CDCES Module 1: Insulin Therapy

Comprehensive vocabulary flashcards covering the pharmacokinetics, packaging, injection techniques, dosing calculations, conversions, and clinical management strategies of insulin therapy based on Module 1.

First-Phase Insulin Release

Physiologic insulin secretion occurring at a meal that peaks in $1\text{--}2\text{ min}$ and shuts off liver glucose output, followed by a second phase lasting $1\text{--}2\text{ hours}$. No commercial insulin acts quickly enough to match it.

Afrezza (Inhaled Insulin) Timing

The commercial insulin coming closest to physiologic mealtime timing, featuring an onset of $12\text{ min}$, a peak at $45\text{ min}$, and a return to baseline at $180\text{ min}$.

Injectable Rapid-Acting Insulin Pharmacokinetics

Analog insulin with an onset of $17\text{--}30\text{ min}$ and a peak of $90\text{--}120\text{ min}$, lagging $2\text{--}3\times$ behind physiologic secretion.

U100 Concentration

The standard insulin concentration representing $100\text{ units}$ of insulin per $1\text{ mL}$ of fluid.

U100 Packaging Volumes

Standard dispensing sizes consisting of $1{,}000\text{ units}$ per $10\text{ mL}$ vial, $300\text{ units}$ per $3\text{ mL}$ pen, and $1{,}500\text{ units}$ per box of $5$ pens.

Afrezza Cartridge Strengths

Color-coded single-dose cartridges loaded into a reusable inhaler available in $4\text{ units}$, $8\text{ units}$, and $12\text{ units}$.

Insulin Glargine (Lantus)

A peakless, once-daily basal insulin lasting approximately $24\text{ hours}$ that cannot be mixed with other insulins due to its acidic pH forming a slow-release subcutaneous depot.

Interchangeable Biosimilar Insulins

Biologics that can be substituted at the pharmacy without prescriber approval, including Semglee and Rezvoglar (for glargine) and Merilog and Kirsty (for aspart).

Follow-On Insulins

Biologics approved under regulatory pathways requiring a distinct prescription and barring pharmacist substitution, including Basaglar (glargine) and Admelog (lispro).

Toujeo

A concentrated U300 formulation of insulin glargine providing $3\times$ the concentration of standard glargine.

NPH Mixing Technique

The procedure of gently rolling the suspension between the palms rather than shaking to resuspend the cloudy insulin without damaging protein molecules.

Standard Pen Needle Length

A $4\text{ mm}$ needle length recommended for most patients because human skin is approximately $2\text{ mm}$ thick regardless of body size.

Pen Priming (Air Shot)

Dialing $2\text{ units}$ and pressing the injection button until insulin appears at the needle tip before every injection to verify flow.

Post-Injection Needle Dwell Time

Holding the pen needle in the subcutaneous tissue for $5\text{--}10\text{ seconds}$ after depressing the plunger completely to ensure delivery of the full dose.

Opened Glargine & Rapid-Acting Stability

In-use stability allowing storage at room temperature up to $86^\top\text{F}$ for up to $28\text{ days}$ (applies to Lantus, Basaglar, Semglee, Rezvoglar, lispro, aspart, and glulisine).

Degludec (Tresiba) In-Use Stability

Long-acting basal insulin outlier that remains stable at room temperature for up to $56\text{ days}$ after opening.

Icodec (Awiqli) In-Use Stability

Weekly basal insulin pen formulated at U700 ($700\text{ units}$, $1{,}050\text{ units}$, or $2{,}100\text{ units}$) that lasts $12\text{ weeks}$ at room temperature once opened.

Maximum Single Pen Dose (Glargine/Degludec)

The highest single dose deliverable in one injection from a standard $3\text{ mL}$ ($300\text{ units}$) glargine or degludec pen, which is $80\text{ units}$.

Insulin Icodec Pharmacokinetics

A once-weekly basal insulin lasting $7\text{ days}$ with a peak at $2\text{--}4\text{ days}$ and reaching steady state within $3\text{--}4\text{ weeks}$; doses are adjusted every $7\text{--}14\text{ days}$.

Icodec Starting Dose (Insulin-Naive)

A starting dose of $70\text{ units}$ injected once weekly in an insulin-naive individual, followed by titration based on fasting glucose trends.

Glargine-to-Icodec Conversion

The formula used when converting daily basal insulin to weekly icodec: daily dose multiplied by $7$ (e.g., $20\text{ units/day} \times 7 = 140\text{ units/week}$).

Icodec Renal Dose Adjustments

Dosage titration protocol based on kidney function: eGFR $\ge 50$ requires no change, eGFR $10\text{--}50$ receives $75\%$ of the standard dose, and eGFR $< 10$ receives $50\%$ of the dose.

Missed Icodec Dose Protocol

Management rule: if $\le 3\text{ days}$ remain before the next scheduled dose, take the dose immediately and adjust the weekly day; if $\ge 4\text{ days}$ remain, take it immediately and maintain the original schedule.

Weekly Basal Insulin Clinical Risks

Slow reversibility if overtreated, lack of immediate feedback from missed doses, and the necessity of temporary management alterations during acute illness or surgery.

Type 1 Basal-Bolus Initiation (Method 2)

Starting total daily dose (TDD) of $0.5\text{--}1.0\text{ units/kg/day}$, split into $50\%$ basal at bedtime and $50\%$ bolus divided equally across three meals.

Type 1 Split-Mixed Regimen (Method 1)

Two daily injections of NPH and Regular combined in a $2:1$ ratio, administering $2/3$ of the TDD before breakfast and $1/3$ before dinner (with the evening NPH covering overnight basal needs).

Afrezza Storage Rules

Unopened foil packs are refrigerated until expiration; foil blister strips removed from foil last $10\text{ days}$ at room temperature; opened strips last $3\text{ days}$; inhalers are replaced after $15\text{ days}$.

Humulin R U500

Concentrated regular insulin ($5\times$ concentration) for individuals requiring $> 200\text{ units/day}$; behaves as an intermediate insulin (peaks in $4\text{--}8\text{ hours}$, duration $13\text{--}24\text{ hours}$) covering both basal and prandial needs.

Humulin R U500 TDD Conversion Rules

Dosing adjustment based on baseline control: if A1C is $< 8\%$, reduce total daily dose by $10\text{--}20\%$; if A1C is $\ge 8\%$, convert on a $1:1$ basis, divided $2\text{--}3\times$ daily before meals and rounded to the nearest $5\text{ units}$.

Humulin R U500 Safety Rule

Mandatory administration using dedicated U500-specific syringes or pens (holding $1{,}500\text{ units}/3\text{ mL}$, dialing in $5\text{-unit}$ increments up to a max single dose of $300\text{ units}$) to prevent fatal dosing errors.

Sulfonylureas and Meglitinides (Basal Initiation Rule)

The only class of oral glucose-lowering agents governed by an unconditional discontinuation rule when starting basal insulin in order to prevent severe hypoglycemia.

DPP-4 Inhibitors (Basal Initiation Rule)

Oral agents that are continued when initiating basal insulin unless a GLP-1 receptor agonist is also being initiated or co-administered.

SGLT-2 Inhibitors (Insulin Co-administration Rule)

Oral medication class maintained when starting insulin due to cardiorenal benefits (ASCVD, CKD, HF), which may lower overall insulin requirements.

Overbasalization

Clinical phenomenon characterized by a bedtime-to-morning or pre-to-post-meal blood glucose drop of $\ge 50\text{ mg/dL}$, frequent hypoglycemia, and high glycemic variability caused by over-titrating basal insulin rather than addressing mealtime spikes.

Type 2 Basal Insulin Initiation & Titration

Starting dose of $10\text{ units/day}$ or $0.1\text{--}0.2\text{ units/kg/day}$, titrated by increasing the dose by $2\text{ units}$ every $3\text{ days}$ toward the target fasting glucose.

Basal Unexplained Hypoglycemia Rule

The clinical management rule requiring an immediate $10\text{--}20\%$ dose reduction of basal insulin when an unexpected or unexplained low blood glucose event occurs.

Prandial Insulin Starting Dose

Starting mealtime coverage with $4\text{ units/day}$ or $10\%$ of the current basal dose administered before the largest meal, titrated by $1\text{--}2\text{ units}$ or $10\text{--}15\%$ twice weekly.

Preferred Initial Injectable in Type 2 Diabetes

GLP-1 receptor agonists (or dual GIP/GLP-1 receptor agonists), which are prioritized ahead of basal insulin unless A1C is $> 10\%$, blood glucose is $\ge 300\text{ mg/dL}$, or type 1 diabetes is suspected.

Intensification Beyond Basal + Prandial

Three therapeutic advancement options for patients uncontrolled on basal plus single prandial: full basal-bolus, self-mixed split NPH plus rapid-acting ($2/3$ AM, $1/3$ PM), or twice-daily premixed insulin regimens (including fixed-ratio combinations like iDegLira and iGlarLixi).