Insulin Therapy

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  • Created by: LBCW0502
  • Created on: 13-11-19 13:53
State features of insulin (1)
Enables glucose transport into cells. Converts glucose to glycogen (stored in muscles and liver). Increases glycogen, fatty acid, protein synthesis and amino acid uptake in muscle
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State features of insulin (2)
Decreases glycogenolysis, gluconeogenesis, ketogenesis, lipolysis, protein catabolism and amino acid output. Facilitates conversion of glucose to fat. Prevents breakdown of body protein for energy
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State features of the endogenous insulin profile
Basal insulin levels. Spikes in insulin appear after increases blood glucose levels. Glucose levels return to normal 2 hours after eating (insulin therapy - aim to mimic insulin profile where spikes match with that of glucose)
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State features of animal/human/analogue (1)
Insulin first extracted from animal pancreas at slaughter house. Differ by 1 (porcine) - 3 (bovine) amino acids and needs purification of contaminants and breakdown products. Affects immunogenicity but there is no glycemic effect
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State features of animal/human/analogue (2)
Human and analogue insulin are made by recombinant DNA technology. Synthetic insulin thought to be less immunogenic. Slight hydrophilic variations mean caution in transferring patients between types
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What are the insulin types and durations? (1)
Ultra rapid acting. Rapid/short acting (onset 5-15 mins/15-60 mins, peak at 60 mins/1-2 hours) duration of 3-5 hours/3-8 hours. Intermediate acting (onset 1-2 hours, peak 6-10 hours, duration 12-18 hours)
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What are the insulin types and durations? (2)
Long/ultra long (onset 1-2 hours, peak with flat profile, duration 18-42 hours). Mix/biphasic (onset 15-60 hours, peak 1-10 hours, duration 12-18 hours) - profiles/diagrams
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What are the names of the rapid acting insulins?
NovoRapid, Humalog, Apidra, Fiasp - usually TDS with meals
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What are the names of the short acting insulins?
Humulin S, Actrapid, Insuman Rapid, Hypurin Neutral (Porcine/Bovine) - usually TDS with meals
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What are the names of the pre-mixed/biphasic insulins?
NovoMix 30. Humulin M3, Humalog Mix 25, Insuman Comb 15, Insuman Comb 25, Insuman Comb 50 - usually BD with meals
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What are the names of the intermediate acting insulins?
Humulin I, Insulatard, Insuman Basal, Hypurine, Isophane (porcine/bovine) - usually OD, can be BD
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What are the names of the long acting insulins?
Abasaglar. Lantus. Levemir - can be BD
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What are the names of the ultra-long acting insulins?
Toujeo, Tresiba - OD
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Describe features of biosimilar insulins (1)
Proteins which produce the same effect as the original (cheaper formulation). Insulin Glargine (Abasaglar, Semglee - biosimilar to Lantus). Insulin lispro (Insulin lispro Sanofi - biosimilar to Humalog). May be some difference in glycemic control
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Describe features of biosimilar insulins (2)
Should monitor patients more closely and not switch between glargine products. Prescribe by brand (lack of evidence for switching insulin brands for patients). More biosimilars on the way
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What are the high strength and new formulations? (1)
High strength insulin - Toujeo (insulin glargine) 300 units/mL, Humanlog (insulin lispro) 200 units/mL, Tresiba (insulin degludec) 200 units/mL, Humulin R (human insulin) 500 units/mL (unlicensed)
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What are the high strength and new formulations? (2)
Not interchangeable with 100 units/mL of the same drug. Altered excipients e.g. insulin aspart Fiasp nicotinamide (vit B3) added for rapid absorption compared to Novorapid
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What are the high strength and new formulations? (3)
New devices e.g. Toujeo doublstar pen delivering doses in 2 unit steps as opposed to single units
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Which patients need insulin? (1)
Patients with type 1 diabetes (insulin needs to be started within 24 h of diagnosis and continued lifelong). Patients with type 2 diabetes (blood glucose levels are inadequately controlled despite dual therapy with oral anti-diabetic drugs (NICE)
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Which patients need insulin? (2)
Used when anti-diabetic drugs are contraindicated or not tolerated. If the individual is symptomatic e.g. rapid weight loss, polyuria, nocturia. Initial HbA1c > 75 mmol/mol
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Describe features of blood glucose targets in type 1 diabetes (1)
HbA1c measured every 3-6 months, aim for 48 mmol/L (6.5%) or individualised target. Blood glucose monitoring at least 4 times a day. Up to 10 times a day if HbA1c target not acheived, hypos, driving (DVLA standards), unwell, before/after sport
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Describe features of blood glucose targets in type 1 diabetes (2)
Up to 10 times a day if pregnant or any other response such as impaired hypo awareness, high risk activity. Aim for fasting plasma glucose 5-7 mmol/L on walking. Before meals 4-7 mmol/L. If testing after meals 5-9 mmol/L taken >90 mins post meal
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State features of the diabetes control and complications trial (1)
Impact of intensive insulin regimen on long term control. Intensive vs standard insulin regimen. Significant reductions in new/worse retinopathy/microalbuminuria/neuropathy in intensive group
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State features of the diabetes control and complications trial (2)
3 times more hypo episodes in study arm, more likely to become overweight
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What are the insulin regimens for type 1 diabetes? (1)
Type 1. Basal-bolus regime (4x injections of insulin per day). Short acting before meals (TDS) - preferred insulin analogues. Basal - BD intermediate-acting Levemir (insulin detemir) preferred or OD long-acting analogue
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What are the insulin regimens for type 1 diabetes? (2)
Twice daily pre-mixed insulin - advantageous profile with just BD dose, requires rigid diet/exercise patterns. (Basal bolus regimen)
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Describe features of the continuous sub cut insulin pump (1)
Battery driven syringe pump. Fine plastic cannula terminates in a sub cut implanted catheter. Short acting analogues, continuous basal insulin infusion and patient activated bolus doses at meal times
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Describe features of the continuous sub cut insulin pump (2)
Appropriate for patients with recurrent hypoglycaemia. Marked AM glucose rise despite optimum multi-injection regimen. Repeated/unpredictable hypos despite optimum multi-injection regimen (factors affecting insulin levels - stress, exercise, diet)
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Describe features of the continuous sub cut insulin pump (3)
(flash glucose monitoring - wear device for up to 2 weeks, scan device, carbohydrate course - patient education, determine adjustment of insulin)
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What are the insulin regimens for type 2 diabetes?
Start basal insulin, OD or BD isophane (NPH) insulin first line depending on need. Use insulin analogues if there is a need to introduce bolus insulin. Twice daily pre-mixed insulin (HbA1c > 75 mmol/mol)
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What are the barriers to starting insulin? (1)
Concerns about dependence on insulin and possible S/E e.g. weight gain, hypoglycaemia. Anxiety about injections. Lack of confidence/skills in their ability to use insulin
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What are the barriers to starting insulin? (2)
Impact on self-perception and life (e.g. feelings of personal failure or self-blame for needing insulin, injections interfering with daily activities, social stigma)
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What are the barriers to starting insulin? (3)
Fears about diabetes progression (e.g. insulin as a sign that diabetes is getting worse, insulin as the last resort, mistaken beliefs that insulin leads to diabetes complications
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What are the aspects of insulin initiation counselling points?
Hypoglycaemia, monitoring, weight management, coping with illness, type 1/2 diabetes, driving, employment, healthy eating, exercise, travel, ongoing care, help and support, alcohol, special occasions and cultural issues (diagram)
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What are the self-management programmes? (1)
NICE (offer everyone a structured education programme after 6-12 months of diagnosis). DAFNE (Dose Adjustment For Normal Eating (type 1)). BERTIE (Beta Cell Education Resources for Training in Insulin and Eating - type 1)
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What are the self-management programmes? (2)
DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed - type 2)
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What is the insulin injection technique? (1)
Wash hands with warm water and soap, dry thoroughly. Remove pen cap, for cloudy insulins roll pen 10 times between palms. Gently invert the pen 10 times to achieve an even milky appearance. Select a new needle, peel off paper seal
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What is the insulin injection technique? (2)
Apply new needle in line with pen. Screw on needle, pull off protective cap. To ensure needle and pen are working properly select 2 units on dose button, hold pen with need pointing upwards
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What is the insulin injection technique? (3)
Fully depress dose button looking for insulin to appear from needle tip. If not seen, repeat steps until insulin seen at needle top. Dial the required dose. Fully insert the needle into the skin at 90 degrees keeping the pen stable
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What is the insulin injection technique? (4)
Press dose button until dose fully injected. Before removing the needle from the skin count to 10 to ensure the full dose is given. Safely remove the needle from the pen. Dispose of the needle into a sharps bin
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Describe features of subcutaneous injection sites (1)
Check injection sites regularly. Arms caution (rapid onset of action). Different rates of absorption between sites e.g. abdomen absorbs quicker then thighs). Rotate injection site. Use different sites for different times of the day
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Describe features of subcutaneous injection sites (2)
E.g. abdomen for morning, buttocks at lunch. Rotate left and right. Lipohypertrophy can affect absorption. If lumpy site develops, stop using site and monitor blood glucose levels
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What needs to be considered before adjusting doses? (1)
Adjustment of regimens (consider causes of hyper/hypoglycaemia, diet/illness, stress, adherence). Increase or decrease by 10%. If erratic blood glucose control - injection technique, injection sites, patient self-monitoring, exercise/lifestyle
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What needs to be considered before adjusting doses? (2)
Psychological/psychosocial issues, organic causes e.g. gastroparesis
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What are the early signs and symptoms of hypoglycaemia?
Sweating heavily, feeling anxious, tingling of the lips, hunger, becoming pale, trembling and shaking, palpitations
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Describe features of hypoglycaemia management (for DM patient able to swallow, follow instructions, has tremor, intense hunger, dizziness, unsteadiness, sweating, BG = 2.9) - 1
Give food/drink. Administer insulin. Contact HCP. Administer 20 or 50% dextrose IV. Administer glucagon IM. Fruit juice, glucose tablets or medicinal glucose in water. Entry on medical notes. Re-measure blood glucose levels later (15 mins)
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Describe features of hypoglycaemia management (for DM patient able to swallow, follow instructions, has tremor, intense hunger, dizziness, unsteadiness, sweating, BG = 2.9) - 2
Give food and re-measure blood glucose levels (for BG > 4, measure levels 2 hours later)
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What are the sick day rules? (1)
Illness generally increases insulin requirements. When ill, glucose monitor min. four hourly, adjust pre-meal insulin dose accordingly. Monitor urinary ketones. Maintain carbohydrate intake, if unable to eat, have sugary drinks or soup
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What are the sick day rules? (2)
Low threshold for hospital admission. Educate NOK in case patient too unwell to monitor/manage. More detailed dose adjustment plans can be individualised by diabetes specialist team
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What are the other acute problems?
Variable rate insulin infusion (VRIII) (when to use it), nil by mouth. Stopping a VRIII. Factors affecting glucose control in patients (steroids, infection, change of diet, insulin of other specialists, loss of usual self-management. DKA/HHS
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What are the steps for the safer use of insulin?
Right person, right insulin, right dose, right device, right way, right time
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State features of the patient safety alerts (1)
Errors in administration of insulin are common, may be severe and can cause death. Two common errors - use of IV syringes (marked in mL, not units), use of abbreviations (e.g. U or IU for units, dose might be misread e.g. 10U read as 100)
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State features of the patient safety alerts (2)
Some errors due to insufficient training in the use of insulin by healthcare team. Risk of severe harm and death due to withdrawing from insulin pen devices (never withdraw from an insulin pen or pen refill)
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Describe features of never event - overdose of insulin due to abbreviations or incorrect device (1)
Patient given a 10 fold or greater overdose of insulin because the words 'unit' or 'international units' are abbreviated, overdose given in a care setting with an EPS. HCP fails to use specific insulin administration device
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Describe features of never event - overdose of insulin due to abbreviations or incorrect device (2)
An insulin syringe or pen was not used to measure the insulin. HCP withdraws insulin from an insulin pen or pen-refill and then administers this using a syringe or needle
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State features of insulin (2)

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Decreases glycogenolysis, gluconeogenesis, ketogenesis, lipolysis, protein catabolism and amino acid output. Facilitates conversion of glucose to fat. Prevents breakdown of body protein for energy

Card 3

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State features of the endogenous insulin profile

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Card 4

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State features of animal/human/analogue (1)

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Card 5

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State features of animal/human/analogue (2)

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