PT 1: Diabetes Part 4

What is the "4-Injection" approach in T1DM?

- AM and/or PM basal + bolus TID before (ac) meals - Initially; your total daily dose of insulin should be divided into: 50% basal insulin and 50% bolus insulin (20% pre-breakfast, 15% pre-lunch & 15% pre-supper)

ADA guidelines on basal insulin titrations for patients using the *predictive 303 algorithm* suggest that: - If the 3 day mean FBG <80 mg/dL, insulin should be: - If the 3 day mean FBG ≥ 80 and < 110 mg/dL, insulin should be: - If the 3 day mean FBG ≥ 110 mg/dL, insulin should be:

- Decreased by 3 units - No change - Increased by 3 units

Gestational diabetes should be managed first with lifestyle modifications and medications should only be added if needed. *Gestational targets include: FBG, 1hrPPBG, 2hrPPBG*

- FBG: <95 mg/dL - 1 hour PPBG: <140 mg/dL - 2 hour PPBG: <120 mg/dL

Pre-gestational targets include: *FBG, 1hrPPBG, 2hrPPBG*

- FBG: ≤90 mg/dL - 1hrPPBG: ≤130-140 mg/dL - 2hrPPBG: ≤120 mg/dL

Basal-Bolus Insulin therapy should be given as 50% basal insulin and 50% bolus insulin. What are the 3 options available when splitting bolus insulin?

- Option 1: 38% breakfast, 28% lunch, 33% dinner - Option 2: Even 3-way split - Option 3: Initiate carbohydrate-counting algorithm

Premixed Insulin's:

-Lin: Regular insulin & NPH -Log: Protaminated group & analog

1. Older healthy adults have an A1C target of: A. <7.5% B. <8% C. <8.5% 2. Complex/Intermediate older adults have an A1C target of: A. <7.5% B. <8% C. <8.5% 3. Very complex/poor health older adults have an A1C target of: A. <7.5% B. <8% C. <8.5%

1. A 2. B 3. C *Older healthy adults & complex/intermediate older adults have a BP goal of <140/90 mmHg* *Very complex/poor health older adults have a BP goal of <150/90 mmHg*

Match the following Detemir doses with the appropriate duration: 1. >0.3 units/kg/day 2. 0.2 units/kg/day A. 14-16 hours B. 24 hours

1. B 2. A *Know that Detemir is usually dosed BID if given in low doses; high doses are just once a day*

What are some of the disadvantages of insulin pumps?

1. Cost (expensive) 2. More education/training is required 3. Device malfunction which can lead to dangerously high levels 4. Catheter site infection 5. More frequent self-monitoring of blood glucose (SMBG)

What are some of the advantages of insulin pumps?

1. Fewer hypoglycemia events 2. More flexibility 3. Improved or similar BG control 4. Additional reduction in A1C 5. More "physiologic" insulin 6. Easier for the younger population

ADA guidelines on basal insulin titrations for clinicians suggest that if the 3 day mean FBG <180 mg/dL, insulin should be: A. Increased by 2 units B. Increased by 4 units C. Decreased by 2 units D. Decreased by 4 units

A

Barriers to Insulin Initiation can be clinician-related, health system-related or patient/medication-related. A. True B. False

A

During the honeymoon phase in T1DM patients, insulin dose should be reduced to: A. 0.1-0.4 units/kg/day B. 0.5-1 units/kg/day C. 0.6 units/kg/day

A

Lispro U-200 pen has the same time profile as Lispro U-100 the only advantage U-200 has over U-100 is that it uses smaller volumes of insulin & has few pen changes each month. A. True B. False

A

Match the following description below with the correct insulin self-management procedure: - Individualized per patient - 1:15 for rough estimate (1 unit covers 15 g) - *INCLUDES the 500/450 rule* - Use 450/TDD when using short-acting insulin - Use 500/TDD when using rapid-acting insulin A. Insulin : Carbohydrate ratio B. Insulin sensitivity factor (ISF) C. CHO counting D. Self-adjustment of insulin E. Record keeping

A

Postprandial blood glucose values should ONLY be measured in children/adolescents when there is a discrepancy between pre-prandial blood glucose values and A1C levels and to help assess glycemia in those on basal/bolus regimens. A. True B. False

A

The risk of malformations increases with increasing maternal glycemia during the first 6-8 weeks of gestation. A. True B. False

A

This GLP-1 and Basal insulin combination product has the following description: - Combination of Dugludec and Liraglutide - ONCE daily injection - Administered with or without food A. Xultophy B. Soliqua

A

This diabetic pathophysiology is often identified with a precipitating event such as an infection or lack of insulin administration? A. Diabetic ketoacidosis (DKA) B. Hyperglycemic Hyperosmolar State (HHS)

A

This long acting insulin works by "forming a precipitate in SC tissue delaying absorption (acidic pH)"? A. Glargine/Lantus B. Detemir/Levemir C. Dugludec/Tresiba

A

This test/exam should be performed once a child is >10 years old OR at the start of puberty once they've had T1DM for >3 years and should be followed-up every 1-2 years: A. Comprehensive eye exams B. Blood pressure C. Albumunuria D. Comprehensive foot exam

A

Three-quarters of all cases of type 1 DM are diagnosed in individuals less than 18 years of age. A. True B. False

A

What is the recommended starting basal dose of insulin (long-acting) if your A1C level is <8%? A. 0.1-0.2 units/kg/day B. 0.2-0.3 units/kg/day

A

When transitioning from basal to premixed insulin, take the total daily dose (TDD) of basal insulin & split it into 2/3 breakfast and 1/3 dinner or 1/2 breakfast and 1/2 dinner while titrating 1-2 units (10-15%) until target is reached. A. True B. False

A

Which of the following conditions is characterized by the description below: - Plasma glucose >250 mg/dL - Arterial pH (low) <7.3 - Bicarbonate (low) <15 mEq/L - Moderate ketonuria or ketonemia - Anion gap (high) >12 mEq/L A. Diabetic ketoacidosis (DKA) B. Hyperglycemic Hyperosmolar State (HHS)

A

You normally screen for this disease in T1DM patients immediately after diagnosis and is repeated within 2 years and again within 5 years? A. Celiac disease B. Auto-immune thyroid disease C. Addison's disease D. Myasthenia gravis

A

What is the ADA recommended A1C goal for all pediatric age groups? A. <7.5% B. <8.5% C. <6.5% D. <7.0%

A *Blood glucose goals should be modified in children with frequent hypoglycemia or hypoglycemia unawareness*

It was shown that combination of insulin glargine (long acting) with Exenatide (GLP-1 agonist) lowered A1C significantly compared to insulin glargine alone. A. True B. False

A *Insulin glargine alone was associated with weight gain while insulin glargine + exenatide was associated with weight loss* *Exenatide alone did not lower A1C significantly* *Most significant adverse event was GI: nausea, vomiting & diarrhea*

Preconception counseling should be part of routine clinic visits for women of childbearing age. Retinopathy should be discussed and dilated eye examinations should occur before pregnancy or in the: A. 1st trimester B. 2nd trimester C. 3rd trimester D. Last trimester

A *Micro and Macro vascular complications should be treated & medication regimens evaluated for pregnancy risk*

This effect is characterized by "a hyperglycemia episode" in the middle of the night carried to the morning? A. Dawn phenomenon B. Samogyi effect

A *Treatment is by INCREASING nighttime insulin*

Children/Adolescents with T1DM that have high-normal blood pressure or hypertension should have *elevated BP confirmed on 3 separate days* with a goal of <90th percentile for age, sex and height. A. True B. False

A *Treatment is with an ACEI/ARB*

Which of the following are considered benefits of insulin? *Select all that apply* A. Improved glycemic control B. Decreased microvascular complications C. Improvement of beta-cell function and/or delayed destruction D. Better outcomes post-MI, sepsis and critically ill E. Improved lipid metabolism

ALL!!!

Which of the following are proper recommendations for insulin management? A. Insulin : Carbohydrate ratio B. Insulin sensitivity factor (ISF) C. CHO counting D. Self-adjustment of insulin E. Record keeping

ALL!!!

ADA guidelines on basal insulin titrations for clinicians suggest that if the 3 day mean FBG >180 mg/dL, insulin should be: A. Increased by 2 units B. Increased by 4 units C. Decreased by 2 units D. Decreased by 4 units

B

How often is NPH administered daily? A. Qdaily B. BID C. TID D. QID

B

Match the following description below with the correct insulin self-management procedure: - Correction factor - Expected change of BG per unit of insulin given - 1:30 for rough estimate (1 unit reduces by 30 mg/dL) - *INCLUDES the 1500/1800 rule* - Use 1500/TDD when using short-acting insulin - Use 1800/TDD when using rapid-acting insulin A. Insulin : Carbohydrate ratio B. Insulin sensitivity factor (ISF) C. CHO counting D. Self-adjustment of insulin E. Record keeping

B

This GLP-1 and Basal insulin combination product has the following description: - Combination of Glargine and Lixisenatide - ONCE daily injection - Should be taken 1 hour before the first meal of the day A. Xultophy B. Soliqua

B

This diabetic pathophysiology commonly presents with renal failure and insufficient insulin for prevention of hyperglycemia but sufficient insulin for suppression of lipolysis and ketogenesis (no acidosis)? A. Diabetic ketoacidosis (DKA) B. Hyperglycemic Hyperosmolar State (HHS)

B

This exam/test should be measured at each visit: A. Comprehensive eye exams B. Blood pressure C. Albumunuria D. Comprehensive foot exam

B

This long acting insulin binds to human albumin and the dose is dependent on duration? A. Glargine/Lantus B. Detemir/Levemir C. Dugludec/Tresiba

B

This long acting insulin is available in U-100 and U-200 FlexTouch pens? A. Detemir/Levemir B. Dugludec/Tresiba C. Glargine/Basaglar D. Glargine/Toujeo

B

What is the initial total daily dose (TDD) when initiating basal-bolus therapy? A. 0.2 units/kg/day B. 0.5 units/kg/day C. 12 units daily in the evening D. 6 units with breakfast and 6 units in the evening

B

What is the recommended maintenance dose of insulin in T1DM patients? A. 0.1-0.4 units/kg/day B. 0.5-1 units/kg/day C. 0.6 units/kg/day

B

What is the recommended starting basal dose of insulin (long-acting) if your A1C level is >8%? A. 0.1-0.2 units/kg/day B. 0.2-0.3 units/kg/day

B

Which of the following conditions is characterized by the description below: - Plasma glucose >600 mg/dL - Arterial pH (high) >7.3 - Bicarbonate (high) >15 mEq/L - Minimal ketonuria and ketonemia - Serum osmolality >320 mosm/L A. Diabetic ketoacidosis (DKA) B. Hyperglycemic Hyperosmolar State (HHS)

B

Which of the following insulin's has the longest duration of action? A. Detemir/Levemir B. Dugludec/Tresiba C. Glargine/Toujeo D. Glargine/Lantus E. Insulin NPH

B

Which of the following rapid acting insulin's is available as a "U-200 pen"? A. Insulin Aspart/Novolog B. Insulin Lispro/Humalog C. Insulin Glulisine/Apidra

B

Which of the following should be monitored once a child has T1DM for 5 years? A.Blood pressure B. Albumunuria

B

You always move the injection site by a ______ from the last area. A. Half B. Quarter C. Third

B

What is the recommended general starting therapy by the AACE & ADA as initial approach to initiating insulin therapy in a T2DM patient? A. 4 injection basal-bolus regimen B. Basal insulin plus oral therapy regimen C. Premixed insulin plus/minus oral therapy D. Basal-bolus therapy regimen

B *Basal alone minimizes injections & covers FBG BUT does not cover PPBG --> requires oral agents*

This effect is characterized by "a hypoglycemia episode" in the middle of the night that the body counter-regulates by increasing FBG "rebound hyperglycemia"? A. Dawn phenomenon B. Samogyi effect

B *Treatment is by DECREASING nighttime insulin*

Which of the following are considered insulin regimens in T2DM? *Select all that apply* A. 4 injection basal-bolus regimen B. Basal insulin plus oral therapy regimen C. Premixed insulin plus/minus oral therapy D. Basal-bolus therapy regimen

B, C, D *4 injection basal-bolus regimen is for T1DM*

Rotation of injection site prevents: A. Lipohypertrophy B. Lipoatrophy C. Both A & B

C

What is the recommended starting dose of insulin in T1DM patients? A. 0.1-0.4 units/kg/day B. 0.5-1 units/kg/day C. 0.6 units/kg/day

C

What is the ADA recommended A1C goal for DM patients pre-conception? A. <7.5% B. <8.5% C. <6.5% D. <7.0%

C *As close to normal as possible before attempting conception*

Which of the following types of insulin is "cloudy"? A. Rapid acting insulin B. Short acting insulin C. Intermediate acting insulin D. Long acting insulin

C *Cloudy BUT not CLUMPY*

A patient with consistent mealtimes & lifestyles or an insulin naive patient on an oral anti-diabetic (OAD) with A1C >8.5% should be started on: A. 4 injection basal-bolus regimen B. Basal insulin plus oral therapy regimen C. Premixed insulin plus/minus oral therapy D. Basal-bolus therapy regimen

C *Once daily: minimizes injections BUT requires consistent mealtime consumption/lifestyle --> PPBG not covered* *Twice daily: covers FBG + breakfast & dinner PPBG; requires consistency & fine tuning*

Basal-bolus insulin therapy is recommended as initial therapy for patients: A. Newly diagnosed with A1C >10% B. Insulin naive patients on oral anti-antidiabetics (OAD) with A1C >8.5% C. Both A & B

C *This regimen adds mealtime insulin to basal insulin regimen*

Which of the following components differentiates diabetic ketoacidosis (DKA) from Hyperglycemic Hyperosmolar State (HHS)? *Select all that apply* A. Unchecked gluconeogenesis leading to hyperglycemia B. Osmotic diuresis leading to dehydration C. Unchecked ketogenesis leading to ketosis D. Dissociation of ketone bodies into hydrogen ion and anions leading to anion-gap metabolic acidosis

C & D *A & B occur the same way in both DKA & HHS*

How do you differentiate between a "dawn phenomenon" & a "samogyi effect"?

Check your BG at 3:00 am

*CASE #1* JT is a 35 yo, 5'5", 65 kg female with a history of Type 1 DM. Her current insulin regimen is 8 units NPH and 2 units lispro before breakfast (7:00 am), 2 units lispro before lunch (12 pm), 2 units lispro before supper (6:00 pm) and 4 units NPH at bedtime (10:00 pm). Her blood glucose value (mg/dl) ranges are as follows: Before Breakfast: 100-120 After Lunch: 200-220 After Supper: 120-140 At Bedtime: 130-150 Which of the following would be the most appropriate recommendation? A. Increase before breakfast NPH dose B. Increase bedtime NPH dose C. Increase before breakfast Lispro dose D. Increase before lunch Lispro dose E. Increase bedtime Lispro dose

D

According to ADA guidelines, pregnant women with T1DM and T2DM should begin _______ at the end of their 1st trimester to help lower the risk of preclampsia. A. High dose aspirin B. Low dose tylenol C. Low dose Ibuprophen D. Low dose aspirin

D

Insulin is degraded in the: A. Liver B. Muscle C. Kidney D. All the above

D

Intermediate-Acting insulin is available as: A. NPH B. Humulin N C. Novolin N D. All the above

D

This long acting insulin is available ONLY as a pen with a 1/3 of the injection volume of Lantus (U-300)? A. Detemir/Levemir B. Dugludec/Tresiba C. Glargine/Basaglar D. Glargine/Toujeo

D

This test/exam is performed at the start of puberty or ≥ 10 years old once they've had T1DM for 5 years and should be followed up annually? A. Comprehensive eye exams B. Blood pressure C. Albumunuria D. Comprehensive foot exam

D

This type of insulin comes in U-100 (orange cap) & U-500 (brown cap)? A. Insulin Aspart/Novolog B. Insulin Lispro/Humalog C. Insulin Glulisine/Apidra D. Regular Insulin E. Insulin NPH

D

When starting premixed insulin therapy ONCE daily, which of the following is TRUE? A. Initial dose of 12 units before evening meal B. Titrate every 3 days C. May maintain oral therapy D. All the above

D

When starting premixed insulin therapy TWICE daily, which of the following is TRUE? A. Initial dose of 6 units before breakfast and dinner B. Titrate evening dose to target morning FBG the titrate breakfast dose to meet pre-dinner goals C. Discontinue sulfonylureas D. All the above

D

Which of the following long-acting insulin's fit the description below: - Approved for >17 y/o with T1DM & T2DM - Approved for >6 y/o with T1DM - Available in 100 units/mL *KwikPen* - Biosimilar long-acting insulin A. Glargine/Lantus B. Detemir/Levemir C. Dugludec/Tresiba D. Glargine/Basaglar E. Glargine/Toujeo

D

A newly diagnosed T2DM patient with A1C >10% or an insulin naive patient on oral anti-diabetics (OAD) with A1C >8.5% should be started on: A. 4 injection basal-bolus regimen B. Basal insulin plus oral therapy regimen C. Premixed insulin plus/minus oral therapy D. Basal-bolus therapy regimen

D *Minimizes physiological insulin secretion, multiple injections & requires frequent monitoring*

Which of the following are considered rapid-acting insulin's? A. Insulin Aspart/Novolog B. Insulin Lispro/Humalog C. Insulin Glulisine/Apidra D. All the above

D *Glulisine is a little faster than Lispro or Aspart*

Which of the following types of insulin's are known as "basal insulin's"? A. Rapid acting insulin B. Short acting insulin C. Intermediate acting insulin D. Long acting insulin

D *Immediate acting insulin is also considered basal insulin*

Which of the following is TRUE regarding "insulin approach in T1DM"? A. People with T1DM should be treated with multiple dose injections (3-4 doses per day of basal + prandial) or continuous SubQ insulin infusion. B. People with T1DM should be educated in how to match prandial insulin dose to carbohydrate intake, pre-meal blood glucose & anticipated activity. C. Most people with type 1 diabetes should use insulin analogs to reduce hypoglycemia risk. D. All the above

D *Lantus at bedtime and Aspart/Novolog before meals is an example*

Which of the following medications can be used for gestational diabetes management? A. Insulin B. Metformin C. Sulfonylureas D. All the above *What is the preferred treatment?*

D - Insulin *Most oral agents cross the placenta or lack long term safety data* *Sulfonylureas: inferior to insulin, increased risk of neonatal hypoglycemia and macrosomia*

According to ADA guidelines, screening for pre-diabetes and type 2 diabetes should be performed in children and adolescents who are overweight or obese with at least one or more additional risk factors. These risk factors include: A. Maternal history of T2DM or gestational DM during the child's gestation B. Family history of T2DM in a 1st or 2nd degree relative C. Race/ethnicity (i.e: Native American, African American, Latino, Asian American, Pacific Islander) D. Signs of Insulin resistance or conditions associated with insulin resistance (HTN, dyslipidemia, PCOS) E. All the above

E

Exubra and Afrezza are known as: A. Rapid acting insulin's B. Short acting insulin's C. Intermediate acting insulin's D. Long acting insulin's E. Inhaled insulin's

E

What is the A1C target level in pregnancy due to the alteration in red blood cell turnover (if it can be achieved without significant hypoglycemia)? A. <7.5% B. <8.5% C. <6.5% D. <7.0% E. <6%

E

Which of the following are considered side effects of insulin? A. Hypoglycemia B. Weight gain C. Lipohypertrophy D. Lipoatrophy E. All the above

E

Which of the following is TRUE regarding rapid-acting insulin's? A. Should be administered 0-15 minutes before a meal B. Should be "clear" insulin C. Used as prandial insulin D. Its administered as a subcutaneous insulin infusion E. All the above

E

Which of the following is TRUE regarding short-acting insulin? A. Should be administered 30-45 minutes before meals B. Should be "clear" insulin C. Used as prandial insulin (OTC) D. Its administered as a continuous IV or SubQ insulin infusion E. All the above

E

Which of the following is TRUE regarding the guidelines for starting "basal insulin"? A. Continue oral agents at the same dosage (with sulfonylureas reduced when nearing FBG target) B. Add single dose of basal insulin either at 10-20 units daily or 0.2 units/kg/day C. NPH should be administered at bedtime while glargine/detemir/degludec at bedtime or morning D. Always titrate to goal E. All the above

E

Which of the following factors affect treatment of DM in children and adolescents? A. Family dynamics B. Developmental stages C. Physiological differences related to sexual maturity D. Social/peer pressures E. All the above

E *Assess psychosocial issues and family stresses that could impact adherence to diabetes management*

Screening for auto-immune diseases should be considered shortly after diagnosis of T1DM in children. Which of the following diseases should you screen for? A. Celiac disease B. Auto-immune thyroid disease C. Addison's disease D. Myasthenia gravis E. All the above

E *Celiac, Thyroid & Myasthenia gravis are the most common*

Which of the following are injection site locations for insulin? A. Upper arms B. Anterior and lateral aspects of the thigh C. Buttocks D. Abdomen E. All the above

E *You achieve the best absorption in the abdomen area*

Remember the goals for blood glucose?

FBG: 80-130 mg/dL 1-2hr ppBG: <180 mg/dL

*CASE #2* 38 y/o male presents with insomnia and morning headache. Insulin: 42 units NPH + 18 units Humalog at 7 am 30 units NPH + 10 units Humalog at 6 pm FPG 11 am 5pm HS 300 100 88 75 260 86 120 218 180 70 220 172 289 98 107 142 What do you recommend?

Fixing FBG --> we do this by increasing the basal insulin

Intermediate-Acting Insulin is known as:

Insulin NPH (Neutral Protamine Hagedorn) *Protamine delays the absorption* *Less expensive & available OTC*

What is the onset and peak of intermediate-acting insulin?

Onset: 2-4 hours Peak: 4-10 hours

What is the onset, peak and duration of short acting insulin?

Onset: 30-60 minutes Peak: 2-3 hours Duration: 5-8 hours

What is the onset, peak and duration of rapid acting insulin?

Onset: 5-15 minutes Peak: 30 minutes to 90 minutes (30 min-2hrs) Duration: 5 hours