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Principles of insulin management
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Flashcards in this deck (23)

Recherche en cours...

  • 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
Notes de cours

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.