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pharm
diabetes mellitus pt1
| Question | Answer |
|---|---|
| glucose | the body's main/preferred source of energy |
| insulin | the key that opens the doors of the cells in your body so glucose can enter |
| glucose comes from | foods and drinks consumed the body's stored glucose (glycogen) |
| without insulin what happens | glucose cant get into the cells and instead builds up in the blood. this leads to high blood sugar and diabetes |
| normal beta cells during meals | secrete insulin to prevent the rise of glucose with meals. the insulin levels peak in a few minutes and decrease to baseline within 2-3 hours |
| normal beta cells throughout the day | secrete small amounts of insulin throughout the day and night; while fasting and in between meals, the liver continuously secretes glucose for cellular energy needs |
| routes for exogenous insulin administration | intravenous, subQ, inhaled |
| intravenous exogenous insulin | can be either IV bolus or continuous IV |
| IV bolus insulin | regular insulin is used as an IV bolus to treat Hyperkalemia along with IV dextrose never pushing a bolus of IV insulin by itself! |
| continuous IV insulin infusion | regular insulin is used as a continuous IV infusion to treat DKA or HHS or hyperglycemia in the ICU Needs to be given as a continuous IV because half-life of IV insulin is only 5 minutes |
| SubQ exogenous insulin | can be either intermittent SubQ or continuous SubQ infusion |
| intermittent SubQ insulin injections | (focus of the class) Lots of different insulin formulations, some are basal insulins and some are bolus insulin, some are combinations of both. available as vials or insulin pens |
| continuous SubQ infusion | also known as "insulin pump" therapy Insulin pumps deliver rapid-acting insulin continuously (for basal needs) and as boluses (to cover meals or correct glucose) |
| inhaled exogenous insulin | Afrezza inhaled regular insulin given before meals (not used very often) |
| oral insulin | not effective because it is a protein, and proteins are destroyed by the proteolytic enzymes in the GI tract! |
| "basal" insulin | intermediate-acting or long-acting insulin regulate BGL in between meals by suppressing hepatic glucose production and maintaining near-normal glycemic levels in the fasting state |
| "bolus" insulin | short-acting or rapid-acting insulin used to cover meals (called "prandial" or "mealtime" insulin) also used to cover glycemic excursions ("corrective" insulin) |
| diabetes mellitus | a diverse group of metabolic disorders with the defining feature of elevated blood glucose. also associated with abnormal fat and protein metabolism |
| type 1 diabetes | Beta cell destruction leading to absolute insulin deficiency may lead to DKA, needs a long acting insulin |
| type 2 diabetes | progressive loss of beta cells insulin secretory function accompanied by resistance to insulin action. insulin can't get the glucose into cells. *most common* |
| gestational DM | DM diagnosed in second or third trimester of pregnancy |
| does insulin classify a patient? | no! patients with any form of diabetes may require insulin tx at some stage of their disease. insulin use does not itself classify the pt. |
| T1DM vs T2DM: type ONE | absolute insulin deficiency most often caused by autoimmune destruction of the pancreatic beta cells |
| T1DM vs T2DM: type TWO | Insulin resistance many factors cause high amounts of insulin to produce normal biological response PLUS progressive beta cell failure |
| T1DM vs T2DM: type ONE treatment | exogenous insulin is required ketosis (DKA) will occur in the absence of adequate insulin |
| T1DM vs T2DM: type TWO treatment | usually initiated with diet, exercise, and/or non-insulin agents insulin may be required as early as time of diagnosis |
| drug therapy for glycemic management of T1DM | Basal insulin plus bolus insulin continuous SubQ insulin infusion pump |
| many factors contribute to pathophys. defects in T2DM: the ominous octet | decreased incretin effect impaired insulin secretion ** main one** inc gluc secretion inc hepatic gluc production neurotransmitter dysfunc (not getting 'full' signal) dec gluc uptake inc gluc reabsorption inc lipolysis (breakdown of lipids/protein) |
| the ominous octet factors all cause | hyperglycemia |
| drug therapy for glycemic management of T2DM | -non-insulin medications -basal insulin plus.. -continuous subQ insulin infusion pump |
| t2dm is a... | progressive disease |
| non-insulin medications for T2DM | non-insulin injectables oral non-insulin agents |
| basal insulin for T2DM plus either... | 1 or more non-insulin injectable or oral agents OR bolus insulin |
| Endogenous human insulin | secreted by beta cells in response to stimulation from glucose OR an insulin secretagogue |
| proinsulin: | long single-chain protein molecule, is produced and processed by beta cells of the pancreas where it is hydrolyzed (cleaved) into insulin and a residual connecting segment called c-peptide |
| c-peptide | has no known physiologic function, but it can be measured to provide an estimate of endogenous insulin synthesis and secretion (to determine if type one or type two) |
| insulin: of proinsulin: | small protein containing 51 amino acids arranges in two chains (A and B) linked by disulfide bridges |
| prototype bolus short acting bolus insulin: | regular insulin U-100 humalin R, novolin R "human insulin" '-lin' = human... R for regular |
| prototype bolus short acting bolus insulin: route | regular can be given IV, inhaled, or subQ |
| prototype bolus short acting bolus insulin: onset, peak, duration of SubQ | onset: 30-60 minutes peak: 2-4 hours duration: 6-10 hours |
| prototype bolus short acting bolus insulin: onset, peak, duration of IV | onset: immediately half-life: 5 minutes duration: 20 minutes (quicker than subq) |
| regular insulin needs to be administered... | 30-60 minutes prior to meal |
| prototype basal intermediate-acting basal insulin: | NPH (aka isophane insulin) Humalin N, Novolin N "human insulin" '-lin' = human... N for NPH |
| NPH stands for | neutral protamine Hagedorn it is a cloudy insulin |
| what is NPH made of that makes it cloudy? | a suspension of crystalline zinc insulin combined with the positively charged polypeptide protamine. this gives it a longer duration of action compared to regular insulin. |
| what do we need to do with NPH before administration? | gently mix it before using |
| prototype basal intermediate-acting basal insulin: route | NPH can ONLY be given subQ |
| prototype basal intermediate-acting basal insulin: onset, peak, duration of SubQ | onset: 2-4 hours peak: 6-10 hours duration: 12-18 hours |
| limitations of NPH insulin | Does not mimic the normal physiological basal insulin profile: Variable absorption, pronounced peak, less than 24 hour duration of action... frequent cause of unpredictable hypoglycemia! |
| how are insulin analogs designed? | through DNA recombinant technology to more closely resemble endogenous insulin |
| insulin analogs compared to regular insulin | rapid acting analogs better mimic the faster onset and offset of endogenous insulin secretion |
| insulin analogs compared to NPH | long acting analogs offer longer duration of action, less variability, more predictability, and less risk of hypoglycemia (especially nocturnal) when compared with NPH |
| ex: insulin analog - insulin lispro | Insulin lispro has the addition of lispro amino acid. Compared to regular insulin, B-chain amino acids at positions 28&29 are reversed, specifically to lysine and proline |
| how does this amino acid change effect insulin analog (lispro) | this change results in more rapid SubQ absorption, and more rapid inactivation. This makes the action more physiologic compared to endogenous insulin. |
| prototype bolus Rapid-Acting insulin: | Insulin Lispro: humalog, Lyumjev, Admelog "insulin analog" '-log' = rapid-acting analogs |
| prototype bolus Rapid-Acting insulin: routes | SubQ available in 2 strengths: U-100 and U-200 |
| prototype bolus Rapid-Acting insulin: onset, peak, duration of SubQ | onset: 5-15 minutes peak: 1-2 effects duration: 4-6 hours |
| Rapid-Acting insulin analog, if given IV | if a rapid-acting insulin analog is given IV, it acts like IV regular insulin (immediate onset, 5-minute half-life) |
| Ideal administration for rapid-acting insulin | rapid-acting insulin analogs are ideally given 0-15 minutes before eating, but can be given up to 20 minutes after starting a meal, especially if a person if not a reliable eater |
| advantages of rapid-acting insulin analogs over regular insulin | compared to Regular Human Insulin, the rapid-acting insulin analogs better mimic physiological secretion of endogenous insulin due to meal intake. regular insulin increased risk of hypoglycemia |
| Prototype basal Long-Acting insulin: | Insulin Glargine comes in two different formulations: U-100 and U-300 "insulin analog" |
| Prototype basal Long-Acting insulin: Insulin Glargine U-100 | Lantus, Basaglar |
| Prototype basal Long-Acting insulin: Insulin Glargine U-300 | Toujeo |
| Prototype basal Long-Acting insulin: route | can ONLY be given SubQ |
| Prototype basal Long-Acting insulin: onset, peak, duration of SubQ | onset: 2-4 hours peak: none duration: 20-24 hours |
| insulin Glargine is usually given when? | Glargine is usually given once daily, although some very insulin-sensitive or insulin resistant individuals benefit from split dosing (twice a day, half dose twice) |
| Basal Long-Acting insulin analogs: Glargine VS NPH | the long-acting insulin analogs mimic physiological secretion of endogenous insulin when pt is fasting and in between meals better than NPH |
| pre-mixed insulins: | Basal + Bolus- premixed alternative for pts who require fewer injections or a simpler regimen. However, these productions are limited by their fixed mixed formulations which can make tailoring the dosing regimen challenging. |
| premixed combo basal + bolus insulins | can be either: basal intermediate-acting + bolus short-acting insulin OR basal intermediate-acting + bolus rapid-acting insulin |
| basal intermediate-acting + bolus SHORT-acting insulin | Humulin 70/30 ex: take 40 units 2x/day Mixture of 70% NPH + 30% regular insulin |
| when to administer basal intermediate-acting + bolus SHORT-acting insulin | Administer 30-60 minutes before breakfast and 30-60 minutes before dinner (since it has short acting). |
| basal intermediate-acting + bolus SHORT-acting insulin equivalent to | Each dose is the equivalent of 28 units NHP + 12 units regular. |
| basal intermediate-acting + RAPID-acting insulin | Humalog 75/25 ex: take 40 units 2x/day mixture of 75% lispro protamine (like NPH) + 25% insulin lispro. |
| basal intermediate-acting + RAPID-acting insulin equivalent to | Each dose is the equivalent of 30 units of lispro protamine + 10 units of insulin lispro |
| when to administer basal intermediate-acting + RAPID-acting insulin | administer 0-15 minutes before breakfast and 0-15 minutes before dinner (since has rapid acting) |
| premixed combo basal + bolus insulins are... | cloudy! need to gently mix before use |
| concentration of insulin | the most commonly used insulin concentration is U-100 100 units/mL higher concentrated insulins may be used for pts that need larger doses of insulin to control their diabetes |
| vials of insulin | U100 vials: 1 vial = 10 mL = 1000 units can be draw up in syringe and administered or drawn up and put in insulin patch or pump for subQ |
| insulin pens | U100, U200, or U300 disposable |
| U100 insulin pen | 3mL = 300 units |
| U200 insulin pen | 3 mL = 600 units |
| U300 insulin pen | 3 mL = 900 units |
| 'in use' pen | multiple insulin pens come in each box. take out one pen and leave at room temp. this will be the 'in-use' pen |
| insulin storage- extra pens | store all other pens in the refrigerator when you get home from the pharmacy. insulin pens that are unopened and stored in the fridge are good until expiration date listed on label. |
| insulin storage- done w 'in use' pen | your 'in use' pen will be used for multiple days until it is empty or until it must be discarded. after removal from fridge or after first use, an insulin pen must be discarded after a certain number of days...ask your pharmacist |
| insulin pumps (continuous subQ insulin infusion) | infuses rapid-acting insulin to cover both basal and prandial insulin needs. require significant pt education and support. can come tubed or tubeless (wireless) |
| benefit of insulin pump | insulin pumps can provide more precise glucose control and allow more flexibility and fine-tune tailoring. |
| IV insulin infusions are usually administered when | usually administered in critical care areas of the hospital |
| indications for IV insulin continuous infusion | -hyperglycemia of critical illness -pts with rapidly changing insulin needs -DKA -HHS |
| recall that IV insulin has | short half-life (5-7 minutes) short biological effect (<20 minutes) |
| safe administration of IV insulin | most hospitals have standardized insulin concentration of 1 units/mL. must waste at least 15mL of infusion through new tubing and every time tubing is changed to allow insulin to bind to the plastic tubing |
| typical hospital standardized IV insulin protocol | usually must monitor BGL every hour and adjust IV insulin rate based on current infusion rate and then change the glucose over the past hour |
| what is used in combo to manage T2DM and decrease the 8 factors? | non insulin agents with different mechanisms: |
| factor: decreased incretin effect | GLP1 agonists DPP4 inhibitors |
| factor: impaired insulin secretion | GLP1 agonists meglitinides sulfonylureas TZDs |
| factor: increased glucose secretion | GLP1 agonist |
| factor increased hepatic glucose production | biguanide TZDs |
| factor neurotransmitter dysfunction | GLP1 agonists |
| factor decreased glucose uptake | biguanide TZDs |
| factor increased glucose reabsorption | SGLT2i |
| factor increased lipolysis | TZDs |
Created by:
ago24