1. TRUE or FALSE
    Commercial insulin does not contain C-peptide loop of insulin so the C-peptide in the blood can be used as test to see if patient is making their own insulin.
  2. Describe the body's normal basil/bolus insulin requirement.
    • The body produces insulin all day long, then produces an additional bolus in response to eating. 
    • Basil = 50% of daily insulin
    • Bolus = 50% of daily insulin
  3. TRUE or FALSE
    By combining insulin w/a protein, the effect of insulin is prolonged.
  4. Name two rapid acting insulins
    • Insulin Lispro (Humalog)
    • Insulin Glulisine (Apidra)
  5. What is the onset of rapid acting insulin?
    • Insulin Lispro (Humalog) <15min
    • Insulin Glulisine (Apidra) 10-15min

    **must have food in sight**
  6. When does rapid acting insulin peak?
    • Insulin Lispro (Humalog) 30-90min
    • Insulin Glulisine (Apidra) 30-90min
  7. What is the duration of rapid acting insulin?
    • Insulin Lispro (Humalog) <5hrs
    • Insulin Glulisine (Apidra) < 3hrs
  8. What are two NPH insulins (intermediate)?
    • Humulin N
    • Novolin N*
  9. What is the onset of NPH insulin (intermediate)?
    • Humulin N 2-4hrs
    • Novolin N* 90min
  10. What is the peak of NPH insulins (intermediate)?
    • Humulin N 4-10hrs
    • Novolin N* 4-12 hrs 

    (need to eat regularly!)
  11. What is the duration of action for NPH insulin (intermediate)?
    • Humulin N 14-18hrs
    • Novolin N* up to 24 hrs
  12. What are the two peakles basal insulins (long acting)?
    • Lantus (Glargine)
    • Levemir (Detemir)
  13. What is the onset of action for the two peakless basal insulins (long acting)?
    • Lantus (Glargine) 1-4hr
    • Levemir (Detemir) 1-4hr
  14. What is the duration of action for the peakless basal insulins (long acting)?
    • Lantus (Glargine) 24hr
    • Levemir (Detemir) 12- 24hr
  15. What kind of insulin comes in an amazing pen that insurance won't cover?
    • Rapid acting (insulin lispro or insulin glulisine).
    • Pen is good for 30days and travels well

    Levemir (intermediate/long acting) can also come in vial or pen form
  16. What is the most precise way to figure out PRE-MEAL insulin dose (where you would give a rapid acting insulin)?
    Carbohydrate counting is the most precise match of insulin to carbs
  17. Tell me about the pre-meal insulin SCALE.
    Take BS and base insulin dose on current BS.

    It's not precise because it doesn't account for the number of carbs about to be consumed.  but it's good until a patient can meet with a diabetic educator.
  18. TRUE or FALSE
    The Best guess method is not as precise but often works well as basis for pre-meal insulin dosing.
  19. Why doesn't nancy like intermediate acting NPH insuin?
    It doesn't mimic the body's schedule but it's only given 2x/day so patient's like it
  20. What is the only CLOUDY insulin?
    • NPH intermediate acting
    • Novolin N and Humulin N
  21. TRUE or FALSE
    Insulin Determir (Levemir) does not usually last full 24hrs when compared to Lantus.
  22. Never mix ______ with any other insulin in the same syringe!
    Lantus or Levemir (longer acting!)
  23. How often is Lantus (Insulin glargine) given?
    Once a day! lasts 24 hrs
  24. When should you give Lantus (Insulin glargine)?
    • Best if given at night.
    • Can use fasting AM blood sugar to track effectiveness. 
    • Increase by 2units Qday based on AM BS until pt gets BS <140 in the morning
  25. What drugs could interact with insulin and cause a hypoglycemia?
    • Oral hypoglycemics
    • Beta Blockers (and could mask effect & impair glycogenolysis-worsens hypoglycemia)
    • Alcohol
  26. What drugs could interact with insulin and cause hyperglycemia?
    • Thiazide diuretics
    • Glucocorticoids
    • Sympathemimetics
  27. So nancy hates NPH insulin because it is'nt physiological and it makes it hard to reach A1C goal of <7%....but if you do use it, when do you schedule it?
    Conventional dosing at breakfast and dinner
  28. What is the intensive insulin dosing schedule?
    • 3 mealtime injections of rapid acting insulin and 1 lantus/levemir injection.
    • Easier to reach A1C goal
    • BUT it's TOO COMPLEX and many patient's don't want 4 injections/day
  29. Insulin can cause hypoglycemia so the patient should carry ____ with them at all times.
    15gm of carbs
  30. How do you avoid lipodystrophies from insulin?
    rotate sites to avoid hard lumps
  31. TRUE or FALSE
    Allergic reactions are rare. Could be syringe or insulin & best to send to allergist.
  32. Bob overdoses on insulin, he's now UNCONSCIOUS !! What kind of kit do you treat with and how does it work?
    Glucagon Emergency Treatment kit

    • MOA: Polypeptide hormone produced by alpha cells of the pancreas
    • Promotes the breakdown of glycogen to glucose & reduces the conversion of glucose to glycogen, and stimulates the synthesis of glucose
  33. TRUE or FALSE
    Oral Diabetic Agents can be used in Type 1 or Type 2 diabetes.
    FALSE! Type 2 only!!
  34. TRUE or FALSE
    If often takes multiple drugs to treat Type 2 diabetes
    TRUE. There are multiple physiological mechanisms occurring and by the time they are diagnosed, 50% of Beta cells are not working.
  35. What do we mean when we say insulin resistance?
    Cell wall is resistant to own or supplemental insulin. Doesn't open proper channels to allow glucose into the cell
  36. Why could a patient's insulin be higher in the morning then when they went to bed (and they didn't eat at night!)?
    the liver produces glucose all night long...called gluconeogenesis
  37. TRUE or FALSE
    Sulfonylureas will work even if the pancreas isn't producing insulin.
    FALSE! They are dependent on the pancreas ability to secrete insulin
  38. Name three Sulfonylureas
    • Glipizide (Glucotrol)
    • Glyburide (micronase)
    • Glimepride (Amaryl)
  39. How do Sulfonylureas work?
    Block ATP-sensitive K+ channels on the Beta cells (from islet of langerhans) which facilitates the calcium influx. This leads to insulin release
  40. How much can Sulfonylureas decrease the A1C?
  41. Name two side effects of Sulfonylureas
    • Hypoglycemia
    • Weight gain
  42. Drug interactions are rare w/Sulfonylureas but what are they?
    NSAIDs, Sulfa abx, alcohol, cimetidine (Tagamet)
  43. Cindy has renal (or hepatic) failure and you need to prescribe a sulfonylurea, why should you use caution?
    It won't clear from blood stream as well so there will be a prolonged action time and cause HYPOGLYCEMIA with next dose!
  44. Name an example of Biguanide
    • Metformin (Glucophage, glucophage XR) 
    • it's the most generic cost effective one
  45. How do Biguanide's (Metformin) work?
    • they decrease glucose production by liver and increase glucose uptake by muscle
    • Suppress Glugoneogenesis
    • **DOES NOT cause hypoglycemia or increased insulin production
  46. Biguanide (metformin) has side effects that require starting slow and going slow....name the side effects!
    GI: diarrhea and flatulence (titrate up and take 4 weeks to reach maintenance dose) Do 500, then 500 BID, then500 AM/1000 PM, then 1000 BID

    Inhibits mitochondrial oxidation of lactic acid (leads to lactic acidosis!)
  47. TRUE or FALSE
    Biguanides (Metformin) contraindicated in pt's with renal insufficiency
    • TRUE!
    • Do not give to those with renal insufficiency, CHF, or IV contrast dye (or in patient's at risk of lactic acidosis)
    • MUST monitor Cr level
  48. TRUE or FALSE
    It's ok to give Biguanide (Metformin) to a patient with severe dehydration, alcholism, or severe liver disease.
    FALSE! Avoid giving it to these patients!
  49. What's great about Incretin Hormones (Sitagliptin) for DM treatment?
    They are PO & taken 1x/day (good compliance) and they are well tolerated (few SE)

    but they are expensive (not generic) and do NOT lower A1C as well as the others.
  50. How do incretin hormones (Sitagliptin) work?
    • Stimulate glucose dependent release of insulin (insulin is released when carbs are eaten)
    • Suppresses postprandial release of glucagon from liver (by blocking DPP4, an enzyme that inactivates increntin hormones) which allows increntin hormones to work better!
  51. TRUE or FALSE
    Metformin is the cornerstone of pharmacologic treatment for DM
    TRUE! It does not cause hypoglycemia, weight loss, & it's generic (cheap!....

    but remember contraindicated in renal/liver disease or those that are predisposed to lactic acidosis--& GI SE
  52. TRUE or FALSE
    Sulfonylureas can cause weight loss
    FALSE! They cause weight GAIN! (as if a DM needed to gain weight!)
  53. As an advanced practice nurse, reaching a target A1C of ____ is very important. As my old basketball coach would say, BE AGGRESSIVE!
    < 6.5-7%
  54. Too diagnosis diabetes, you have fasting glucose ≥ ___mg/dL or a plasma glucose concentration ≥ ____mg/dL.
    • fasting glucose more than 126
    • plasma glucose concentration more than 200
    •  (or 2 hr post load glucose tolerance test of more than 200)
  55. If your A1C is greater than ___%, you have diabetes!
  56. Prediabetes is an A1C of ____%
    5.7 to 6.4%
  57. What is the pre-prandial plasma glucose goal of diabetes treatment?
    90-130 mg/dL
  58. What is the peak postprandial plasma glucose goal of diabetes treatment?
    <180 mg/dL
  59. During pregnancy, you want tighter control of blood sugar and a level of _____ pre and post prandial
  60. Rick's A1C is 6.5-7.5%, what is the treatment algorithm and how often do you make changes?
    • Make change Q3M (do not delay!)
    • Monotherapy (Metformin 1st line agent)
    • Dual therapy (Metformin + GLP-1, DPP4, glinide, or sulfonylurea)
    • Triple therapy (Metformin, +GLP-1 or DPP4, + TZD, glinide, or sulfonylurea)
    • Insulin therapy
  61. After a year of trying oral agents, Rick's insulin secretory capacity of his beta cells has been exceeded and he must start insulin therapy. What should be discontinued?
    • Sulfonylureas and glinides should be discontinued.
    • Exenatide and DPP4 inhibitors can not be used with insulin.
    • Metformin is best drug to combine with insulin!
  62. Joe has an A1C of 7.6-9% (wow!). What is the treatment algorithm and how often would you change tx?
    • Change tx Q3M if not working.
    • Start with dual therapy (Metformin + GLP1, DPP4, TZD, sulfonylurea, or glinide)
    • Triple therapy ( Metoformin + GLP1, DPP4, + TZD, sulfonylurea)
    • Insulin therapy: DC all oral meds except metformin
Card Set
diabetes....Nancy's specialty!