Diabetes: Background, Type I, and Insulin

Diabetes

a condition where the body does not produce insulin or does not use insulin properly

200, polyuria, 126, 200, 6.5, 200, prandial

Diabetes Diagnosis: Lab Work

-Random glucose > ___ with hyperglycemic symptoms (_______, polydipsia)

-Fasting glucose > ___ on two separate occasions, no repeat necessary if one value is over ___

-Hemoglobin A1C > _._%, which is the most common testing and a better predictor of co-morbidities

• Measures glucose-hemoglobin linkage in blood, measure q3 months

• Inaccurate with certain types of anemia

-2 hour oral glucose tolerance test (OGTT) with glucose > ____ mg/dl after drinking 75g glucose drink

• Better at detecting post-________ hyperglycemia

6.5, 5.7, 6.4, 126, 100, 125, 200, 140, 199, tolerance

American Diabetes Association Diagnostic Criteria

-HbA1c > _._% → diabetes

-HbA1c _._ - _._% → prediabetes

-Fasting plasma glucose > ___ mg/dL (diabetes), ___-___ mg/dL (prediabetes)

-2 hour OGTT > ___ mg/dL (diabetes), ___-___ mg/dL (prediabetes)

• The OGTT is notably more sensitive in identifying individuals with impaired glucose ____________ who might not be picked up by A1C of FPG

Type 1 Diabetes

Body does not produce insulin due to autoimmune cause

Type 2 Diabetes

Body does not use insulin sufficiently due to multiple causes including genetics and lifestyle

Type 1.5 Diabetes (LADA)

Body initially behaves as type 2 DM but +antibodies that lead to eventual type 1 DM treatment

Ketosis-Prone DM

Still producing insulin but presents with DKA, typically when a type 2 patient is so uncontrolled that their pancreas “wears out”. If treated with insulin for a period of time, pancreas can restart producing insulin, and the patient may be able to return to oral agents

Gestational Diabetes

insulin resistance during pregnancy that resolves after delivery, leads to an increased risk of DM in the future

Monogenic Dm (MODY, neonatal diabetes)

Heterogenous group of inherited forms of diabetes, disrupted beta cell development. Overall patient picture doesn’t fit type 1 or 2 DM, typically mild fasting hyperglycemia

Beta, insulin, glucose, hyperglycemia, polyuria, coma

Fill in the blanks, 1-6 on the image

autoimmune, beta, viruses, insulitis, antibodies, hyperglycemia

Type 1 Diabetes: Etiology and Background

-Etiology: An ______________ process where pancreatic ____ cells are destroyed. Can be due to environmental factors like early exposure to certain __________ or ______, which is lymphocytic infiltration of pancreatic islets that destroys the beta cells

-An identical twin has 50% chance, sibling 5%, offspring 6%

-Typically presents around age 10-14yo

-__________ typically found prior to symptom onset

ill, nausea, thirst, mental status, dehydration, UA

Type 1 Diabetes: Presentation

-Presents to clinic or ER appearing acutely ___. Complains of abdominal pain, _________, weight loss, increased ______, polyuria, polyphagia, sometimes blurry vision, and ______ _______ changes

-Exam may reveal signs of _____________, tachycardia, hypotension, fruity breath, and glucosuria on __

-Can have other autoimmune issues, such as thyroid or rheumatoid arthritis

A1C, C-peptide, GAD, IA2, DKA

Type 1 Diabetes: Labs

-Hemoglobin ___ or oral glucose tolerance test → A1C can be done in clinic and is more convenient

-_-_______ with glucose

-Islet cell antibodies, ___ (glutamic acid decarboxylase), ___ (tyrosine phosphatase-related islet antigen 2), zinc transporter antibodies or IAA

-Consider STAT urinalysis and BMP or check beta hydroxybutyrate to rule-out ___

insulin, basal, bolus, oral, pumps, less

Type 1 Diabetes: Treatment

-Must have ________

-______ or long-acting insulin should be taken nightly or twice a day

-______ or prandial/mealtime insulin should be taken with meals as a set amount of carb ratio

-Cannot use ____ agents or non-insulin injections

-Insurance covers insulin _____ and/or CGMs better with type I

-Tend to need ____ insulin than type 2 DM

Rapid

Insulin Lispro, Aspart, or Glulisine are examples of ______ acting insulins

-Start in 5-10 minutes, peaks in 30-90 minutes

Short

Regular insulin is an example of ____ acting insulin

-Start in 30 min-1 hour, peaks in 2-3 hours

Intermediate

Insulin NPH is an example of an ____________ acting insulin

-Starts in 1-3 hours, peaks in 4-12 hours

Long

Insulin Determir or Glargine are examples of ______ acting insulins

-Starts in 1-2 hours, never peaks

Pregnancy

NPH and Levemir are basal insulins that are really only used in ____________

Glargine, daily, 300, 200

Basal Insulin

-NPH → 10-20 hours, BID dosing, peaks around 6-7 hours

-Detemir (Levemir) → 12-20 hours, sometimes BID dosing, no peak

-__________ (Basaglar, Lantus) → 24 hours so ______ dosing without peak

-Glargine U-___ (Toujeo) → up to 36 hours without peak, daily dosing

-Degludec U-100, U-___ (Tresiba) → over 42 hours without peak, daily dosing

Lispro, 5-15, rapid

Bolus Insulin

-Regular → starts within 30-60 minutes, peaks at 2 hours, lasts about 5-8 hours

-_______, Aspart, Glulisine U-100 and some U-200 (Humalog, Admelog, Novolog, Apidra) → starts within _-__ minutes, peaks at 1 hour, lasts 3-4 hours

-Lispro (U-100, U-200) and Aspart (U-100) ultra _____ works within 5-10 minutes, peaks at 1 hour, lasts 2-4 hours

biosimilar, biologic, generic

__________ Insulins

-Insulins that are highly similar to an already FDA-approved reference ________ insulin in terms of structure, function, safety, and effectiveness

-Because insulin is a _______ drug, it can’t be exactly duplicated like a pill. That’s why instead of “______”, these insulins are called biosimilar

100, not, 500, long, short, large

Concentrated Insulins

-Most insulin is U-100, meaning ____ units per 1 mL. The majority of concentrated insulins have the same pharmacokinetics as U-100 (___ U-500).

-U-___ is different. It is another concentrated type with both ____ and _____-acting insulin effected.

• Reserved for patients needing _____ amounts of insulin

• Off-label use in pumps

0.4, body weight, basal, 3

Calculating Daily Insulin Needs: Prandial Dosing

-Total Daily Dose = _._ - 0.8 units per kg of ____ ______

-50% of that number is allotted for your daily _____ insulin dose, while the other half is for the prandial insulin dose

-The prandial insulin dose is then divided by _

500, TDD, 1 unit, flexibility

Insulin Dosing: Carb Ratio

-500 rule → ___ divided by ___ = amount of carb _ ____ of insulin will cover

-Allows for more _________ in eating

1800, 1500, ISF, lowered, 1, scale

Correcting High Sugars

-_____ rule (insulin naive) or _____ rule (insulin resistant) to calculate Insulin Sensitivity Factor

• 1800/1500 are divided by TTD = ___

• ISF is the amount blood glucose that can be __________ by _ unit of insulin

• Can be used to create targeted sliding _____

• Start with common sliding scale to simplify

younger, 1, 2, anti-rejection, renal

Pancreatic Transplant

-Pancreas or islet cell transplant

-Consider if severe hypoglycemia/hypoglycemic unawareness or co-morbidities, especially in ________ patients

-90% of patients are Type _, consider Type _ if patient is also insulinopenic

-Lifelong ____-_________ drugs with their own spectrum of side effects

-Frequently if also getting _____ transplant due to renal failure