Insulin Management

7.5%

an A1C of < ___ indicates the need for monotherapy

7.5%, 9%

an A1C of > ___ and <___ indicates the need for dual or triple therapy

dual or triple therapy

an A1C of >9% WITHOUT symptoms indicates the need for...

insulin +/- other agents

an A1C of >9% WITH symptoms indicates the need for...

10%

an A1C of > ___ WITH or WITHOUT symptoms indicates the need for insulin +/- other agents

basal and bolus (prandial) insulin

--> basal insulin + rapid insulin given with each meal

Type 1 diabetes requires...

non-insulin ants fail to provide desired blood sugar control

in type 2 diabetics, insulin is more often added when...

<7%

80-130 mg/dL

<180 mg/dL

HbA1C, fasting glucose, and 2-hour postprandial glucose goals

children (<7)

elderly

intellectual disability

mentally ill

hypoglycemia unawareness

what are some special populations that may require relaxed treatment goals?

hypoglycemia unawareness

repeated hypoglycemic events over time reduce a patient's ability to detect drops in blood sugar

GLP-1

SGLT2i

tx plan for one with DM and ASCVD

GLP-1

SGLT2i

tx plan for one with DM and CKD

SGLT2i

tx plan for one with DM and heart failure

GLP-1

TZD ?

tx plan for one with DM and stroke/TIA

insulin

--> increases risk of hypoglycemia, weight gain, CHF

--> does NOT reduce MACE, stroke, fatty liver

what is the most effective class for glucose monitoring?

improved glucose control

decreased hyperglycemic symptoms

reduced risk of diabetic complications

reduced non-insulin medication burden

survival

pros of insulin use

injections

weight gain

hypoglycemia

hypertrophy of SQ fatty tissue

cost

cons of insulin use

medicare

the $35/month cap on insulin is only available for those on...

truck drivers

pilots

branches o the military

some patients are reluctant to start insulin in fear of the impact it may have on their employment. what careers can be impacted by one being on insulin?

32 gauge, 28 gauge

insulin needles are ________, accucheck needles are _________.

45, 90

when delivering insulin, one should pinch the skin, inject subcutaneously at ____ degrees using needle and syringe, and at ___ degrees using insulin pen

poor, rapid

in an intradermal injection, absorption is ______, in an IM injection, absorption is _______.

abdominal wall (2" away from navel)

arms

legs/buttocks

where are some potential sites of insulin injection?

hypertrophied subcutaneous fatty tissue

patients should alternate sites of injection to reduce incidence of...

pro -- least expensive

cons:

--> lack of portability

--> less discreet

--> possibilities of error

--> stigma attacked to the system

--> requires manual dexterity and visual acuity

what are some pros and cons of multiuse vials?

in the refrigerator

unopened vials of insulin are stored...

open, refrigerator/controlled temperature room

once the vial is punctured, it is considered ____, and they are stored in the ___________.

reach room temperature

vials removed from the refrigerator must be allowed to ____________ before injection

NPH

____ requires the vial to be mixed before use

portable, convenient, and discrete

shortest/sharpest needles available

accurate delivery

good for people with visual or dexterity impairments

pros of refilled pens

cost

max dose (80 units per injection)

can't make a custom mix of insulin

cons of refilled pens

do not keep in HOT places

do not leave in indirect sunlight

do not leave in EXTREMELY COLD places (Freezer)

--> discard if insulin is frozen

NEVER USE IF INSULIN IS EXPIRED

insulin is sensitive to light and temperature, so what are some recommendations to ensure insulin does not expire?-

28 days

how long does unopened insulin last if it is not stored in the fridge

refrigerator

one should store unused insulin pens in the...

controlled room temperature

--> NOT IN THE REFRIGERATOR

once a pen is used, it should remain at a...

individualized basal rate capability

bolus dosing with push of a button

less hypoglycemia

less glucose variability

flexibility of lifestyle

pros of insulin pumps

need for extensive training

site changes every 2-3 days

cost

cons of insulin pumps

pros -- no injections

cons

--> contraindicated in underlying lung disease (asthma/COPD)

--> cough, throat irritation

--> expensive

pros/cons of insulin inhalers (Afrezza)

sweating

shakiness

dizziness

headache

hunger

anxiety or nervousness

irritability or moodiness

symptoms of hypoglycemia

glucose tabs

oral glucose gel

hard candy

IM glucagon kit

--> glucagon vial (1mg)

--> disposable syringe with sterile water (1 mL for reconstitution)

aspects of a hypoglycemia tx plan

Metformin

GLP-1 agonists

SGLT2 inhibitors

+/- DPP4 inhibitors

oral meds to continue if one is started on insulin

Sulfonylureas (-ides)

Meglinitides (-glinides)

TZDs (-azones)

oral meds to STOP if one is started on insulin

basal, both basal and prandial coverage

patients with type 2 DM will often need ______ supplementation at first, with time, they may need....

Human insulin

structurally identical to natural human insulin

Analog insulin

differs structurally from natural human insulin; more predictable mechanism of action; more uniform duration of action; more expensive

rapid-acting (Bolus)

short-acting (regular)

intermediate-acting (NPH)

long-acting (basal)

ultra-long acting (basal)

mixed preparations

types of insulin

Aspart (Novolog)

Lispro (Humalog)

Glulisine (Apidra)

rapid acting insulin agents

10-20 min, WITH each meal

rapid acting insulin takes about _______ to begin to work, so it should be taken _____________.

Humulin R

Novolin R

short acting insulin agents

1/2 hr-1 hr, 30-45 min BEFORE each meal

short acting insulin takes about _______ to begin to work, so it should be taken _____________.

Rapid acting insulin

analog insulin; more expensive; clear; given 5-15 minutes prior to a meal (works almost immediately)

prandial coverage

ISF correction

indications for rapid acting insulin

Short acting insulin

human insulin; cost effective; clear; given 30-45 min before meals; produces depot effect with variable absorption

prandial coverage

ISF correction

indications for short-acting insulin

NPH insulin

neutral protamine Hagedorn; regular insulin + protamine; protamine prolongs the activity of the regular insulin

Intermediate-acting insulin

human insulin; cost effective; CLOUDY color; prolonged duration but variable; typically dosed BID or daily

roll the insulin bottle between their hands to mix

when taking intermediate-acting insulin, patients must be educated to...

NPH

Novolin N

Humulin N

intermediate-acting insulin agents

Long-acting (Basal) insulin

analog insulin; more expensive; clear; slightly delayed onset (3-4 days until steady state); long duration of action; little to no peak; CANNOT BE MIXED WITH OTHER INSULIN!!

Glargine U-100 (Lantus)

Detemir (Levemir)

long-acting (basal) insulin agents

Ultra-long acting (Basal) insulin

analog insulin; MOST EXPENSIVE; clear color; ultra-long duration of action (up to 42 hours); NO peak (<5 days until steady state); CANNOT be mixed with other insulin

glargine U-300 (Toujeo)

delugec (Tresiba)

Ultra-long acting (Basal) insulin agents

Mixed preparations

premixed insulin that combines long-acting basal insulin with mealtime insulin; often given BID; provides a mealtime peak as well as basal coverage

Humulin 70/NPH 30

Novolin R 70/NPH 30

Humalog 75/Humalog + Protamine 25

Novolog 50/Novalog + Protamine 50

mixed insulin formulations

always draw clear liquid into syringe first, then draw the desired amount of cloudy into the same syringe

how to mix your own insulin preparations

prevents NPH (cloudy) insulin from contaminating bottle of rapid or regular insulin

--> contamination with NPH can prolong the activity of these clear insulins

why is insulin mixed from clear to cloudy?

type 2 diabetics uncontrolled on non-insulin therapies alone

indication for basal insulin alone

0.1-0.2 units/kg

what is used to calculate the starting total daily dose of basal insulin in one whose A1C is <8

0.2-0.3 units/kg

what is used to calculate the starting total daily dose of basal insulin in one whose A1C is >8

increase basal dose

if a type 2 diabetic is started on basal insulin, and all of their readings are above targets, what should you do?

add GLP-1, RA, SGLT2i, or DPP-4i

increase/add prandial insulin dose

if a type 2 diabetic is started on basal insulin, and their postprandial glucose readings are above targets, what should you do?

decrease basal dose

if a type 2 diabetic is started on basal insulin, and they are experiencing hypoglycemia, what should you do?

investigate lifestyle, activity, and alcohol habits

evaluate meal/carb intake

look for hypertrophies

may be a pump candidate/continuous glucose monitor

if a type 2 diabetic is started on basal insulin, and they are having frequent, unpredictable glycemic fluctuations, what should you do?

increase/decrease bedtime dose accordingly

if a type 2 diabetic is started on basal insulin, and early morning glucose levels are not at target, what should you do?

disease progression will cause postprandial hyperglycemia -- worsening HgbA1C

Patients have not achieved A1C goal despite large amounts of basal insulin

when should one consider adding a prandial dose to basal insulin?

Overbasalization

patients who have steadily increased their basal insulin over time but are not controlled; i.e. patients using >0.5 units/kg per day of basal

normal, increased

in patients are overbasalized, FBS may be ________ but A1C will be _______

weight based basal + modified prandial

weight based basal + basal bolus

carb coverage

insulin sensitivity factor score

prandial dosing options

90% basal

10% rapid acting

when switching one from basal alone to weight based basal and modified prandial glucose measurements, how should one split the patients TDD?

2 hr postprandial >140

next pre-meal glucose is >180

when switching one from basal alone to weight based basal and modified prandial glucose measurements, one should increase prandial dosing by 1-2 units for any meal if...

weight-based basal + basal bolus

if a patient has failed to achieve goal with diet/lifestyle mod, non-insulin therapies, basal insulin, and weight-based basal + modified prandial, one should start...

1. calculate new total daily dose of insulin

2. divide new TDD into basal and prandial doses

how to calculate weight-based basal + basal bolus

Carbohydrate coverage

connomy used insulin strategy for Type 1 diabetics, mimics normal physiologic response of the body to meals; anticipates the amount of rapid-acting insulin needed; requires patients to count carbs

grains (rice, oatmeal, barley)

grain based foods (pasta, break, cereal)

starchy veggies (corn, peas, beans)

fruits

sweets and snack foods

juice, soda, and tea

what is considered a carbohydrate?

attention to serving size

total carbohydrate content

what should patients note on a nutrition label

start with the number of grams of carbohydrates then subtract the number of grams of dietary fiber

how to calculate carb count in one serving

500 rule

Rapid acting insulin: 500/TDD = total number of grams covered with 1 unit of rapid acting insulin

--> inject 1 unit of rapid acting insulin for every x carbohydrates you consume

does not account for varying degrees of insulin sensitivity and resistance

does not account for changes in insulin needs in relationship to stress or activity

allows for hypoglycemia to occur and does not prevent hypoglycemia

why is the traditional sliding scale not used anymore?

Insulin Sensitivity Factor

predicts the mg/dL reduction one can expect in response to 1 unit of rapid-acting insulin; accounts for varying degrees of insulin sensitivity and resistance, allows for more predictable blood sugar reduction before or between meals

1800 rule

1800/TDD = mg/dL reduction expected in response to 1 unit of rapid-acting insulin

--> round up