University:
West Coast University
Course:
PHAR 742 | IPC Endocrine
Academic year:

2024
Views:

103

Pages:

76
Author:

Asal A.

guidelines AIA andBAE Tina Menedjian, PharmD tmenedjian@westcoastuniversity.edu Clinical Assistant Professor, Department of Pharmacy Practice West Coast University| School of Pharmacy Ambulatory Care Pharmacist | Saban Community Clinic Ohare to Insulin Three main physiologic functions 1. Signals the liver to convert glucose into glycogen 2. Necessary for glucose uptake by muscle cells to be used for energy 3. Converts excess glucose to fat Basalinsulin as helpsglugosecontrol Insulin cont. Healthy Person • Pancreas releases consistent level of insulin at all times (basal amount ) • More insulin post-prandial insulintherapyfortypesdiabetes loss GaAlcocerto't Bsover3,00katabolismmegill fatig Patient with diabetes • Insulin is given to mimic normal physiological process • Long acting or intermediate- for basal control • Rapid or short acting bolus to control post-prandial blood glucose elevations Tiger yn Insulin Preparation Onset of Action Peak Duration of action Rapid-Acting (Meal time) Lispro (Humalog) 10-30 minutes 0.5-3 hours 3-5 hours Aspart (Novolog) 10-30 minutes 0.5-3 hours 3-5 hours Glulisine (Apidra) 10-30 minutes 0.5-3 hours 3-5 hours Inhaled insulin (Afrezza) ~ 15 minutes ~ 1 hour 2-3 hours Short-Acting (Meal time) Regular (HumulinR, Novolin R) 15-30 minutes 2.5-5 hours 6-8 hours Humulin R U-500 15-30 minutes 4-8 hours 4-12 hours 1-2 hours 4-12 hours 12-18 hours 30 minutes 2-12 hours 18-24 hours 3-4 hours - 18-23 hours 3-4 hours Toujeo – 6 hours - 22-24 hours 1 hours - > 40 hours Intermediate –Acting (Basal) NPH (Humulin N, Novolin N) Humulin 70/30, Novolin 70/30 Long-Acting (Basal) Detemir (Levemir) Glargine (Lantus, Basaglar, Toujeo, SoloStar) Degludec (Tresiba Flex Touch) IS A ADA Glp 0 Trulia ozempic 0.25 victoza o 6 Monsour 2.5 up Hom µ 80then goal insistent Wsdferformostofty 7h day first A f byYonts postprandial 9180 WToÉggsg ADA To mealtime Ej Bolus to skip A Dat Insulin Peaks Fam tshoutest longest shortest glutsine longest Detemir deghdec Npitiglorgire • Which of the following insulins has the shortest duration of action? a. b. c. d. Glulisine Detemir Glargine 3 Regular Rapid Acting Insulin • Aspart (NovoLog) • Lispro (HumaLog, HumaLog KwikPen) • Glulisine (Apidra) • • • • • Commonly called prandial or meal-time insulin Give 15 minutes before meals or immediately after Warning: hypoglycemia, hypokalemia (shifts K into the cell) Side effects: weight gain, injections site reactions Afrezza: oral inhalation powder • Not for pts with acute bronchospasm (asthma/COPD) • Not known if safe / effective use in smokers Short Acting Regular Insulin • Regular Insulin (HumuLIN R, NovoLIN R) • • • • • Commonly known as prandial or meal-time insulin Give 30 minutes before meals Side effect: same is rapid acting insulin Can be used in IV solutions Available OTC Concentrated Regular Insulin • HumuLIN R 500 U-500 • HumuLIN R 500 U-500 KwikPen • 5 times as concentrated as regular insulin • Should only be used for pts who require > 200 units/ day • All patients using U-500 must be prescribed U-500 syringe to avoid dosing errors • Rarely used in practice due to high risk of confusion • Never mix with other insulins, administer IV, IM or used in a pump Intermediate Acting hey Then 2 Cloudy so TAA godlyNDH • NPH Insulin (HumuLIN N, HumuLIN N KwikPen, NovoLIN N, NovoLIN N ReliOn) • • • • • • Commonly known as basal insulin Dosed once or twice daily NPH insulins are cloudy (including pre-mixed) Available OTC Can be mixed with rapid or short acting Same ADRs as other insulins • Insulin mixing- NPH with Regular: https://youtu.be/cV51engpO0I?si=x05V-3Cm93MuOdPH Long-Acting Insulins • Detemir (Levemir, Levemir FlexTouch) • Glargine (Lantus, Lantus SoloStar, Basaglar KwikPen, Toujeo SoloStar) • • • • Commonly known as basal insulin Given at bedtime (sometimes twice daily) Same ADRs as other insulins Cannot be mixed with other insulins Ultra Long-Acting Insulins • Degludec (Tresiba Flex Touch) • Duration of action ~42 hours Insulin Dosing:T2DM BS 309Katabolic Plot Ak É • Basal insulin is initiated when patient fails to reach glycemic control with oral agents • Started at 0.1-0.2 units/kg/day (TBW) or 10 units per day • Dose is titrated by 10-15 % or 2 units every three days for FBG >130* • If A1C remains above goal, despite control of fasting BG, addition of bolus insulin is recommended • 4 IU a day or 10 % of the basal dose with the largest meal of the day Boyt ADA Jeff • Jeff: 52y/o male, wt: 74 kg • PMH: T2DM X 10 years, HTN x 5 years, hyperlipidemia X 10 years • Current medications: metformin 1000 mg PO BID, Januvia 100 mg PO daily, atorvastatin 40 mg PO daily, ASA 81 mg PO daily, lisinopril 40 mg PO daily • Last A1C (3 weeks ago): 9.0 • Fasting BG range: 180-200 mg/dL got TgadosBo Jeff To HoyABW orto unitperday on ozeniths 7.9 14.8 unitHayor Ofunits day • How would you initiate basal insulin? titrate traits every 3 days If fasting Bsstillabove • 0.1-0.2 units/kg/day (TBW) target Above131 • 7-15 units/ day • or 10 units per day • Recommend: Lantus 10 units SC Q HS ofbots Yunitsofinsulinbefore mealIlf sugareventedpostmore Humdog • Follow up? Ak 3month general2 4weeks • When should be next A1C check? nth Inotcontrolled 3mg Don'thaveonsbesalinsulin me Insulin Dosing: T1DM • Pump or multiple daily injections start• Basal and bolus attlesonetime • Screen patients for autoimmune disorders (thyroid disorders, Vit B12 deficiency, celiac disease) pick Go • Total daily dose (TDD) of 0.4-0.6 units/kg/day based on TBW Golf • 50 % basal (Long-acting) • 50 % bolus (Rapid/short-acting) • If using NPH: use 2/3 of the TDD as the NPH N and 1/3 as NPH R A Meet Jack • Jack: 19 y/o male, wt: 70 kg • Jack is diagnosed with T1DM and needs to be initiated in insulin regimen. Rapid long • Start a basal-bolus regimen with Lantus and Humalog 32 501Basalclog 0.9 a6unitlasiday pickosfotDD 0 u unitday 1 35unitday TDD us so Bows Rapid short 18Mt Bought Totalbolousforwholeday and Basal 18 unit so Royndupl 17.5 unitbeforeeachmeal Actaltitforboluspermeal b ifs eachmeneachday Initiating Basal-Bolus Insulin • Jane: 21 y/o f, wt: 65 kg mealtrehastobe Longusosal • Start a basal-bolus regimen with Basaglar andRapids Apidra a TDD on 0 2 3212 16.25 GritApidg 65 32.5 Wittig Ionit Based Initiating Basal-Bolus Insulin • Star: 23 y/o male, wt: 57 kg • Start a basal-bolus regimen with NPH (N and R) I 28 S TDD n Of 57 43OFTPD An NPA 43TDD Ma NP HII 29unit Hay 29 23 19.3 zuniga stounitTDsonits 29 13 9.6 BD nits Insulin to Carbohydrate Ratio (ICR) Primarily used in T1DM • An insulin-to-carb ratio tells you how much rapid acting or regular acting* insulin is needed to cover a specific amount of carbohydrate. • ICR is patient specific and helps determine the units of insulin required to cover the grams of carbohydrate in a meal (ICR may be given on exam) • Rule of 500 (rapid-acting) • 500/TDD=grams of carbohydrate covered by 1 unit of rapid acting insulin • Rule of 450 (regular acting) • 450/TDD=grams of carbohydrate covered by 1 unit of regular insulin Works well for pts that are able to count carbs and do the math. Does not work for most patients d Correction Factor Primarily used in T1DM Sunita zooorso • A Correction Factor (sometimes called insulin sensitivity), is how much 1 unit of rapid acting insulin will generally lower blood glucose • For the average patient, 1 units of insulin will lower BG by 50 mg/dL • For insulin sensitive individuals, 1 unit may lower BG by as much as 100 mg/dL • For insulin resistance individuals, 1 unit may lower BG by as little as 25 mg/dL • When blood glucose is unexpectedly high, a correction bolus can be used to bring it down ICR = insulin sensitivity 40 A Correction Factor • Rule of 1800 (used for rapid acting insulin) • 1800/TDD=correction factor for 1 unit of rapid acting insulin • Rule of 1500 (used for regular insulin) • 1,500/TDD=correction factor for 1 unit of regular insulin • Correction dose • (BG now)-(target BG)/correction factor =correction dose do normally130 ELI Correction Dose • Correction dose: amount of rapid-acting or short acting insulin needed to return an elevated BG to target level • Correction dose of insulin is added to the dose normally taken for that meal • Correction dose • (BG now)-(target BG)/correction factor =correction dose say beforelunchis 3g beCoy tobe ableto eattheirlunch Example pt on Gunito sugarto funny mad needpre Back to Jack • His target pre-lunch BG is 130, but it is currently 250 because he ate a big plate of pancakes for breakfast • How much rapid-acting (Humalog) insulin should he inject to account for elevated BG before lunch? Loop 1800 correction dose meat'T 3 21250 1301 Gunit 12 51 TDD 2.352 zonitofinsalin unitofinsulinbefore lunch moldl Stoltz 103 do frompreviousslide Back to Jack y Totaldailydose 1. Need to figure out the correction factor 1800/35 units= 51 • • 1 unit of rapid-acting will lower BG by 51 mg/dL 2. Calculate the correction dose • (250-130)/51=2.35~2 units of insulin 3. Add the correction dose to the usual* dose • 6 units + 2 units= 8 total units before lunch meal Time TDD 2gunit SIMD 151 More Practice with Jack’s Friend Jill longactingBasalt Rapidacting no 5 units TID. Jill has T1DM and injectsmy Lantus 20 units, Apidra 3,5021 Ifp She is about to eat her usual lunch (she usually injects 5 units Apidra before). Her premeal BS is 250 (before lunch). By What is her correction factor? 1388 5.92451unit What is her correction dose? 12591303 2.35 Zunit How much insulin total should she inject before her lunch today? 2 5 I ontoFinsalin Jack is Back to Practice ICR every I unit is is me Let’s say Jack has ICR 15. He wants to have a meal that has 45g carbs. How much rapid-acting insulin would he need to inject for that meal? 99 3unitofinsulin Let’s Bring it Altogether tosoradt high need i Super no carbs”. He does not want to do 5 units TID Jack wants to use “counting Kemetypp since he has different types of meals and his blood sugar fluctuates too Breakfest much. Jack’s ICR is 15 and his BS is at 300mg/dL before lunch and his correction factor is 50. He is about to eat a 45g carbohydrate meal for breakfast. How much insulin does he need to inject for the meal alone? I KImethod 7 Usggrb 3unitinsulin 3 qunit zenit unit ofinsulininty Itfmif Insulin Conversions • 1:1 (unit –per –unit) conversion can be done in most cases • Exceptions: • Converting from BID NPH to once daily insulin glargine (Lantus, Toujeo, Basaglar) èuse 80 % of the total daily NHP dose Fair • (TDD NPH)*0.8 = dose of once daily long-acting insulin • Converting form once daily Toujeo to once daily Lantus or Basaglar or NPH èuse 80% of the total daily Toujeo dose as the initial dose of Lantus /Basaglar or NPH • (Dose of Toujeo)*0.8 = TDD of NPH or once daily long-acting insulin or • Convert the following insulin regimens as instructed below – include specific medications and dosing Theionversionistt not • Novolin 70/30 31U BID to a basal + 3-dose mealtime regimen TH Egaloryopbrunitspiragweer dIIisnPI 434 186 BNII regular 3 Basal 43 0.8 34.9yzyunitforbasal mealtimeis tonersion malfthdy mealtime innit day D • Convert the following insulin regimens as instructed below – include specific medications and dosing Basal70/30 BasalR 7U BID to Novolin • Humulin N 14U BID + Humulin TDD 14 14 4zunit 7 7 Init Nobolin70130 42g't 21ofnovolin70130 why • Convert the following insulin regimens as instructed below – include specific medications and dosing • Humulin N 20U BID + Humulin R 12U TID to basal + 3-dose mealtime regimen TDD 20 20 art In a 76units 40 0.8 3 2onit 12 12 12 36unit 3meal aday 12unitmealfineas • Convert the following insulin regimens as instructed below – include specific medications and dosing • Levemir 55U daily + Humalog 10U TID AC to Novolin 70/30 TDD 55 lotto110 85units 82 42.5 93Units BID Ac Exam TDD asunitiksidey 05139.54 204 SoiBasore 8 so i Bonus AA 28 Ind • A 12 y/o M, recently diagnosed with T1DM. His current weight is 87 lb. • Which of the following is the most appropriate starting dose for his basal insulin? a. b. c. d. Insulin aspart 15 units daily Insulin glargine 20 units daily Basal 10 units daily Insulin detemir Insulin lispro 10 units daily about • Patientgo is taking Novolog Mix 70/30, 10 units BID. How many units of insulin aspart does the patient inject in the morning? a. b. c. d. 10 units Rapid 7 units 20 units 3 units tounity30 31hitinthemmay thenGunit Hooeral Notmentionmoney Rapid mph re • A patient is taking NovoLOG Mix 70/30, 15 units BID. • How many units of insulin aspart does the patient inject in the morning? ISunit x301 4.5 • 5 units Sunt Yolanda • • • • Based• 48 y/o Hispanic female with T2DM Weight 167 lb Ht: 65in BP 138/86 (today) PMH: T2DM x 13 yrs, HTN X 10 yrs, dyslipidemia X 10 yrs Medications onacting apid • • • • • • • • Levemir 34 units SC QHS Humalog 10 unts TID AC Metformin 1000 mg PO BID Lisinopril 10 mg daily HA1C: 13.8 (6 weeks ago) Microalbumin: 36.6 Lipid panel (TC/LDL/HDL/TG): 310/179/41/515 LFT: WNL JB.tt's Yolanda’s SMBG Bone stays 80 130 teeniest ldaatysypueshouddd 30 Fasting p Pre-Lunch Pre-Dinner 132 186 fat 222 310 122 172 202 285 148 184 188 257 132 192 193 228 142 189 202 264 121 190 188 201 160 188 199 312 178 206 268 175 320 387 above 150 145 Bait'shigh oo we should'tleirbreakfastdose M 1501901507 Bedtime of Max 6 8week theirunit Basal Yolanda Basal Hevemirl by zunits Maxagonit • Is she currently at goal? • How should the insulin therapy be adjusted? • Would you change current regimen? • Add other agents? 80130 130 1150 Fasting 130 Before lunch Before dinner Bedtime Monday 98 128 250 150 Tuesday 109 105 228 111 Wednesday 102 119 239 139 Thursday 113 108 278 150 Atggli wottouchingthe Basalinsulin hotAdj Bleated Boats Breakfast Molorzaunit Adjlunchtime Which value is consistently out of range? How should it be corrected? Which value is consistently out of range? How should it be corrected? ExampleE 80130 180 Fasting 2 hrs after breakfast 2 hrs after lunch 2 hrs after dinner Monday 122 187 196 202 Tuesday 109 189 188 212 Wednesday 102 209 193 199 Thursday 113 198 278 200 gÉ mealtimefor all mealshavetobeAdjust Mrs. Smith • 62 y/o white female with T2DM • Weight 219 lb • Medications • Levemir 42 units SC QHS • Metformin 1000 mg PO BID • Pioglitazone 45 mg PO daily Mrs. Smith Fasting Pre-Lunch Pre-Dinner Bedtime 132 186 222 310 122 172 202 285 148 184 188 257 132 192 193 228 142 189 202 264 121 190 188 201 133 188 199 312 137 178 206 268 119 175 320 387 Startboysinsulinfor atleastan Mrs. Smith meals 3 Leveyby Yunits initiatehomey UnitsBB • Is she currently at goal? • How should the insulin therapy be adjusted? • Would you change current regimen? • Add other agents? so hypergye Both ofthem Somogyi Effect and the Dawn Phenomenon intomoney • For people who have diabetes, the Somogyi effect and the dawn phenomenon both cause higher blood sugar levels in the morning. • The dawn phenomenon happens naturally, but the Somogyi effect usually happens because of problems with diabetes management routine Dawn Phenomenon • The dawn phenomenon is a surge of hormones that the body produces daily in the early morning hours before you wake up. • All people have the “dawn phenomenon the early-morning (4 a.m. to 8 a.m.) rise in blood glucose. • People with diabetes don't have normal insulin responses to adjust for this, and may see their fasting glucose go up. • The rise in glucose is mostly because body is making less insulin and more glucagon • The less insulin made by the pancreas, the more glucagon pancreas makes as a result • Glucagon signals the liver to break down glycogen into glucoseè FBG ↑ Somogyi Effect • Reactive hyperglycemia which is also called the Somogyi Effect. • This is when a low blood sugar in the middle of the night triggers the liver to dump sugar into the blood in an attempt to stabilize blood sugar. • The Somogyi effect is most likely to occur following an episode of untreated nighttime hypoglycemia, resulting in high blood sugar levels in the morning. Somogyi or Dawn phenomenon • People who wake up with high blood sugar may need to check their blood glucose levels in the middle of the night (for example, around 3 AM). • If their blood sugar level is falling or low at that time • ↑food intake or ↓insulin dose in the evening • The only way to prevent the Somogyi effect is to avoid developing hypoglycemia in the first place • If blood sugar is highè untreated hyperglycemia from the evening • Not enough insulin è ↑ dose of insulin at night or ↓ food intake Hypoglycemia • Normal fasting BG in a person without DM is 70-99 mg/dL • Hypoglycemia is defined as BG < 70 mg/dL • Symptoms of hypoglycemia: • Dizziness, headache, anxiety, irritability, shakiness, diaphoresis, hunger, nausea, confusion, lack of coordination, tremors, palpitations, blurred vision • Seizures, coma and death can occur with sever hypoglycemia Drugs That Cause Hypoglycemia • Insulin: the primary cause of drug-induced hypoglycemia • Insulin secretagogues: • SUs, meglitinides, pramlintide • Other drugs that can lower BG • Linezolid, lorcaserin, octreotide*, non-selective beta-blockers, quinine, quinolones • All beta-blockers can mask hypoglycemia symptoms of shakiness, palpitations, and anxiety (sweating and hunger are not masked) *Octreotide can cause hyperglycemia in T2DM and hypoglycemia in T1DM. It exerts pharmacologic actions similar to the natural hormone, somatostatin. It is a more potent inhibitor of growth hormone, glucagon, and insulin than somatostatin. Hypoglycemia Treatment BS IO Rule of 15 1. Take 15 grams of glucose or simple carbohydrate • Added fat slows the absorption and will prolong hypoglycemia 2. Wait 15 minutes and recheck BG Ohhh 3. If hypoglycemia continues, repeat step # 1 4. Once BG is normal, patient should eat a small meal or snack with protein 15 Grams of Carbohydrates • 3-4 glucose tablets (or hard candy/lifesavers) • 1 serving of gel tube • 2 tbs of raisins • ½ glass of regular soda or orange juice • 1 table spoon of sugar, honey, or corn syrup my Glucagon moteseatunconscious • Should be prescribed to all patients at severe risk of hypoglycemia (hypoglycemia unaware patients) • Glucagon should only be administered if the patient is unconscious or not conscious enough to self treat • Glucagon must be reconstituted before administration • Inject glucagon SC, IM, or IV • Once patient is conscious, administer a carbohydrate source Insulin Stability • Unused insulin vials, pens, and cartridges are stored in the refrigerator • Expiration date of refrigerated insulin is the manufacturer’s expiration date on the label • Most insulin is stable at room temperature for 28 days • Pens sometimes have shorter stability simply because they do not last long; almost all pens contain 3 mL (except Toujeo’s 1.5 mL) and are stable for 10, 14, or 28 days – except for the basal pens (& vials) which last 28, 42, or 56 days. Clinical Summary Biggest decrease in A1C (> 1 %) Mounjaro, GLP-1s, Insulins (“infinite”), metformin, SUs, TZDs Greatest hypoglycemia risk Insulins, SUs, meglitinides, pramlintide (with insulin) Most likely to cause weight gain Insulins, SUs, meglitinides, TZDs Most likely to cause weight loss Mounjaro, GLP-1 agonists, SGLT2 inhibitors, Intermediate- DPP4I, MTF Cardiovascular benefits JIVOT Least expensive Metformin, SUs, TZDs, DPP4Is Injectables Insulin, GLP-1 agonists, Mounjaro, pramlintide Insulin Drug Interactions • Meglitinides and SUs should never be used with insulin • Decrease insulin dose with: • • • • • TZDs SGLT2 inhibitors DPP-4 inhibitors GLP-1 agonists Pramlintide Drug classes Metformin, SGLT2 inhibitors, exenatide, glyburide TZDs, saxagliptin (and alogliptin) Canagliflozin Contraindicated if eGFR or CrCl < 30 mL/min Note ADA 2023 new updates: for patients with DM/CKD with albuminuria- can be used in patients with eGFR as low as 20mL/min Heart failure Peripheral neuropathy, PAD of diabetic foot ulcers GLP-1 agonists, pramlintide, Gastroparesis or other GI disorder Mounjaro (Mounjaro- not recommended in severe GI disorder or gastroparesis, not yet studied) SFUs Sulfa allergy SFUs G6PD deficiency Drugs/ Drug Classes Major Risks Metformin Lactic acidosis TZDs, alogliptin Hepatotoxicity SGLT2 inhibitors hypotension/dehydration, UTI/genital infections Canagliflozin (hyperkalemia), insulin (hypokalemia) K abnormalities DPP4-inhibitors, GLP-1 agonists Pancreatitis DPP4 –inhibitors, SUs Hypersensitivity reactions SGLT2-inhibitors Ketoacidosis Pioglitazone, dapagliflozin (bladder cancer) GLP-1 agonists (thyroid cancer) Cancer Drug Advantages Disadvantages Insulin No limit dose however insulin resistance possible, low $, ↓ microvascular Injections, stigma, monitoring, hypoglycemia, weight gain, analogs high $ Sulfonylureas Low $, experience, ↓ microvascular Weight gain, hypoglycemia, limited efficacy TZDs No lows, improves lipid profile, maybe lower MI risk Fluid retention, CHF, weight gain, bone fractures, bladder CA GLP-1 Agonist & Mounjaro Weight loss, no lows, may ↑ B- cell function Injections, GI SE, high $, less experience, thyroid tumors DPP-4 Inhibitors Weight neutral, no lows, well tolerated Upper respiratory infxns, urticaria, angioedema, pancreatits Meglitinides Dosing flexibility, ↓ post prandial glucose TID, hypoglycemia, weight gain, high $ α-glucosidase inhibitors Weight neutral, no lows, ↓ post prandial glucose, may ↓ CVD GI SE, TID, moderate $ Combination Products Metformin + SU Metformin/glipizide Metaglip Meformin + Meglitinide Metformin/repaglinide (PrandiMet) Metformin +TZD Metformin/pioglitazone (Actoplus Met, Actoplus Met XR) Metformin/rosiglitazone SU+TZD Glimepiride/pioglitazone (Duetact) Glimepiride/rosiglitazone Metformin+ DPP4 Inhibitor Metfromin/alogliptin (Kazano) Metformin/linagliptin (Jentadueto, (JentaduetoXR) Metformin/sitagliptin (Janumet, Janumet XR) Metfromin/saxagliptin (Kombiglyze XR) DPP4 Inhibitor + TZD Alogliptin/pioglitazone (Oseni) Metformin + SGLT2 Inhibitor Metformin/canagliflozin (Invokament, Invokamet XR) Metformin/dapagliflozin (Xigduo XR) Metformin/empagliflozin (Synjardy, Synjardy XR) DPP4 Inhibitor + SGLT 2 Inhibitor Linagliptin/empagliflozin (Glyxambi) Saxagliptin/dapagliflozin (Qtern) GLP1 Agonist + Long –Acting Insulin * Liraglutide/insulin degludec ( Xultophy) Lixisenatide/insluin glragine (Soliqua) * Newest combinatuion produts • Which of the following is the most appropriate treatment to reverse hypoglycemia in a patient that is unconscious? a. b. c. d. ½ cup of regular soda 5 hard candies 3 glucose tablets Glucagon injection EEers Ete For • A patient is prescribed Gluvovance. What are the individual components? a. b. c. d. Metformin/glyburide Metformin/pioglitazone Metformin/sitagliptin Metformin/repaglinide • A 55 kg male is newly diagnosed with T1DM and is started on a basalbolus regimen with Basaglar and Novolog. How much Basaglar should he inject daily? 28 05 55 27 5 a. 5 units b. 10 units c. 15 units d. 20 units 2 214 15forbased I Focus Rapid • A patient is starting mealtime insulin with the Humalog KwikPen. What is the correct counseling information regarding storage and expiration once in use? a. b. c. d. Store in the refrigerator and discard after 21 days Store at room temperature and discard after 28 days Store in the refrigerator and discard after 28 days Store at room temperature and discard after 21 days • B.L. is a 70-year-old patient who was given a diagnosis of T2DM 28 years ago. His C-peptide concentration is undetectable, and he Rapid Long receives a basal/bolus insulin regimen of glargine and lispro insulins. His insulin requirements total 100 units of insulin per day. • Which value best approximates B.L.’s insulin sensitivity? A. 15 mg/dL. I B. 16 mg/dL. C. 17 mg/dL. D. 18 mg/dL. of amount RapidRaged cops • Which best approximates B.L.’s insulin/carbohydrate ratio? A. 3. s B. 4. C. 5. D. 6. KR Offbeat • B.L.’s predinner blood glucose reading today is 184 mg/dL (goal of 130 mg/dL), and he plans to eat 60 g of carbohydrates at dinner. Which best approximates B.L.’s predinner lispro insulin dose? A. 15 units. Correctionfactor ICR J 11 B. 16 units. 1800 pteatingbogofcorb C. 17 units. D. 18 units. dose 6g 12 3 151 It If surf • Which option most appropriately lists the insulins in order from the most rapid acting to the longest acting? • Degludec (Tresiba), glargine (Lantus), regular, aspart (NovoLog). • Lispro (Humalog), regular, neutral protamine Hagedorn (NPH), degludec (Tresiba). • Glargine (Lantus), detemir (Levemir), regular, glulisine (Apidra). • Regular, NPH, glulisine (Apidra), glargine (Lantus). Pipeline (Insulin) • Rezvoglar: FDA approved December 2021; anticipated availability is currently unknown. Rezvoglar is approved as a biosimilar to Lantus. • Lyumjev (insulin lispro-aabc injection (Lilly): FDA approved June 2020

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