Basal Component
Homeostatic glucose release by liver
Increased nocturnal glucose release (dawn phenomenon)
Bolus (Prandial) Component
Elevated glucose (PP& excursions)
Short Acting Insulin Products
Aspart
Glulisine
Lispro
Regular
Aspart Brand Name
Novolog
Glulisine Brand Name
Apidra
Lispro Brand Name
Humalog
Aspart Onset and Duration
O: 5-15 min
D: 3-5 hr
Glulisine Onset and Duration
O: 5-15 min
D: 3-5 hrs
Lispro Onset and Duration
O: 15-20 min
D: 4-5 hr
Regular Onset and Duration
O: 30-60 min
D: 4-8 hr
Longer Acting Insulin
Detemir
Glargine
NPH
Detemir Brand Name
Levemir
Glargine Brand Name
Lantus
Detemir Onset and Duration
O: 2 hr
D: 20-24+ hr
Glargine Onset and Duration
O: 1-2 hr
D: 10-24 hr
NPH Onset and Duration
O: 1-2 hr
D: 10-16 hr
When do you use once daily insulin?
When oral meds fail and you need more (add to)
When do you 2+ injections daily/mutliple types of insulin?
Contraindication to oral meds
High baseline FBG or A1c
Once daily insulin
As second or third agent when A1c >9%
Oral agent failure
Continue oral +/- SU
Once daily insulin starting dose
0.1-0.25 u/kg (0.3-0.4 for increased BG)
6-10u elderly/thin
Then titrate up a little at a time
Short acting insulin pealrs
Lower PP (bolus) Timing before meals is important Rapid acting preferred over regular (unless picky eaters)
NPH pearls
Cloudy
Can be mixed
Glargine pearls
Improved glucose control Decrease hypoglycemic events Low does = BID Cannot be mixed Acidic so can burn
Detemir pearls
Dose dependent duration of action
Less weight gain
Decreased hypoglycemia
Binds to albumins
Advantages to Two Daily Injections
Easier to learn the MDI
Cheaper
No shots at school
Less chances of forgeting
Disadvantages to Two Daily Injections
Requires meals to be at certain times Requires constant carb intake Snacks needed Overnight hypoglycemia risk Difficult to achieve treatment goals
Advantages to Three Daily Injections
Decrease risk for overnight hypo
Less than four injections
Better control of Dawn Phenomenon
Disdvantages to Three Daily Injections
Require meals to be at certain times Requires constant carb intake Snack needed More than 2 injections Difficult to achieve treatment goals
Advantages to Four Daily Injections
Meal times, carb intake can vary
Less insulin overlap
Best option for blood glucose control
Disadvantages to Four Daily Injections
Multiple injections each day
Difficult for some to do math
More costly
Consideration for selecting a regimen?
ADA recommend basal-bolus Daily schedule Activity level Meal and snack intake Education level Pt preference Insurance
Total Daily Dose for Type 1
Initially 0.3-0.5 u/kg/d
Use the amount of insulin required per day to obtain blood sugar control from hospital
Total Daily Dose for Type 2
Initially 0.2-0.6 u/kg/d
NPH regimen
Give 2/3 of total daily dose in the morning (2/3 NPH, 1/3 rapid)
Give 1/3 of total daily dose in the evening (2/3 NPH, 1/3 rapid or 50/50)
Basal-Bolus Dosing
Basal: 40-60% of total daily dose
Bolus: divide the remaining between meals or use insulin to carb ratio with insulin sensitivity factor
Carb counting
Helps pts with diabetes plan meals
Allows for better blood glucose control
Regardless of type, pts should be away
Carb Exchange System
Estimates the number of grams of carbs contained in a product based on a common exchange (15g)
Carb Gram Counting
Counts the exact number of grams of carbs contained in a product
Insuling to Carb ratio
The amount, in grams of carbs, that is covered by 1 unit of insulin
Used to calculate bolus
Insulin Sensitivity Factor
The amount of reduction in blood glucose per 1 unit of insulin
Flexible dosing
Dosing technique that allows patient to adjust short acting insulin dose based on predicted needs
Offers proactive adjustments
Gives pt more control and freedom
I:CHO Rule
Rule of 500
500/total daily insulin dose = grams covered by 1 unit of short acting insuline
ISF Rule
Rule of 1800
1800/total daily insulin dose = mg/dl covered by 1 unit of rapid acting insulin
(1500 for regular)
Goals of Management
Maintain daily ranges so as not to inhibit ADL’s
Prevent te occurrence and/or progression of longterm macro/microvascular complications
Prevent acute complications
Control other comorbidities
Incorporate and foster self-management
Type 1 <6 yrs Goal BG and A1c
Fasting: 100-180
Bedtime: 110-200
A1c 7.5-8.5%
Type 1 6-12 yrs Goal BG and A1c
Fasting: 90-180
Bedtime: 100-180
A1c <8%
Type 1 13-19 yrs
Fasting 90-130
Bedtime 90-150
A1c <7.5%
Type 1 >19 or Type 2
Fasting 70-130
Bedtime 110-150
PP <7%
Assessment of Plan
Evaluate daily blood glucose records (A1c)
Assess ability of pt to perform ADLs
Condiser pt comfort and satsifcation
Adjust to any issues
AM Rapid/Short Insulin affects
NOON blood sugar
PM Rapid/Short Insulin Affects
HS blood sugar
AM Intermediate affects
PM blood sugar
Bedtime Intermediate or long acting affects
AM blood sugar
Somogyi Phenomenon
Nocturnal hypoglycemia followed by early AM hyperglycemia
Results of too much PM insulin
Can lead to ketone formation and spilling of glucose into urine