Insulin Management (Clin Reason)

What are the management for DM with insulin based on A1C

< 7.5 % = Monotherapy

7.5-9% = Dual Therapy

> 9% w/o Symptoms = Dual/Triple Therapy

> 9% w/ Symtpoms = Insulin ± Other Agents

> 10% = Insulin ± Other Agent

What should be understood when talking about insulin

Know the indications

Determine treatment goals

Identify barriers

Understand insulin types and their use

Feel confident to discuss the pros/cons of insulins and delivery systems

Effectively educate and demonstrate insulin use

Realize it often takes several attempts to convince patient

What type of insulin does T1Dm need

Basal and Bolus

How can blood glucose be monitored by the patient?

Frequent / continuous blood sugar checks

Continuous glucose monitor (CGM)

When does insulin get added for T2DM

Non-Insulin Agents fail

What is the goals of insulin theatpy

HgbA1C: <7%

Fasting glucose: 80-130 mg/dL

2-hour postprandial glucose: <180 mg/dL

Minimize hypoglycemia

What should individual patient goals for insulin be made on

Quality of life

Comorbid conditions (ASCVD)

Hypoglycemia risk

Patient motivation

Cost $$$

Age and life expectancy

What populations have more lax treatment goals for insulin

Children (especially <7 yrs.)

Elderly (overall health and life expectancy)

Intellectual disability

Psychiatric disabilities

Hypoglycemia unawareness

What non-insulin agents help with ASCVD?

GLP-1

SGLT2

What non-insulin agents help with CKD?

GLP1

SGLT2

What non-insulin agents help with Obesity?

GLP1

What non-insulin agents help with Heart Failure?

SGLT2

What non-insulin agents help with Strokes?

GLP1

TZD

What non-insulin agents help with OSA?

GLP1

What is the most effective agent to reducing glucose

Insulin

Risks of using insulin

Hypoglycemia

Weight gain

Congestive heart failure

Trypanophobia

Fear of blood injections

Pros to using insulin

Improved glucose control

Decreased hyperglycemic symptoms

Reduced risk of diabetic complications

Reduced non-insulin medication burden

Survival

Cons to Using Insulin

Injections

Weight gain

Hypoglycemia

Hypertrophy of subcutaneous fatty tissue

Cost $$$ (varies by insulin)

reluctant to start insulin in fear of the impact it may have on their employment

What occupations have limitations due to insulin

Trunk Drivers

Commerical Airline Pilots

Branches of the Military

What needle is used for inslun

32g

What needed is used for finger glucose monitoring

28g

What angle is insulin injectd

For needles and syringes = 45

For pens = 90

What type of injection is insulin

SubQ

Where can insulin be injected

Abdominal Wall 2’’ from Navel

Arm

Legs

Buttocks

What educations should be given on injections sites

Clean with ETOH before

Altenate sites reduce hypertrophied SubQ Fatty Tissue

What is pros to multiuse vials

Least Expense

What are cons to mutliuse vials of insulin

Lack of portability

Less discreet

Possibilities for error

Stigma attached to the system

Requires manual dexterity and visual acuity

When should insulin be thrown away

Expired

Previously frozen

Exposed to extreme heat

Appearance is abnormal

Open for > 28 days

Where should insulin be stored

Refrigerator

What are pros to prefilled insulin pens

Portable, convenient and discrete

Shortest/sharpest needles available

Accurate delivery

Good for people with visual or dexterity impairments

What are cons to prefilled insulin pens

Cost

Maximum dose (80 units per injection)

Can’t make a custom mix of insulins

Once a pen used, where should it be kept

Room Temperature

What are pros to using insulin pumps

Individualized basal rate capability

Bolus dosing with push of a button

Less hypoglycemia

Less glucose variability

Flexibility of lifestyle

What are cons to using insulin pumps

Need for extensive training

Site changes every 2-3 days

Cost and insurance coverage $$$

What are pros to using insulin inhalers

No injections

Dry powder, ultra-rapid acting insulin

What are cons to using insulin inhalers

Contraindicated in underlying lung disease (asthma/COPD)

Cough, throat irritation

Cost $$$

Afrezza

Insulin Inhaler

Signs of Hypoglycemia

Sweating

Shakiness

Dizziness

Headache

Hunger

Anxiety or nervousness

Irritability or moodiness

What can be used for hypoglycemia palns

Glucose tabs

Oral glucose gel

Hard candy

Traditional glucagon kits

What non-insulin agents should be discontinued with insulin

Sulfonylureas

Meglinitides

TZDs

What are the types of insulin

Rapid-acting (Bolus)

Short-acting (Regular)

Intermediate-acting (NPH)

Long-acting (Basal)

Ultra-long acting (Basal)

Mixed preparations

When is rapid insulin given

With meals

What are the rapid-acting insulins

Aspart (Novolog)

Lispro (Humalog)

Glulisine (Apidra)

What are the short acting insulins

Humulin R

Novolin R

When is short acting insulin given

Before a meal

Uses of rapid/short acting insulin

Prandial coverage

ISF correction

When is intermediate insulin given

BID or Daily

What are the intermediate acting insulins

NPH

Novolin N or Humulin N

when are the long acting insulins

Daily

What are the long acting insulins

Glargine U100 (Lantus)

Detemir (Levemir)

What are the ultra long acting insulins

Glargine U300 (Toujeo)

Degludec (Tresiba)

When are the ultra long acting insulins given

Daily

How is NPH made

Insulin being prolonged by adding protamine

What type of insulin is cloudy

Intermeditae

What must be done to intermediate insulin prior to use

Roll the bottle

What is the most expensive insulin

Ultra Long-Acting

What are the types of basal+prandial insulin

Weight based basal + modified prandial

Weight based basal + basal bolus

Carbohydrate Coverage

Insulin Sensitivity Factor (ISF)

Indication for Basal Insulin Alone

T2DM

What is the starting dose for basal insulin alone

A1C < 8% = 0.1-0.2 units/kg daily

A1C > 8% = 0.2-0.3 units/kg daily

When calculating the TDD of basal insulin, how should it be rounded?

Down

How should insulin be titrate

Fixed increase method

Adjustable increase method

Fixed increase method

Gradually increases 2units of insulin every 2-3 days until patient reaches fasting goal: 100-130 mg/dL

Adjustable increase method

A tirtration of basal insulin based on FBS

• FBS > 180% = Increase 20% TDD

• FBS 140-180 = Increase 10% TDD

• FBS 110-140 = Increase 1 unit

How does basal insulin dose get altered for hypoglycemia

BS < 70 = Decrease 10-20%

BS < 40 = Decrease 20-40%

When is bolus dosing considered to add to basal insulin

Disease progression

Not achieving A1C goal with large amount of basal insulin

Overbasalization

Patients who have steadily increased basal insulin over time but are not controlled

i.e. patients using > 0.5 units/kg per day of basal

What is the modified prandial method

Take the current TDD

• 90% of TDD = New Basal Dose

  • 10% of TDD = Pradial Dose at Largest Meal

What indicates further titrate after modified prandial dosing

Morning hyperglycemia

Alternative Modified Prandial

Add 5 units of rapid to the largest meal of the day

What is the order of intensity for blood sugar control

Diet and lifestyle modifications alone

Non-insulin therapies

Basal insulin alone

Weight Based Basal + Modified Prandial

Weight Based Basal + Basal Bolus

How is basal bolus found

Calculate new TDD

50% TDD = Basal Dose

50% TDD / 3 meals = Bolus Dose

Carbohydrate Coverage

A method of bolus dosing for T1DM that anticpates the needed coverage for bolus influesion

What are concerns with carbohydrate coverage

Does NOT account for varied levels of insulin resistance

Does NOT account for elevated blood sugars that are present before the meal

How is carbohydrate coverage calculated?

Total carbs - Total Fiber = Carb Count

500 / TDD = 1 unit to cover (X) carbs (Rounded up)

Carb Count / (X) Carbs

What replaced the sliding scale

ISF

Insulin Sensitivity Factor (ISF)

Predicts the mg/dl reduction one can expect in response to 1 unit of rapid-acting insulin

How is ISF calculated

1800 / TDD = 1 unit of rapid will low BS by (X) mg/dL (Rounded up)

ISF Action Plan

A table that uses a patient’s ISF to have a quick reference to give rapid-acting insulin