Insulin therapy

Question 1

What is Intensive Therapy? What is the other name for it?

Answer 1

Matching insulin to food, activity and life events using individualized adjustment guidelines based on glucose results
Basal-bolus

Question 2

what are the components of basal bolus insulin therapy

Answer 2

􏰥 Multiple daily injections (MDI)

􏰥 Continuous subcutaneous insulin infusion

Question 3

Whom is basal-bolus therapy for?

Answer 3

Type 1, Type 1.5 , Type 2, gestational

Question 4

What is type 1.5 diabetes

Answer 4

diabetes that initially presents as t2 but progresses rapidly to require insulin

Question 5

Benefits of intensive therapy

Answer 5

• 45% reduction in microvascular complications associated with type 1 (DCCT)
• 42% risk reduction in any cardiovascular event
• Overall risk (both t1 and t2) of microvascular complications were shown to be decreased by 35%
• Insulin therapy can be integrated into the individual’s preferred lifestyle habits
• Quality of life is improved
• Overall better control

Question 6

Disadvantages of intensive therapy

Answer 6

• more injections-> possible stigmas
• Carbohydrate counting should be part of the deal- Not usually attractive!!
• Frequent monitoring (4x/day) is necessary-> More “homework”
• Should keep in contact with educator
• Weight gain due to :
  tighter control = less glycosuria
  Extra insulin for extra food
  Over treating of reactions e.g. treating low sugar with carbs-> extra calories

Question 7

Define targets for A1C

Answer 7

≤6.5% adults with t2 diabetes o reduce the risk of CKD (chronic kidney disease) and retinopathy if at low risk of hypoglycemia
≤7.0 MOST ADULTS with T1 or T2 diabetes
7.1-8.5 for :
- Functionally dependent 7.1-8.0
- Recurrent severe hypoglycemia and/or hypoglycemia unawareness: 7.1-8.5%
- Limited life expectancy: 7.1-8.5%
- Frail elderly and/or with dementia: 7.1-8.5%

Question 8

What is the upper limit on A1C target table and why

Answer 8

8.5
Values higher than this should be avoided to minimize risk of symptomatic hyperglycemia and acute and chronic complications

Question 9

Values for preprandial PG and 2h postprandial PG to achieve a target A1c of <7% :

Answer 9

preprandial PG: 4.0-7.0 (4.0-5.5 if A1C not at target)*
2h postprandial PG 5.0-10.0 (5.0-8.0 if A1C not at target)*

*To be considered, but balanced against the risk of hypoglycemia- these conditions will help us achieve A1c of <7% faster, but pose a risk of hypoglycemia

Question 10

How does the impact of preprandial PG and 2h postprandial PG on A1C differ depending on the values of A1C

Answer 10

• when A1C is very high (10-9) we first try to target the 2h post-prandial PG as these values have a bigger impact on high A1C
• once A1c gets closer to 7, we start focusing on preprandial PG

the impact of post and pre PG differs depending on where patients A1C is at

Question 11

What is the number 1 killer of people with diabetes?

Answer 11

CVD

Question 12

What is PPG that is out of control a risk factor for? in people with T2. What about T1?

Answer 12

In subjects with type 2 diabetes, there is evidence that PPG is an independent risk factor for myocardial infarction

• > Such an association has yet to be defined for type 1 diabetes…
• But Hyperglycemia can acutely alter normal homeostasis, it is reasonable to hypothesize that this effect will be accentuated in any individual with diabetes.

Question 13

Factors that alter PPG

Answer 13

• meal composition:
  high fat= longer digestion
  high protein = slower digestion
  fiber
• stress, illness, exercises and hormones
• physical activity
• insulin timing
• pre-meal glucose and timing of injection

time of day
- post breakfast is often more difficult

• gastroparesis (delayed gastric emptying)-macrovasuclar complication (decreased gastric motility)

is basal adequate
- if meal is skipped… is BG at target?

Question 14

Which meal is usually the most problematic?

Answer 14

• breakfast- not always, but this is often the case
• breakfast is the largest glycemic spike of the day
• may be due to dawn syndrome

Question 15

When do we recommend to inject rapid-acting insulin?

Answer 15

rapid acting insulin is recommended to be injected 10-15 min before a meal (Nova, Humalog)
- administration of rapid-acting insulin analogs 15 min before mealtime result in lower postprandial glucose excursions and more time spent in the 3.5-10 mmol/l range, without increased risk of hypoglycemia.

Question 16

What is the mean peak time of postprandial glucose
when do rapid-acting insulin analogs display a maximum effect

What can you conclude?

Answer 16

mean peak time of postprandial glucose: 75 min
Rapid-acting insulin analogs display a maximum effect at ~100 min after subcutaneous injection.
The insulin peak action is better synchronized with the glycemic excursions after a meal, thereby potentially minimizing the height of the postprandial glucose excursions.

Question 17

Symptoms of hypoglycemia

Answer 17

􏰥 “Wicked” morning headache
􏰥 “Foggy head”
􏰥 Waking up with messed up blankets
􏰥 Nightmares or vivid dreams

Question 18

What is the chain reaction of hypoglycemia

Answer 18

Having one reaction increases the risk for another!!

􏰥 Second reaction will be harder to recognize due to depleted

Question 19

Why is A1C not always representative of good control

Answer 19

as A1C only represents an average - values can fluctuate a lot, but A1C won’t reflect this fluctuation

tip: ask for log book with blood sugar values

Question 20

What are the components of TDD?

Answer 20

TDD includes both BASAL and BOLUS insulin needs per day

Question 21

What is the ideal split of TDD? Give an example of when that would be different?

Answer 21

Ideally 50% of total dose given as basal insulin and 50% as rapid insulin
e.g. athlete that consumes a lot of food would need more rapid than basal

Question 22

What is the TDD of insulin for t1 adult? in u/kg per day For new onset T1?
What is the average does used per kg? For young adults?

Answer 22

Type 1 adult diabetics require an insulin dosage of 0.3-1.0 u/kg per day
􏰧 New onset Type 1: 0.3 units/kg
􏰧 On average 0.5 - 0.7 u/kg is most commonly used; J Walsh uses 0.53 u/kg for adults*
􏰧 Young adults (age 18-21) “still growing” causing insulin resistance…higher doses required (0.7-1.0 u/kg)

Question 23

Insulin initiation and titration regimens for people with t2

• healthy BW
• overweight
• obese with A1C> 9%

Answer 23

0. 5u: healthy body weight
1. 7u: overweight
2. 0u: obese with A1c>9%

Question 24

is insulin to carb ratio always constant?

Answer 24

no
ratio can change with seasons
ratios are different for different people
Ratios can vary per meal. Strongest ratio usually at breakfast

Question 25

What is insulin to carb ratio

Answer 25

How many grams of CHO are “covered” by 1 unit of insulin

Question 26

What are the 2 ways of estimating insulin to carb ratio

Answer 26

1.a) When TDD (total daily dose) is greater than 40 units total: 500/TDD = 1 unit : _____ g CHO 1.b) When TDD is less than 40 units total: 450/TDD = 1 unit : _____ g CHO 2) Compare with weight requirements formula: (5.7 x wt (kg))/TDD : _____g CHO

Question 27

1:10 and 1:8 insulin to carb ratio | which requires less insulin?

Answer 27

1:10 ratio-> smaller amount of insulin for the same amount of carbs than 1:8 ratio

Question 28

What is sensitivity/correction factor? Why do we need it?

Answer 28

- The drop in mmol/L that each unit of rapid insulin will provide - Useful for correcting glucose once a target is set = better control - Patients should know their ISF, so as to calculate their own correction insulin doses

Question 29

How to calculate sensitivity/correction factor

Answer 29

100/ TDD= ISF (insulin sensitivity factor)

Question 30

example of using ISF | ISF= 3; actual BG= 12 and the target is 6. How many units of insulin do we need to achieve the target?

Answer 30

(12-6)/3= 2 units | aka If ISF = 3, the blood sugar level will be brought down by 3 mmol by 1 unit

Question 31

What is the duration of an insulin dose

Answer 31

about 4h

Question 32

rules of good control

Answer 32

- Check A1c (+ make sure that its the true value as disease states may affect A1C values) - Hypoglycemia ??... when, where and how frequent-> Treat this first!! - Is this a basal insulin or bolus insulin problem?? - Is Basal adequate (how would you know?)-> Check overnight first (bedtime/AM glucose) score should be NO MORE than 2 mmol/L difference with the morning value - Bolus: look at mealtimes 2hr post to evaluate carb ratio-> aim for NO MORE than 3 mmol/l elevation (look at BG 2h before and after the meal) - Any patterns that need solving???

Question 33

What is self-management education?

Answer 33

A systematic intervention that involves active patient participation in self-monitoring of health parameters and/or decision-making. SME should be patient-centered, collaborative and interactive!!!

Question 34

What is sliding scale?

Answer 34

sliding scale refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges. Sliding scale insulin regimens approximate daily insulin requirements. this scheme is more reactive- we wait for BG t go up before giving insulin

Question 35

What does ACB, PCB, ACL, HS stand for

Answer 35

``` ACB- before breakfast PCB- after breakfast ACL- before lunch ACS - before supper HS0 before bed ```

Question 36

When is it a good time to calculate CHO ratio? | e..g 48g CHO and 4 units hUmalog

Answer 36

When blood sugar is in target before a meal and doesn’t rise more than 3 mmol/L at 2hrs post-meal —> good time to calculate CHO ratio. Patient ate 48g CHO and injected 4 units of Humalog 48g ÷ 4 units = CHO ratio of 12 (therefore, 1 unit of Humalog covers 12g of CHOs)