Therapeutics I: Exam 3 - Type 1 Diabetes and General Diabetes Principles RW

At what age does T1DM usually occur?

Usually occurs before age 30

BUT can occur at any age

(LADA)

What causes T1DM?

Autoimmune disease in which insulin-producing β cells in the pancreas are destroyed, leaving the individual insulin deficient

Loss of 80-95% of beta cells at diagnosis

What are the classic symptoms of acute hyperglycemia?

3 P’s: Polyuria, Polydipsia, Polyphagia

Significant, rapid weight loss (unintentional)

Fatigue

Blurred vision

Muscle cramps

Headache

Poor wound healing

What are signs of T1DM?

Severe hyperglycemia (elevated A1c,FPG,Random BG)

ketosis

negligible C-peptide

Autoantibodies: islet cell, insulin

What is LADA (latent autoimmune diabetes in adults)?

Form of autoimmune diabetes

Milder autoimmune process and slower progression of B-cell failure

What is the usual age of onset of T1DM?

Childhood

What is the speed of onset of T1DM?

Abrupt

Is there a strong family history associated with T1DM?

Negative FH

What is the body type of patients with T1DM?

Thin

Are autoantibodies present in T1DM?

Present

What symptoms are present in T1DM?

Polyuria

Polydipsia

Polyphagia/rapid weight loss

Are there ketones at diagnosis with T1DM?

Present

Are there acute complications with T1DM?

DKA

Are there microvascular complications at diagnosis with T1DM?

Rare

Are there macrovascular complications at diagnosis with T1DM?

Rare

What is the usual age of onset of LADA?

Over 30

What is the speed of onset of LADA?

Gradual

What produces insulin?

Insulin and glucagon produced in the pancreas by cells in the islets of Langerhans

β cells: 70% to 90% of the islets and produce insulin

α cells produce glucagon

What is the body type of patients with LADA?

Thin

Are autoantibodies present in LADA?

Present

Is there a strong family history associated with LADA?

Positive FH

Are there ketones at diagnosis with LADA?

Dependent on B-cell function

Are there acute complications with LADA?

DKA possible

Are there microvascular complications at diagnosis with LADA?

Dependent on length of disease at diagnosis

Are there macrovascular complications at diagnosis with LADA?

Dependent on length of disease at diagnosis

What symptoms are present in LADA?

Polyuria

Polydipsia

Polyphagia/rapid weight loss

What is the usual age of onset of T2DM?

Adult

What is the speed of onset of T2DM?

Gradual

Is there a strong family history associated with T2DM?

Positive FH

Are autoantibodies present in T2DM?

Rare

What is the body type of patients with T2DM?

Overweight/obese

What symptoms are present in T2DM?

Asymptomatic

Are there ketones at diagnosis with T2DM?

Uncommon

Are there microvascular complications at diagnosis with T2DM?

Common

Are there macrovascular complications at diagnosis with T2DM?

Common

Are there acute complications with T2DM?

Rare

What is the main function of insulin?

decrease blood glucose

What is the main function of glucagon?

increases blood glucose

What maintains physiological process maintains fasting blood glucose?

Opposing actions of insulin and glucagon

Normally maintain fasting values between 79 and 99 mg/dL

What is the normal fasting glucose maintained by the body?

79 to 99 mg/dL

What is hemoglobin A1c?

Glucose interacts with hemoglobin in red blood cells to form glycated derivatives

Most prevalent derivative is A1c

Increased glycation with increased blood glucose levels

Red blood cell life span is approximately 3 months

What is A1c a measure of?

Average glucose levels over 3 months

How often should A1c be monitored?

Every 6 months if at goal

Every 3 months if uncontrolled or changes in therapy

What are the criteria for diagnosis of diabetes, of any type?

A1c ≥6.5%

FPG ≥126 mg/dL

2hr PPG ≥200 mg/dL

Random ≥200 mg/dL and classic s/s of hyperglycemia

What is the A1c criteria for diabetes diagnosis?

A1c ≥6.5%

What is the FPG criteria for diabetes diagnosis?

FPG ≥126 mg/dL

What is the 2hr PPG criteria for diabetes diagnosis?

2hr PPG ≥200 mg/dL

What is the random BG criteria for diabetes diagnosis?

Random ≥200 mg/dL and classic s/s of hyperglycemia

If the patient doesn't have hyperglycemia, how can diagnosis be confirmed?

Repeat testing

What are the goals of diabetes therapy?

A1c <7%

Pre-prandial (FPG) 80-130 mg/dL

Peak post-prandial <180 mg/dL

What is the A1c goal for diabetes therapy?

A1c <7%

What is the pre-prandial (FPG) goal for diabetes therapy?

Pre-prandial (FPG) 80-130 mg/dL

What is the post-prandial goal for diabetes therapy?

Peak post-prandial <180 mg/dL

What is self-monitoring blood glucose (SMBG)?

Typically done via fingerstick

Provides 'point-in-time' reflection of blood glucose

What is the typical SMBG testing frequency for T1DM patients?

4-6 times per day

What is the typical SMBG testing frequency for T2DM patients?

1-3 times per day

What is the difference between interstitial fluid vs. blood glucose?

Interstitial fluid levels delayed 5-10 minutes compared to blood

Can typically replace finger sticks

Unless signs of hypoglycemia or rapids changes

What is used for treatment of T1DM?

Requires exogenous insulin to replace the endogenous loss of insulin from the nonfunctional pancreas

What insulin regimen mimics normal insulin physiology?

basal-bolus

Basal insulin response: intermediate or long-acting insulin

Bolus release around meal: short or rapid-acting insulin

Generally, basal insulin makes up approximately 50% of the total daily dose with remaining 50% bolus doses around three daily meals.

What is the best therapy regimen for T1DM?

Physiologic (intensive) insulin regimens (Basal + bolus)

Indicated for optimal control of T1DM

How many units of insulin are T1DM pt.'s typically started on?

Typically start 0.4-0.6 unit/kg/day

Titrated until glycemic goals are reached

How many units of insulin are most T1DM pt.'s on?

Between 0.6 and 1 unit/kg/day

What are the types of bolus insulins?

Regular (short-acting) insulin

Rapid acting insulin

What are the names of the regular (short-acting) insulins?

Humulin R (U-100)

Novolin R (U-100)

What are characteristics of the regular (short-acting) insulins?

Delayed onset & peak

Longer duration of action than rapid acting insulins

(increased hypoglycemia)

When should the regular (short-acting) insulins be administered?

Administer 30 minutes before meals

What is the average onset of the regular (short-acting) insulins?

30-60 mins

What is the average peak of the regular (short-acting) insulins?

2-4 hrs

What is the average duration of the regular (short-acting) insulins?

5-8 hrs

What are the names of the rapid-acting insulin injections?

Lispro (Humalog)

Aspart (Novolog)

Glulisine (Apidra)

all (U-100)

What are the names of the rapid-acting insulin inhalations?

Recombinant regular insulin (Affreza)

4, 8, or 12 unit cartridges

When should the rapid-acting insulins be administered?

Administer 15 minutes before meals

What is the average onset of the rapid-acting insulins?

15-30 mins

What is the average peak of the rapid-acting insulins?

0.5-1.5 hrs

What is the average duration of the rapid-acting insulins?

3-5 hrs

What are the types of basal insulins?

Long-acting insulin

What are the names of the long-acting insulins?

Glargine (Basaglar, Semglee, Lantus, Toujeo)

Detemir (Levemir)

Degludec (Tresiba)

All injectable

What are the brand names of Glargine?

Basaglar, Semglee & Lantus (U-100)

Toujeo (U-300)

What are the brand names of Detemir?

Levemir (U-100)

What are the brand names of Degludec?

Tresiba (U-100 or U-200)

What are characteristics of the long-acting insulins?

Relatively constant insulin concentration over 24 hours (’peakless’)

Cannot be given IV or mixed with other insulins

Administered irrespective of meals or time of day

May be less hypoglycemia with Toujeo or Tresiba

When should the long-acting insulins be administered?

Generally once-daily-dosing

Cover between meals & overnight

Administered irrespective of meals or time of day

What is the average onset of the long-acting insulins?

2-4 hrs

(Toujeo (glargine) = 6hr)

What is the average peak of the long-acting insulins?

Flat

What is the average duration of the long-acting insulins?

About 30 hrs

(Toujeo (glargine) = 36 hr)

What are the names of the intermediate (NPH) insulins?

Humulin N

Novolin N

Both U-100

What are intermediate (NPH) insulins used for?

Cover insulin requirements in between meals and/or overnight

What are characteristics of intermediate (NPH) insulins?

Can be mixed with regular/rapid insulin

Use has declined because of:

· Inability to predict accurately when peak effects occur

· Duration of action of less than 24 hours

What is the average onset of the intermediate (NPH) insulins?

2-4 hrs

What is the average peak of the intermediate (NPH) insulins?

4-10 hrs

What is the average duration of the intermediate (NPH) insulins?

10-24 hrs

What are examples of combination insulins?

Humulin 70/30 (U-100)

Novolin 70/30 (U-100)

Humalog 70/30 (U-100)

Novolog 70/30 (U-100)

Humulin 50/50 (U-100)

Humalog 75/25 (U-100)

What are combination insulins?

Pre-specified ratio of intermediate & regular or rapid insulins

(1st number = % intermediate per unit of insulin)

What are combination insulins used for?

Meant to cover 2 meals

OR 1 meal + snack

Usually given before breakfast and evening meal

What are characteristics of combination insulins?

Can reduce number of injections per day

More difficult to adjust

What are tips for administration of insulin?

Given subcutaneously (SQ) by pen or syringe

Rotate sites to minimize fat buildup/scar tissue

Can give in abdomen, thighs, arms, buttocks

Absorption varies between sites due to blood flow

(Abdomen fastest, buttocks slowest)

Use same area of body - rotate sites

Shorter needles typically don't have to 'pinch'

90-degree angle, hold injection for 10 seconds

What insulin do pumps use?

Rapid-acting insulin

(Physiologic regimen)

How is insulin released from pumps?

Patient sets a “BASAL” hourly rate, automatically infused via catheter

Patient administers “BOLUS” (meal-time) dose based on their individual insulin: carbohydrate ratio (ex. ICR 1:10) for carbs at that meal; patient must count carbs

What is a limitation of insulin pump therapy?

Patients must accept MORE frequent SMBG

Patient must count carbs

What are factors in patient choice of insulin pump therapy?

Freer lifestyle

Improved A1c

Improved BG control

Flexibility in meal timing and size

Fewer & less severe insulin reactions

Ability to exercise without losing control

Control while traveling or working variable schedules

Peace of mind