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Principles of insulin management
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  • What are common types of insulin regimens?

    • Once/twice daily intermediate or long acting insulin
    • 1/2/3 daily premixed insulin
    • Basal-bolus therapy
    • Mealtime rapid acting insulin
    insulin regimens

  • What components does premixed insulin contain?

    • A basal component
    • A short acting (meal) component
    premixed insulin

  • How does premixed insulin act around meals?

    • Allows a large increase with a meal then sustained action until the next meal
    premixed pharmacology

  • Give common dosing schedules for premixed insulin.

    • Once daily with largest daily meal
    • Twice daily with breakfast and dinner
    • Three times daily with each meal
    premixed schedules

  • What is the basal–bolus insulin regimen?

    • Long acting small dose at bedtime for basal coverage
    • A bolus of rapid acting insulin at each meal
    basal-bolus insulin

  • Which injection sites are recommended for subcutaneous insulin?

    • Upper outer arms
    • Abdomen
    • Buttocks
    • Upper outer thighs
    injection sites

  • Why must injection sites be rotated?

    • To prevent lipohypertrophy
    injection rotation

  • Name a disadvantage of delivering insulin subcutaneously versus portal delivery.

    • Insulin is delivered into systemic rather than portal circulation
    subcutaneous disadvantage

  • How does subcutaneous insulin delivery affect liver versus peripheral exposure?

    • Liver is exposed to less insulin while periphery is exposed to more
    pharmacology insulin

  • What feedback and pharmacodynamic issues arise with subcutaneous insulin?

    • Loss of normal feedback mechanism
    • Pharmacodynamics altered, making matching supply to requirement difficult
    subcutaneous limitations

  • What glucose level is considered an alert value requiring treatment?

    • Glucose \(<4\) — alert value requiring treatment
    hypoglycaemia thresholds

  • What glucose level is considered clinically significant hypoglycaemia?

    • Glucose \(<3\) — clinically significant
    hypoglycaemia thresholds

  • How is severe hypoglycaemia defined?

    • Any hypoglycaemia associated with severe cognitive impairment requiring external assistance for recovery
    hypoglycaemia severe

  • Name three early sympathetic symptoms of hypoglycaemia.

    • Shaking
    • Sweating
    • Palpitations
    hypoglycaemia symptoms

  • Give three neuroglycopaenic symptoms of hypoglycaemia.

    • Double vision
    • Difficulty in conversation
    • Slurring of speech
    hypoglycaemia neuroglycopaenia

  • List three severe manifestations of hypoglycaemia.

    • Unconsciousness
    • Hemiplegia
    • Seizures
    hypoglycaemia severe

  • What does 'paraesthesiae' mean in the context of hypoglycaemia?

    • Paraesthesiae: abnormal sensation e.g. pins and needles
    hypoglycaemia terms

  • List causes of hypoglycaemia given in the notes.

    • Excssive insulin administartion
    • Unpredictible absorption of insulin
    • Altered clearance of insulin
    • Decreased insulin requiremnt
    • Recurrent hypoglycaemia of an undiagnosed DM
    hypoglycaemia causes

  • What is the first-line management step for a conscious person with hypoglycaemia?

    • Give 15g of oral glucose
    hypoglycaemia management

  • After giving oral glucose for hypoglycaemia, what are the next steps?

    • Recheck glucose after 15 mins
    • If above 4mmol offer 15-20d of complex carbs
    hypoglycaemia management

  • If a patient is unconscious, what dose of glucagon should be given and by which routes?

    • 1 mg glucagon, given SC or IM
    emergency glucagon

  • If a patient is unconscious, what dextrose preparation and volume should be given intravenously?

    • 50 ml of 50% dextrose IV
    emergency dextrose

  • Name two immediate treatments listed for an unconscious patient.

    • 1 mg glucagon SC or IM
    • 50 ml 50% dextrose IV
    emergency treatment
Study Notes

Overview

Brief summary of common insulin regimens, injection practice, limits of subcutaneous insulin, and recognition plus acute management of hypoglycaemia.

Types of insulin regimens

  • Once/twice daily intermediate or long‑acting insulin for baseline coverage.
  • Premixed insulin (contains a basal and a short‑acting component) gives a meal‑time glucose rise followed by sustained action.
  • Basal–bolus therapy: a long‑acting basal insulin for background plus rapid‑acting boluses at meals.
  • Mealtime rapid‑acting insulin used to cover carbohydrate intake.

Typical premixed/timing options

  • Once daily (with the largest meal).
  • Twice daily (breakfast and dinner).
  • Three times daily (with each main meal).

Basal–bolus details

  • Basal: long‑acting insulin given (often at bedtime) to provide 24‑hour background.
  • Bolus: rapid‑acting insulin given before each meal to cover prandial glucose excursions.

Injection sites and technique

  • Common sites: upper outer arms, abdomen, buttocks, upper outer thighs.
  • Rotate injection sites within the same anatomical area to reduce risk of lipohypertrophy.
  • Use correct needle length/angle and avoid reusing needles where possible.

Disadvantages of subcutaneous insulin

  • Requires injections (patient burden).
  • Delivered into systemic rather than portal circulation, so the liver sees less insulin while peripheral tissues see more.
  • Altered hepatic effects (insulin signalling in liver not normalised), and possible effects on IGF pathways.
  • Loss of normal endogenous feedback control makes matching supply to metabolic need harder.
  • Variable absorption and pharmacodynamics can complicate dosing.

Hypoglycaemia: definitions

  • Alert value: blood glucose \(<4 ext{ mmol/L}\) — requires treatment.
  • Clinically significant: blood glucose \(<3 ext{ mmol/L}\).
  • Severe hypoglycaemia: any hypoglycaemia causing severe cognitive impairment needing external help.

Symptoms of hypoglycaemia

  • Sympathetic / early: shaking, sweating, tremor, paresthesia, hunger, palpitations, headache.
  • Neuroglycopenic: blurred or double vision, difficulty speaking, slurred speech.
  • More advanced: confusion, behavioral change.
  • Severe: seizures, hemiplegia, unconsciousness.

Common causes of hypoglycaemia

  • Excessive insulin dosing.
  • Unpredictable or altered insulin absorption (e.g., injection site, lipohypertrophy).
  • Reduced insulin clearance (e.g., renal impairment).
  • Reduced insulin requirements (missed meals, increased activity, alcohol).
  • Recurrent hypoglycaemia unrecognized in undiagnosed diabetes.

Acute management

If the patient is conscious and able to swallow

  1. Give fast‑acting carbohydrate: \(15 ext{ g}\) oral glucose (e.g., glucose gel, sugary drink).
  2. Recheck capillary glucose after \(15 ext{ min}\).
  3. If glucose > \(4 ext{ mmol/L}\), provide a longer‑acting carbohydrate snack (e.g., \(15\text{--}20\text{ g}\) complex carbs).
  4. If still < \(4 ext{ mmol/L}\), repeat treatment with another \(15 ext{ g}\).

If the patient is unconscious or cannot swallow

  • Give \(1 ext{ mg}\) glucagon subcutaneously or intramuscularly if available and no contraindication.
  • Alternatively, give \(50\text{ mL}\) of \(50\%\) dextrose IV (hospital/IV access required).
  • Monitor and transfer for further care; once responsive, give oral carbohydrate when safe.

Practical points and prevention

  • Educate patients on early symptoms and carbohydrate counting.
  • Adjust insulin for exercise, missed meals, or intercurrent illness.
  • Encourage site rotation and inspection for lipohypertrophy.
  • Keep glucagon kits and fast‑acting glucose accessible.

Quick reference (key numbers)

  • Alert glucose: \(<4 ext{ mmol/L}\).
  • Clinically significant: \(<3 ext{ mmol/L}\).
  • Oral glucose dose: \(15 ext{ g}\); reassess after \(15 ext{ min}\).
  • Complex carb snack: \(15\text{--}20\text{ g}\).
  • Emergency: \(1 ext{ mg}\) glucagon SC/IM or \(50\text{ mL}\) of \(50\%\) dextrose IV.