Quiz 4: Pharmacotherapy- Insulin Delivery

What is the most common insulin delivery device today?

Insulin pens

Why should patients change pen needles with every injection?

To avoid infection, dull needles, and painful injections

What is the purpose of priming an insulin pen?

To ensure the device works and remove air bubbles

How much insulin is used for priming?

2 units; 4-5 units if first use

What are the three recommended insulin injection sites?

Abdomen (not within 2 inches of navel), outer upper arms, and outer thighs

Why is rotating injection sites important?

To prevent lipohypertrophy/scar tissue and ensure consistent absorption

At what temperature should insulin be injected?

Room temperature

How long should the pen needle remain under the skin after injection?

5-10 seconds

How should used pen needles be disposed?

In a sharps container

Should insulin currently in use be refrigerated?

No, keep at room temperature

How should unopened insulin be stored?

In the refrigerator; do not freeze

How long are most insulins stable at room temperature after opening?

~28 days (Degludec = 56 days)

What are the three common side effects of insulin?

Hypoglycemia, weight gain, injection site reactions

How does the ADA define hypoglycemia?

Blood glucose <70 mg/dL

What are common symptoms of hypoglycemia?

shakiness, hunger, irritability, dizziness, tachycardia, anxiety, sweating, blurred vision, headache, weakness

What is the "Rule of 15s" for hypoglycemia management?

1. Check BG

2. If <70, take 15-20 g carbs (e.g., 4 glucose tablets, ½ cup juice/soda)

3. Recheck in 15 min

4. Repeat if <70

5. Once normalized, eat small snack

How does the ADA define clinically significant hypoglycemia?

BG <54 mg/dL

What is the treatment for severe hypoglycemia in an unconscious patient?

Glucagon administration (IM, ready-to-use injection, or intranasal)

What counseling is important for glucagon kits?

Know location, check expiration, and ensure family/friends know how to use it

What is hypoglycemia unawareness?

Lack of symptoms when BG is low

Who is at risk of hypoglycemia unawareness?

Patients with type 1 DM, frequent lows, long disease duration, stress/depression, beta-blocker use, alcohol use

How can hypoglycemia unawareness be improved?

Raise glycemic targets temporarily to avoid lows

What is the 500 Rule for ICR?

500 ÷ total daily insulin dose (TDD) = grams of carbs covered by 1 unit of insulin

Example: If TDD = 50 units, what is the ICR?

500 ÷ 50 = 10 → 1 unit covers 10 g carbs

What is the 1800 Rule for ISF?

800 ÷ TDD = mg/dL drop in BG per 1 unit of insulin (for rapid-acting)

Example: If TDD = 60 units, what is the ISF?

1800 ÷ 60 = 30 → 1 unit lowers BG by ~30 mg/dL

What are key advantages of insulin pumps?

More physiologic delivery, flexible basal/bolus adjustment, improved A1C, less hypoglycemia

What are disadvantages of insulin pumps?

Cost, device maintenance, potential for DKA if infusion set fails

What is the issue with Mary's insulin dosing, and what is the appropriate intervention?

Case: Mary has type 2 DM, persistently elevated blood glucose despite basal insulin.

Issue: Basal insulin alone is not sufficient — postprandial hyperglycemia is unaddressed.

Teaching Point: She requires prandial (bolus) insulin in addition to basal insulin, OR consideration of a GLP-1 receptor agonist if appropriate. Correctional insulin (“sliding scale”) should not be used alone.

Key Takeaway: If A1C remains above goal on basal insulin >0.5 units/kg, add mealtime insulin.

What teaching point does Perry's case highlight regarding insulin adherence?

Case: Perry frequently forgets insulin doses, leading to hyperglycemia.

Issue: Missed doses undermine glycemic control.

Teaching Point: Emphasize adherence strategies — set reminders, pair insulin with meals, simplify regimen if possible (e.g., switch from multiple daily injections to basal-only + GLP-1 RA or consider long-acting basal).

Key Takeaway: Patient education on timing and adherence is just as important as dose adjustments.

What is Jasmine's main concern and what intervention should be considered?

Case: Jasmine reports frequent hypoglycemia.

Issue: Her current insulin dose is too high or mismatched to meals/activity.

Teaching Point:

Re-evaluate her insulin regimen — reduce basal or bolus insulin.

Assess meal timing and carbohydrate counting accuracy.

Educate on recognizing early hypoglycemia signs and following the “Rule of 15s.”

Key Takeaway: Safety first — avoid hypoglycemia by reducing insulin doses and educating on lifestyle adjustments.

What does Bob's case illustrate regarding high daily insulin requirements?

Case: Bob is obese with type 2 DM, requiring >200 units/day of insulin.

Issue: Large injection volumes with U100 insulin can cause poor absorption and injection burden.

Teaching Point:

Consider concentrated insulin formulations (e.g., U500 regular, U200 degludec, U300 glargine).

Review injection technique and adherence.

Address underlying insulin resistance with lifestyle, adjunct therapies (metformin, GLP-1, SGLT2i).

Key Takeaway: Concentrated insulins improve absorption and reduce injection volume in patients with severe insulin resistance.