Terms in this set (82)
Short acting (regular)
Humulin R U-500
Regular insulin but behaves like NPH
Short acting (regular)
Afrezza (technosphere insulin)
Humulin N (nph)
Novolin N (NPH)
Glargine 100 units/ml (Lantus)
Glargine 300 units/ml (Toujeo)
Ultra Long acting
Insulin glargine U-100 (Basaglar)
Follow on biologic
(very equivalent to Lantus)
Ultra long acting
What does A1c measure?
Percentage of RBC bound to glucose
How often is A1c ordered?
Every 3 months
What factors can falsely decrease A1c?
Any condition that shortens the life cycle of a RBC
- Blood loss (within three months)
- Hemolytic anemia
What factors can falsely increase A1c?
- Untreated iron deficiency anemia
- Blood transfusion (within three months)
What is the ADA recommendation on glycemic targets in adults? (Nonpregnant)
- 1-2 hr PPG
HbA1c : <7% (for most)
Pre-prandial /FPG : 80-130mg/dL
1-2 hr PPG : < 180 mg / dL
What are the ADA recommendations on glycemic targets in children and adolescents less than 18 years of age?
HbA1c : <7.5%
FPG : 90-130
Bedtime : 90-150
What are the ADA recommendations on glycemic targets in adults older than 65 years of age?
Very complex / poor health
: few coexisting conditions, intact cognitive/functional status
Bedtime glucose: 90-150
Complex / intermediate
: multiple coexisting conditions, 2+ instrumental ADL impairments, mild-to-moderate cognitive impairment
Bedtime glucose: 100-180
Very complex/ poor health
: long-term care, end-stage chronic illness, 2+ ADL dependencies, moderate-to-severe cognitive impairment
Bedtime glucose: 110-200
What are the ADA recommendations on glycemic targets in pregnancy?
FPG: <95 mg/dL
1 hour PPG : <140 mg/dL
2 hours PPG: <120 mg/dL
What is first line treatment for someone with T2DM?
What is the number one cause of death in diabetic patients?
Cardiovascular : heart attacks and strokes
What is the blood pressure goal for someone with diabetes with comorbid HTN?
What are recommendations for CVD risk management in diabetes patients?
• Low dose aspirin therapy
• Statin therapy for those with ASCVD or >40 y/o with increase CVD risk
What is insulin's A1c lowering abilty?
Approx. 1.5-3.5 %
What percent of beta cell function has been lost at time of diagnosis?
~50% and decreases as the disease progresses
What is the onset, peak and duration of Afrezza?
Onset: 12-15 minutes
Peak: 30 minutes
Duration: 3 hours
What are some ADRs of inhaled insulin?
• Throat/ mouth irritation
• Acute bronchospasm (susceptible pts, i.e. asthmatics)
• Hypersensitivity reactions
What test is required of a patient who takes Afrezza?
Pulmonary Function Tests @ baseline, 6 months, and annually
Afrezza is contraindicated in what patients?
Which patients is it less efficacious in?
C/I in patients with COPD (caution in asthmatics)
Less efficacious in smokers
What dosages is inhaled insulin available in?
4 unit- blue
8 unit- green
12 unit- yellow
What is the dosage for a insulin naive patient taking inhaled insulin?
Inhale 4 units with each meal
Titrate every 7 days by 4 units per meal until PPG within goal range
What is the difference between glargine U-100 and glargine U-300?
• 3x concentration
• Released more slowly from the subcutaneous tissue to prolong its duration of action (~36 hours)
• More predictable absorption -> less interpatient variability
• Less severe and nocturnal hypoglycemia with U-300
What is the onset peak and duration of insulin glargine U-100 (Basaglar)?
Onset: 1-2 hours
Peak: No appreciable peak
Duration: 10- 24 hours
What is the onset, peak, and duration of Insulin degludec U-100/ U-200 (Tresiba)?
Onset: 0.5-1.5 hours
Peak: No Appreciable Peak
Duration: 42 hours
What is the onset, peak, and duration of insulin glargine U-300 (Toujeo)?
Onset: 6 hours
Peak: No appreciable peak
Duration: 36 hours
What is the dosing of glargine U-300 for an insulin naive patient with:
T1DM: 0.2 to 0.4 units/kg for TDD of insulin
(starting dose of U-300 glargine is 30-50% of TDD - bolus insulin should satisfy the remainder)
T2DM: 0.2 units/kg for initial dose
What is the dosing of glargine U-300 for a patient who's prior Tx of insulin was once daily basal insulin in:
T1DM- 1:1 conversion given once daily
T2DM- 1:1 conversion given once daily
What is the dosing of glargine U-300 for a patient whose prior Tx of insulin was twice daily NPH in:
T1: 80% of NPH TDD
T2: 80% of NPH TDD
What is the difference between degludec and glargine U-100?
• degludec has less nocturnal hypoglycemia
• degludec has flexible dosing : 8-40 hours (Good for noncompliant patients)
What is the starting dose of degludec in:
- Insulin naive?
- Pt converting from another basal insulin?
Insulin naive: 10 units daily
Another basal insulin: 1:1 conversion given once daily
What time of day do you administer degludec?
When is steady state achieved?
Administer any time of the day with 8 hours b/w doses
Steady state is achieved after 2-3 days
What kind of patients need ultra long acting insulin?
- Anyone that requires basal insulin is a good candidate
- Pts at high risk of hypoglycemia
- Pts experiencing hypoglycemia on NPH
- Pts on 2x/day insulin glargine U-100 or detemir
- Pts who need flexible dosing schedules
- Pts requiring high doses >80 units/day
- Pts who aren't getting 24 hours of coverage
- Obese/ insulin resistant patients
Is Basaglar bioequivalent to Lantus?
But it does have the same pk, safety, and efficacy and comparable A1c lowering ability and potential for weight gain
Who might insulin Lispro U-200 (Humalog Kwikpen U-200) be appropriate for?
Patients who require large mealtime doses
BUT most likely created because they wanted to keep their market share because its bioequivalent to U-100 Lispro
What is the onset, peak, and duration of Humulin R U-500?
onset: 30 minutes
Peak: 1-3 hours
Duration: 8-24 hours
When should you consider prescribing Humulin R U-500?
When the patient is on >200 units of insulin per day
How do you convert someone to U-500 insulin?
If A1c >8%:
- Start with 100% of U-100 TDD
If A1c <8% or mean glucose <183 for the past 7 days:
- Start 80% of U-100 TDD
If given BID:
- 60% w/ breakfast & 40% w/ dinner
If given TID:
- 40% w/ breakfast & 30% w/ lunch and 30% w/ dinner
What are some patient-related barriers to initiating insulin in T2DM?
- Feelings of failure
- Negative impact on social life
- Injection phobia
- Limited training on use
- Inadequate provider education
- Concern over weight gain and hypoglycemia
What are some provider-related barriers to initiating insulin in T2DM?
• Therapeutic/clinical inertia
• Perceived patient reluctance/resistance
• Lack of knowledge/training
How would you overcome patient barriers to insulin?
• Review progressive nature of DM
• Discuss role of insulin at time of dx
• Ask about concerns - dispel misconceptions/myths
• Prescribe thinnest, shortest needle
• Injection tools (i.e. autoshield, Injectase)
• Try pens
• Use rapid acting and ultra-long acting insulins
How would you overcome provider barriers to insulin?
• Multidisciplinary approach to care - refer to Diabetes Self Management Education (DSME) and medical nutritional therapy
• Develop rapport with patient
• Simplify regimens
What are some advantages of early use of insulin?
- Reduce glucose toxicity
- Facilitates beta cell "rest" - preserving function
- Prevent or minimize diabetes related complications
- May protect against endothelial damage
- Overcome patient and clinician barriers
What are some disadvantages to early use of insulin?
- Most studies that show benefit use Multiple daily Injections or Extensive therapy
- Complex instructions
- More healthcare utilization
What is the typical starting dose of insulin in a T1DM pt who is metabolically stable?
- 0.5 units/kg/day
- 1/2 to 2/3 = basal
- 1/3 to 1/2 = bolus (divided among meals)
What is the weight-based dosing for a patient with T1DM?
TDD = 0.4 - 1 unit/kg/day
Do patients with T1DM require basal or bolus coverage?
BOTH! Because pancreatic beta cells are destroyed!
Explain the initiation of basal insulin in Type 2 diabetes
- 10 units/day OR 0.1-0.2 units/kg/day
- 10-15% OR 2-4 units 1-2x/wk to reach FPG goal
If hypoglycemia occurs, determine and address cause
-If no clear cause, decrease dose by 4 units or 10-20%
Explain how to add rapid acting insulin injection before the largest meal in T2DM
- 4 units, 0.1 unit/kg OR 10% of basal dose
- 10-15% or 1-2 units 1-2x/week until target reached
Explain how to change from basal insulin to premixed insulin twice daily (before breakfast and dinner) in T2DM
- Divide current basal dose into 2/3 am, 1/3 pm OR 1/2 am, 1/2 pm
- 10-15% or 1-2 units 1-2x/week until target reached
What would you do if there is FPG dysfunction?
Adjust basal insulin
What do you do if there is pre- or post-prandial dysfunction?
Adjust bolus insulin
What do you do if there is hyperglycemia all day?
"fix the fasting first" - once fasting is fixed you would fix the post prandial from there
How do you adjust bolus insulin?
Titrate 10-15% or 1-2 units 1-2x/week until PPG target reached
How do you adjust basal insulin?
Titrate 10-15% or 2-4 units 1-2x/week until FPG goal
Which insulin would you adjust if the dysfunctional glucose is post-breakfast or before lunch?
Pre-breakfast bolus insulin
Which insulin would you adjust if the dysfunctional glucose is post-lunch or pre-dinner?
Pre-lunch bolus insulin
Which insulin would you adjust if dysfunctional glucose is post-dinner or bedtime?
Pre-dinner bolus insulin
Which insulin would you adjust if dysfunctional glucose is in the early morning?
Basal insulin or PM dose of NPH
How do you switch from NPH to detemir?
1:1 TDD conversion given once daily
How do you convert from NPH to glargine U-100/U-300 or degludec
Once daily NPH - 1:1 conversion given once daily
Twice daily NPH - 80% of TDD given once daily
How do you convert from glargine to detemir?
How do you convert from glargine U-100 OR detemir to glargine U-300 OR degludec
1:1 conversion given once daily
How do you convert form glargine U-100 or detemir to NPH?
1:1 conversion - split NPH into 2 doses BID
Can consider 80% TDD to be conservative
How to convert between bolus insulins (rapid or short acting)?
Watch for meal timing
- rapid-acting insulins are given with meals whereas short-acting insulins (i.e. regular) are given 30 min. before meals
Signs and symptoms of hypoglycemia
- Impaired vision
What is considered hypoglycemia?
BS < 70 mg/Dl
How do you treat hypoglycemia?
Ingestion of quick-acting glucose (not complex carbs)
• Check glucose
• Consume 15g carb (4 oz. or 1/2 cup fruit juice, 1 tbsp sugar, 3-4 sugar tabs, etc.)
• Recheck glucose after 15 min.
• Repeat until glucose normalizes
For severe hypoglycemia (LOC), do not use oral carbs - use glucagon kit
Accumulation of subcutaneous fat deposits - can reduce insulin absorption
May or may not be painful
Usually due to repeated injections at same time OR reuse of needles - rotate sites and use new needles each time
Can also be d/t length/size of needle - use thin and short needles (higher gauge = thinner needle)
What are the various syringe capacities for insulin?
• 1 mL - holds up to 100 units; each line represents 2 unit
• 0.5 mL - holds up to 50 units; each line represents 2 unit
• 0.3 mL - holds up to 30 units; each line represents 1 unit