Naplex 2022 Diabetes Part 2 (Insulin and others)
Signs/symptoms of hyperomolar hyperglycemic state?
-confusion, delirium -BG > 600 mg/dL with high serum osmolality > 320 mOsm/L -Extreme dehydration -pH > 7.3, bicarbonate > 25 mEq/L
What are the classic signs of hypoglycemia?
-dizziness -anxiety/irritability -shakiness -headache -diaphoresis (sweating) -hunger -confusion -nausea -ataxia -tremors -palpitations/tachycardia -blurred vision
if using NPH and regular insulin, how should TDD be divided
2/3 of the TDD is given as NPH and 1/3 is given as regular insulin
How many mL does Humulin R U500 comes as?
20 mL
What needles do not require the skin to be pinched when giving insulin?
4 mm and 5 mm needles Best for thinner patients and children
When do you inject rapid acting insulin?
5 - 15 minutes before meals
What is the 50/50 Premixed insulin?
50% lispro protamine/50 % lispro (Humalog Mix 50/50)
What are the 70/30 Premixed Insulins?
70% NPH/30% regular (Humulin 70/30, Novolin 70/30) 70% aspart protamine/30% aspart (Novolog Mix 70/30)
What are the 75/25 Premixed Insulins?
75% lispro protamine/25% lispro (Humalog Mix 75/25)
What insulin needle sizes need the skin to be pinched?
8 mm and 12.7 mm (obese patients)
What is the duration of basal insulins?
> 24 hours
What are the rapid acting (bolus) insulins?
Aspart (Novolog, Fiasp) Lispro (Humalog, Admelog, Lyumjev) Lispro U-200 (Humalog U-200) Insulin Glulisine (Apidra)
Symptoms of Diabetic Ketoacidosis
BG > 250 mg/dL Ketones (urine and serum, fruity breath) -Anion gap acidosis (arterial pH < 7.35, anion gap > 12)
What are Intermediate acting insulins given as?
Basal insulin
What drugs can cause both hypo and hyperglycemia?
Beta blockers, Quinolones and Octreotide
How are premixed insulins given?
Can be given BID (before breakfast and dinner), or sometimes TID (with rapid acting insulins)
How is intermediate acting insulin sometimes used?
Can be used as a basal insulin
What drugs to avoid in diabetes with peripheral neuropathy, PAD, foot ulcers?
Canagliflozin
What drugs to avoid in diabetes with osteopenia/osteoporosis?
Canagliflozin (decreased BMD and fractures) TZDs (fractures)
How does insulin degludec usually come as?
Comes in a vial and a pen Vial is 100 units/mL and pen can come in 100 units/mL and 200 units mL
What drugs to avoid in diabetes with sulfa allergy
Consider avoiding sulfonylureas
What drugs to avoid in diabetes with Pancreatitis?
DPP-4 inhibitors, GLP agonists
What is the ultra long acting insulin?
Degludec (Tresiba)
What do you do when you find the TDD?
Divide the TDD into 50% basal and 50% rapid acting and then split the rapid acting insulin among 3 meals
Contraindications that applies to all insulins
Do not administer during episodes of hypoglycemia
What is the duration of regular insulin?
Duration lasts up to 6 - 10 hours
How do you find the TDD of regular insulin in premixed insulin?
Example Humulin 70/30 is 7-% NPH and 30% regular patient takes 60 units for breakfast and 20 units for dinner Regular dose is 60 units x 0.3 (30%) = 18 unitd Regular dose is 20 units x 0.3= 6 units 18 + 6 units = 24 units TDD
How do you dispense Insulin?
Example- patient takes 35 units of Lantus a day, how many pens would be dispense to provide a 30 day supply 1) calculate total number of units needed: 35 units/day x 3- days = 1,050 units of insulin needed 2) calculate the number of units per pen based on concentrate of insulin: Lantus 100 units/mL x 3 mL per pen = 300 units per pen 3) Calculate the number of pens to be dispensed: 1,050 units/300 units = 3.5 pens round to 4 pens
How do you treat DKA and HHS?
Fluids for all paitents -- start with NS, then when glucose reaches 200 mg/dL, change to D5W1/2 NS Regular insulin infusion-- 0.1 unit/kg bolus, then 0.1 units/kg/hr OR 0.14 units/kg/hr continous infusion Prevent hypokalemia Treat acidosis if pH < 6.9 - can be treated with fluids but can give sodium bicarbonate if needed
What drugs to avoid in diabetes with gastroparesis or GI disorders?
GLP-agonists, pramlintide
What insulins are stable at room temp for 10 days?
Humalog 50/50 and 75/25 pens (rapid acting mix) Humulin 70/30 pen (regular/NPH)
what rapid acting insulin comes concentrated?
Humalog Kwikpen Lyumjev Kwikpen (lispro) Come as 200 units/mL
What insulins are stable at room temp for 14 days?
Humulin N pen (intermediate insulin) Novolog Mix 70/30 pen (rapid acting mix)
What insulins are stable at room temp for 31 days?
Humulin R U-100, N and 70/30 vials
What insulin is stable at room temp for 40 days?
Humulin R U-500 Vial
what regular insulin comes concentrated?
Humulin R U-500 pen and vial: 500 units/mL
What is the warnings for all insulin?
Hypoglycemia and Hypokalemia
what does ICR indicate?
ICR indicates the grams of carbohydrates covered by 1 units of insulin
What is regular insulin preferred for?
IV infusions, including PN
When can the intermediate insulin dose be split?
If patient has nocturnal hypoglycemia, the dose can be split (2/3 QAM and 1/3 QHS)
How do you adjust mealtime insulin if the postprandial BG is high or low?
If the postprandial BG is high or low following the same meal on most days The regular or rapid acting insulin taken prior to that meal should be either increased for high BG or decreased for low BG
Where must IV regular insulin be prepared?
In Non-PVC container
What insulins are stable at room temp for 42 days?
Novolin R-U 100, N, and 70/30 vials Levemir vial and pen
What is the onset of regular insulin?
Onset of 30 minutes
What is the onset of rapid acting insulin?
Onset of ~15 minutes
What is the P in NPH?
P stands for protamine
What is the peak of regular insulin?
Peaks at ~2 hours
What drugs to avoid in diabetes with cancer?
Pioglitazone (bladder) GLP-agonists (thyroid)
How do you convert from NPH insulin BID to insulin glargine dosed daily?
Use 80% of the NPH dose Example NPH 30 units breakast and 20 units dinner = 50 units NPH daily 50 x 0.8 = 40 units daily
How do you conver from Toujeo to insulin glargine or insulin detemir?
Use 80% of the Toujeo dose
What is rapid acting insulin used for?
Used as prandial insulin (prevent high BG from a meal) and for correction doses when BG is high (often by sliding scale)
What is short acting insulin used as?
Used as prandial insulin and for correction doses
When is insulin recommended in type 2 diabetes?
Usually if a patient is type 2 diabetic, a glp agonist is preferred But if the patient is already on one or the A1C > 10% or BG > 300 mg/dL, then you can given Insulin
Side Effects for All Insulins?
Weight gain and Lipoatrophy
What is diabetic ketoacidosis?
a life threatening crisis with - *high BG* - *ketoacidosis* - *ketouria* DKA is most common in *type 1* but can occur in type 2
What are the Long-Acting (Basal) Insulins?
glargine (Lantus, Toujeo, Basaglar, Semglee) detemir (Levemir)
What does protamine do in NPH insulin?
helps to delay absorption/extend the duration of effect
how to adjust basal insulin for fasting BG
if Low BG trend: ↓ the basal or NPH dose If High BG trend: ↑ the basal or NPH dose
How do you adjust mealtime insulin if the preprandial BG is high or low?
if the preprandial BG is high or low before the same meal (like lunch) on most days The regular or rapid acting insulin dose taken before the previous meal (breakfast) should be either increased for high BG or decreased for low BG
Basal and rapid-acting insulins are called _____
insulin analogs When basal insulin is used with mealtime rapid-acting insulin, the profile is analogous (similar) to the natural pattern of insulin secretion from the pancreas
What is the onset of intermediate acting insulin?
onset of 1-2 hours
What is the onset of basal insulins?
onset of 3 - 4 hours
What is the peak of rapid acting insulin?
peak in 1 - 2 hours
What is the peak for intermediate acting insulin?
peaks at 4-12 hours
What insulins are preferred in type 1 diabetes?
rapid acting and long acting basal insulins are preferred
What do basal insulins impact?
fasting glucose
What can you give that has 15 grams of simple carbs for Rule 15
-4 ounces (1/2 cup) of juice - 8 ounces (1 cup) milk - 4 ounce regular soda - 1 tablespoon sugar, honey or corn syrup - 3 to 4 glucose tables or 1 serving of glucose gel
What insulins are stable at room temp for 28 days?
-Aprida, Humalog, Novolog, Admelog, Lyumjev, Fiasp vials and pens -Humalog Mix 50/50 and 75/25 vials -Novolog Mix 70/30 vial -Novolin R u-100, N and 70/30 pen -Humulin R U-500 pen -Lantus, Basaglar, Semglee vials and pens
What drugs can cause hyperglycemia?
-Beta blockers -Thiazide & loop diuretics -Tacrolimus, Cyclosporine -Protease Inhbitors -Quinolones -Antipsychotics (olanzapine, quetiapine) -Statins -Steroids (systemic) -Cough syrups -Niacin others: Azole antifungals, beta-agonists, octreotide
What insulins are Basal Insulins?
-Glargine -Detemir -Ultra long acting degludec
What is hyperosmolar hyperglycemic state?
-Insulin deficiency resulting in dehydration and HYPERosmolarity -Extremely high blood sugars Primary case is illness (infection, stroke)
What drugs can cause hypoglycemia?
-insulin and sulfonylureas -GLP agonists, DPP4, TZDs and SGLT2 have low risj but increased with used in combo with insulin -Alcohol can increased hypoglycemia when used with insulin or SU -Beta blockers if non-selective can cause hypoglycemia and can mask symptoms of hypoglycemia (shakiness, palpiations, anxiety), not sweating or hunger
What is the typical starting dose for T1D?
0.5 units/kg/day
What is the correction factor for regular insulin?
1,500 Rule
What is the correction factor for rapid acting insulin?
1,800 rule
how many mLs do insulin vials come as?
10 mL
What rapid acting insulin is contraindicated in COPD or Asthma patients?
Inhaled insulin (Afrezza)
If the premixed insulin contains rapid acting insulin, how should it be administered?
Inject 15 minutes before a meal
If the premixed insulin contains regular insulin, how should it be administered?
Inject 30 minutes before a meal
When do you administer short acting insulin?
Inject 30 minutes before a meal
How are long-acting insulins administered?
Injected Once dailu Detemir may be given twice daily
What drugs to avoid in diabetes with hypokalemia
Insulin
What is the intermediate acting insulin?
Insulin NPH
What is rapid acting insulin?
Insulin aspart Insulin lispro Insulin glulisine
What drugs to avoid in diabetes with hypoglycemia?
Insulin, SU, meglitinides and pramlintide
What can you do when blood glucose is higher than targeted range?
It can be corrected with a bolus called a correction dose
How is short acting similar to rapid acting insulin?
It can be given as a bolus at mealtimes like rapid acting insulin
What else does protamine come as?
It can come as lispro-protamine and aspart protamine which has the same onset, peak and duration as NPH These come in premixed solutions only and are combined with the standard rapid acting insulin
What is regular U-500 insulin?
It is a concentrated insulin Onset is similar to regular U-100, but duration can last up to 24 hours
What is different about Toujeo insulin?
It is a concentrated insulin with 300 units/mL
What makes insulin a "high-alert" drug?
It is a high alert drug due to human errors, such as misreading measurements, using the wrong insulin type strength, dose or frequency and skipping meals
Insulin is a high alert what?
It is a high alert medication, which means it has a high risk of causing patient harm and requires extra care during handling and administration.
What is Inhaled insulin?
It is a mealtime insulin
What is different with Humulin R U-500
It is five times as concentrated
What drugs to avoid in diabetes with renal insufficiency (eGFR or CrCl < 30)?
Metformin, SGLT2 inhibitors, exenatide, glyburide
What drugs to avoid in diabetes with lactic acidois?
Metformin, increase risk with renal impairment, alcoholism, hypoxia
What must be prescribed with Humulin R U-500 insulin?
Must be prescribed U-500 insulin syringes
What are the intermediate-acting (basal) insulins?
NPH (Humulin N, Novolin N)
What is rapid acting insulin preferred for?
Preferred for insulin pumps
What part of the finger do you use to check blood glucose?
Prick side of finger as its less painful
What insulin is used for sliding scale?
Rapid acting is preferred or regular insulin
When is HumuLIN R U-500 used?
Recommended only when patients require > 200 units of insulin per day
What are the Short-acting (Bolus) insulins?
Regular (Humulin R, Novolin R) Other- Concentrated Regular (Humulin R U-500)
What is the short acting insulin?
Regular insulin
How are NPH and regular (or rapid acting insulins) mixed?
Regular or Rapid Acting Insulin is clear and drawn up in the syringe first and then the NPH is drawn second because its cloudy
What long acting insulins come concentrated?
Tresiba Flextouch: 200 units Toujeo: 300 units/mL
What insulins are stable at room temp for 56 days?
Tresiba pen Toujeo pen
How is Regular U-500 insulin often dosed?
Twice daily or TID before meals
What is the treatment for hypoglycemia when patient is conscious and able to swallow?
Rule of 15 1. take 15 - 20 grams of glucose or simple carbohydrates 2. Recheck BG after 15 minutes 3. If hypoglycemia continues, repeat steps 1 and 2 4. Once BG is normal, eat a small snack or meal
What ICR formula is used for Regular Insulin?
Rule of 450
What ICR formula is used for Rapid acting Insulin?
Rule of 500
What drugs to avoid in diabetes with UTI?
SGLT2 inhibitors
What drugs to avoid in diabetes with ketoacidosis?
SGLT2 inhibitors (can occur when BG < 250 mg/dL)
What drugs to avoid in diabetes with hypotension/dehydration?
SGLT2 inhibitors.....
What drugs to avoid in diabetes with weight gain/obesity?
SUs, meglitinides, TZDs, insulin
How is intermediate acting insulin typically dosed?
Sometimes dosed twice daily
What drugs to avoid in diabetes with hepatotoxicity?
TZDs, alogliptin
What drugs to avoid in diabetes with heart failure patients?
TZDs, alogliptin, saxagliptin
How do you calculate the bolus dose of each meal?
The bolus dose is calculated with the insulin to carbohydrate ratio (ICR)
What does the thickness for the gauge mean?
The higher the gauge, the thinner the needle
How are rapid acting insulines provided?
These provide a bolus dose, similar to the pancreas releasing a burst of insulin in response to food
What is special about the basal insulins?
They are peakless
What weight is used for dosing insulin?
Total body weight
What is the treatment for hypoglycemia if the patient is unconscious?
Treat with dextrose if there is IV access or with glucagon injection
What drugs can decrease blood glucose?
beta blockers quinolones tramadol Others: Linezolid, Octreotide, Pentamidine, Quinine
What are the severe symptoms of hypoglycemia?
coma, seizures, death
What is the duration of rapid acting insulin?
duration is 3 - 5 hours (gone by the next meal)
What is hypoglycemia?
defined as BG < 70 mg/dL
What is the unpredictable duration of intermediate acting insulin?
duration of action (14 -24 hours)