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.
TRUE!
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
TRUE or FALSE
By combining insulin w/a protein, the effect of insulin is prolonged.
TRUE
Name two rapid acting insulins
Insulin Lispro (Humalog)
Insulin Glulisine (Apidra)
What is the onset of rapid acting insulin?
Insulin Lispro (Humalog) <15min
Insulin Glulisine (Apidra) 10-15min
**must have food in sight**
When does rapid acting insulin peak?
Insulin Lispro (Humalog) 30-90min
Insulin Glulisine (Apidra) 30-90min
What is the duration of rapid acting insulin?
Insulin Lispro (Humalog) <5hrs
Insulin Glulisine (Apidra) < 3hrs
What are two NPH insulins (intermediate)?
Humulin N
Novolin N*
What is the onset of NPH insulin (intermediate)?
Humulin N 2-4hrs
Novolin N* 90min
What is the peak of NPH insulins (intermediate)?
Humulin N 4-10hrs
Novolin N* 4-12 hrs
(need to eat regularly!)
What is the duration of action for NPH insulin (intermediate)?
Humulin N 14-18hrs
Novolin N* up to 24 hrs
What are the two peakles basal insulins (long acting)?
Lantus (Glargine)
Levemir (Detemir)
What is the onset of action for the two peakless basal insulins (long acting)?
Lantus (Glargine) 1-4hr
Levemir (Detemir) 1-4hr
What is the duration of action for the peakless basal insulins (long acting)?
Lantus (Glargine) 24hr
Levemir (Detemir) 12- 24hr
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
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
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.
TRUE or FALSE
The Best guess method is not as precise but often works well as basis for pre-meal insulin dosing.
TRUE
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
What is the only CLOUDY insulin?
NPH intermediate acting
Novolin N and Humulin N
TRUE or FALSE
Insulin Determir (Levemir) does not usually last full 24hrs when compared to Lantus.
TRUE
Never mix ______ with any other insulin in the same syringe!
Lantus or Levemir (longer acting!)
How often is Lantus (Insulin glargine) given?
Once a day! lasts 24 hrs
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
What drugs could interact with insulin and cause a hypoglycemia?
Oral hypoglycemics
Beta Blockers (and could mask effect & impair glycogenolysis-worsens hypoglycemia)
Alcohol
What drugs could interact with insulin and cause hyperglycemia?
Thiazide diuretics
Glucocorticoids
Sympathemimetics
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
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
Insulin can cause hypoglycemia so the patient should carry ____ with them at all times.
15gm of carbs
How do you avoid lipodystrophies from insulin?
rotate sites to avoid hard lumps
TRUE or FALSE
Allergic reactions are rare. Could be syringe or insulin & best to send to allergist.
TRUE
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
TRUE or FALSE
Oral Diabetic Agents can be used in Type 1 or Type 2 diabetes.
FALSE! Type 2 only!!
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.
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
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
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
Name three Sulfonylureas
Glipizide (Glucotrol)
Glyburide (micronase)
Glimepride (Amaryl)
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
How much can Sulfonylureas decrease the A1C?
1-2%!!!!
Name two side effects of Sulfonylureas
Hypoglycemia
Weight gain
Drug interactions are rare w/Sulfonylureas but what are they?
NSAIDs, Sulfa abx, alcohol, cimetidine (Tagamet)
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!
Name an example of Biguanide
Metformin (Glucophage, glucophage XR)
it's the most generic cost effective one
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
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!)
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
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!
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.
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!
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
TRUE or FALSE
Sulfonylureas can cause weight loss
FALSE! They cause weight GAIN! (as if a DM needed to gain weight!)
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%
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)
If your A1C is greater than ___%, you have diabetes!
6.5%
Prediabetes is an A1C of ____%
5.7 to 6.4%
What is the pre-prandial plasma glucose goal of diabetes treatment?
90-130 mg/dL
What is the peak postprandial plasma glucose goal of diabetes treatment?
<180 mg/dL
During pregnancy, you want tighter control of blood sugar and a level of _____ pre and post prandial
<90
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
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!
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)
