day with 50% basal and 50% prandial (divided into meals)
0.5
What is the starting daily dose of insulin for T2DM? ____ units daily. Then titrate by 2 units every 3 days until your patient reaches their fast glucose target.
10
If you started your T2DM patient on 10 units of basal of insulin and have been titrating correcting, but have not been able to reach their FBG goal, you can add prandial insulin. How do you add this?
Start with 4 units
When should you introduce insulin early to a T2DM patient?
ALL the of above
Overbasalization is when A1c is not at goal despite fasting glucose being at target.
True
If you are planning to increase of decrease insulin, you should do so by 10-20%.
True
Before consuming a meal, a patient with type 1 diabetes estimates the meal's approximate carbohydrate load, and administers a rapid-acting "prandial" insulin to control postprandial glucose levels. Which of the following types of insulin would be most appropriate to accomplish this goal?
aspart
Forms of insulin that have very long durations of action are most commonly used to control fasting "basal" glucose levels that are present in-between meals. Which of the following insulin formulations has this pharmacokinetic characteristic?
detemir
Study Notes
Insulin and Diabetes Management
- The A1C goal for children with type 1 diabetes is <7.5%, for adults with type 1 diabetes is <7%, for adults with type 2 diabetes is <7%, and for gestational diabetes is <6%.
- The normal/acceptable fast blood glucose range for a child with type 1 diabetes is 80-120 mg/dL.
- The order of absorption rate of insulin from fastest to slowest is: abdominal (1), arms (2), and legs (3).
- The major site of insulin clearance is the liver.
Insulin Side Effects and Interactions
- A patient taking insulin who presents with weight gain, headache, nasopharyngitis, pharyngitis, rhinitis, nausea, and edema likely has insulin-induced hypoglycemia.
- Levels of hypoglycemia include mild (54-69 mg/dL), moderate (40-53 mg/dL), and severe (<40 mg/dL).
- Signs of hypoglycemia include anxiety, confusion, dizziness, hunger, shakiness, and sweating.
- Management options for a Level 3 hypoglycemic event include oral or IV glucose, glucagon, and/or IV fluids; however, intramuscular or subcutaneous glucagon is not recommended for an unconscious patient.
Insulin Type and Usage
- Humalog, NovoLog, and Apidra are examples of rapid-acting insulin used for mealtime coverage and correction of high blood sugar.
- Inhaled Exubera is an inhaled delivery of ultra-rapid acting insulin, contraindicated in smokers and COPD patients.
- Examples of short-acting bolus insulin available OTC include Humulin R and Novolin R.
- Prescription short-acting regular insulin requires its own syringes and is given in 2-3 injections per day.
- Intermediate NPH insulin products, such as Humulin N and Novolin N, are dosed QD/BID as basal insulin.
- Basaglar and Lantus are preferred basal options, especially for T1DM.
- Xultophy is a combination of insulin and liraglutide.
Insulin Dosing and Administration
- A patient should administer their insulin 15-30 minutes before a meal.
- T1DM patients require BID dosing for their basal insulin, with higher amounts needed during puberty, pregnancy, and medical illness.
- The standard dose range for T1DM is 0.5-1.5 units/kg/day with 50% basal and 50% prandial (divided into meals).
- The usual starting dose for initiating insulin in T1DM is 0.5 units/kg/day with 50% basal and 50% prandial.
- The starting daily dose of insulin for T2DM is 10 units daily, titrated by 2 units every 3 days until the patient reaches their fast glucose target.
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