ES Type I Diabetes

What is glucagon used for?

severe hypoglycemia

Ultra rapid acting insulins

- aspart w/ niacinamide (Fiasp)

- recombinant human insulin regular (Afrezza)

Rapid acting insulins

- lispro (Humalog, Admelog, Lyumjev)

- aspart (Novolog, Apidra)

- glulisine (Apidra)

Short acting insulins

regular (Humulin R/Novolin R)

Intermediate acting insulins

neutral protamine hagedorn (NPH) (Humulin N/Novolin N)

Long acting insulins

- glargine u-100 (Lantus, Basaglar, Semglee)

- glargine u-300 (Toujeo)

- degludec (Tresiba)

- Humulin R u-500 concentrated

Combination pre-mixed insulins

- Humulin 70/30, Novolin 70/30

- Humalog Mix 75/25, 50/50

- Novolog Mix 70/30

Combination basal insulin + GLP-1 agonists

- degludec/liraglutide (xultophy)

- glargine/lixisenatide (soliqua)

Lispro

Humalog, Admelog, Lyumjev

Aspart

Novolog

Glulisine

Apidra

Aspart w/ niacinamide

Fiasp

Recombinant human insulin regular

Afrezza

Regular insulin

Humulin R, Novolin R

Glargine U-100

Lantus, Basaglar, Semglee

Glargine U-300

Toujeo

Degludec

Tresiba

Neutral protamine Hagedorn

Humulin N/Novolin N

Degludec/liraglutide

Xultophy

Glargine/lixisenatide

Soliqua

T1DM

autoimmune disease that destroys insulin-producing beta cells in the pancreas (insulin deficiency)

T2DM

progressive loss of beta-cell insulin secretion commonly due to cellular insulin resistance

LADA (latent autoimmune diabetes in adults)

Type I diabetes with delayed onset

Beta cells

produce insulin (decreases blood glucose)

Alpha cells

produce glucagon

Liver

stores glucose as glycogen and provides glucose via gluconeogenesis

Classic symptoms of diabetes

polyuria, polydipsia, unexplained weight loss

FPG (fasting plasma glucose) for diabetes diagnosis

≥ 126 mg/dL (no caloric intake for at least 8 hours)

PPG (post prandial glucose) for diabetes diagnosis

≥ 200 mg/dL during OGTT

OGTT

oral glucose tolerance test

A1c for diabetes diagnosis

≥ 6.5%

FPG (fasting plasma glucose) for pre-diabetes diagnosis

100-125 mg/dL

PPG (post prandial glucose) for pre-diabetes diagnosis

140-199 mg/dL

T1DM clinical presentation

- onset in childhood or adolescence

- abrupt onset

- thin

- no metabolic syndrome

- autoantibodies present

- symptomatic

- ketones at diagnosis

- DKA possible

- microvascular and microvascular complications at diagnosis are rare

T2DM clinical presentation

- onset in adulthood

- gradual onset

- positive family hx

- obese

- metabolic syndrome is common

- autoantibodies rare

- asymptomatic

- ketones not common

- acute complications rare

- microvascular and microvascular complications at diagnosis are common

LADA clinical presentation

- onset over age 30

- gradual onset

- positive family hx

- thin

- no metabolic syndrome

- autoantibodies present

- symptomatic

- presence of ketones at diagnosis depend on beta cell function at time of diagnosis

- DKA possible

- microvascular and macrovascular complications depend on length of disease at time of diagnosis

Self-monitoring blood glucose monitors

- analyzes blood

- point-in-time evaluation of glucose levels that vary depending on many factors

- can use several points of data to establish glucose patterns

Continuous glucose monitors

- patients w/ T1DM and certain patients w/ T2DM

- enhanced monitoring method

- analyzes interstitial fluid

When is urine or blood ketone monitoring indicated?

- patients w/ T1DM

- can be useful in patients w/ GDM or T2DM as well

- patients prone to ketosis during stressful events (acute illness)

A1c goal

- < 7%

- evaluate q 3 months until goal --> then q 6 months

Preprandial plasma glucose goal

80-130 mg/dL

Peak postprandial plasma glucose goal

<180 mg/dL

Time in range w/ CGM goal (70-180 mg/dL)

> 70%

Glycemic variability w/ CGM goal

< 36%

GMI (glucose management indicator) w/ CGM goal (A1c estimation)

< 7%

What are ultra rapid acting insulins used for?

Quickly manages blood sugar spikes immediately before, during, or shortly after meals

What are rapid acting insulins used for?

cover insulin response to meals

What are short acting insulins used for?

cover insulin during and after meals

What are intermediate acting insulins used for?

cover insulin requirements in between meals and/or overnight

What are long acting insulins used for?

relatively constant insulin concentration over 24 hours

Ultra rapid acting insulin onset, peak, duration

onset 10-15 min

peak ~1 hr

duration ~3-5 hrs

Rapid acting insulin onset, peak, duration

onset 15-30 min

peak 0.5-1.5 hrs

duration ~3-6 hrs

Short acting insulin onset, peak, duration

onset 30-60 min

peak 2-4 hrs

duration 5-8 hrs

Intermediate acting insulin onset, peak, duration

onset 2-4 hrs

peak 4-10 hrs

duration 10-24 hrs

Long acting insulin onset, peak, duration

onset ~1-4 hrs

peak flat

duration ~24-42 hrs

What kinds of insulin are used in a pump?

regular or rapid acting (rapid acting is more commonly used)

What kinds of patients use insulin pumps?

any type of DM, but must be on multiple daily insulin injections

Insulin to carb ratio

how many units of insulin "covers" a certain amount of carbohydrates

Calculating insulin to carb ratio

divide 500 by total daily doses of insulin

Correction factors

amount of additional insulin for correction based on premeal glucose

Calculating correction factors

divide 1700 by total daily dose of insulin

How to get glucose from mg/dL to mmol/L

multiply by 0.0555

Which patients are at higher risk of hypoglycemia?

patients on several anti diabetic agents or other medications that may interact with those medications

Blood glucose levels for hypoglycemia

< 70 mg/dL

Symptoms of hypoglycemia

shakiness, sweating, fatigue, hunger, headaches, confusion

Oral carbohydrates for hypoglycemia

**15 grams of carbs q 15 minutes

raisins, orange juice, skim milk, glucose tablets

When is glucagon indicated?

patients w/ hypoglycemia experiencing loss of consciousness

How is glucagon administered?

IM or subQ

Presentation of patient w/ DKA

- S/S develop rapidly w/in one day

- fruity or acetone breath

- N/V

- dehydration

- polydipsia

- polyuria

- deep and rapid breathing

Core treatment for DKA

- fluid replacement w/ normal saline

- potassium and other electrolytes PRN

- sodium bicarb when pH < 6.9

- regular insulin

HHS (hyperosmolar hyperglycemic state)

- due to inadequate insulin in older patients w/ T2DM

- no ketonemia and acidosis

Treatment of HHS

- rehydration

- electrolyte corrections

- continuous insulin infusion

Inpatient insulin for critically ill patients

IV insulin therapy at 180 mg/dL w/ goal range of 140-180 mg/dL

Inpatient insulin for not critically ill patients

scheduled subq w/ basal, bolus, and correction