25 - Insulin and Diabetes Mellitus
Diabetes Mellitus – Basic Review
1. What are the products of the pancreas?
• Exocrine: enzymes (i.e., trypsinogen, chymotrypsinogen, lipase,
amylase) released into ducts
• Endocrine: Islets of Langerhans cells release products into bloodstream
- α cells — glucagon
- β cells —
- δ cells — somatostatin
2. What other diseases are associated with diabetes mellitus?
• Cardiovascular disease
•
•
3. What are the symptoms of diabetes mellitus? (LP p286)
• Polyuria
•
• Polyphagia
• Weight loss
4. What are the differences between type 1 and type 2 diabetes mellitus? (LP p286-287)
Diabetes Mellitus Type 1 Type 2
Cause Cell destruction no insulin Inability of β cells to produce adequate
production ____________________
Insulin resistance
Clinical History Onset usually in childhood Obese
Undernourished appearance More prevalent
Moderate genetic tie Strong genetic tie
Treatment Exogenous insulin Lifestyle modifications (weight loss, diet,
exercise)
Oral medication
- Improve tissue sensitivity
- Improve insulin secretion
Insulin
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Insulin Basics
1. Insulin is synthesized as precursor that must be cleaved to produce active
insulin. (LP p287)
- What information is collected from C-Peptide measurements?
• Low in
• High in
• in factitious disorder
2. How is insulin secretion regulated? (LP p287-288)
•
• Amino acids: leucine, arginine
• Digestive hormones: GLP-1, GIP, glucagon, cholecystokinin
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Prandial =
3. What are the actions of insulin?
• Muscle – protein and glycogen synthesis
• Liver –
• Adipose tissue – triglyceride storage
• Pancreas – reduces insulin secretion
•
4. How is insulin used to treat hyperkalemia?
Insulin + (50% dextrose in water)
5. What enzyme breaks down insulin? (LP p288)
6. What are the adverse effects of insulin? (LP p288)
7. What are the symptoms of hypoglycemia?
•
• Dizziness
• Sweating
•
• Anxiety
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8. In general, should be avoided (or used with caution) in patients
with diabetes who are at risk for hypoglycemia.
9. Why does insulin administration often result in weight gain?
effects and increased eating to prevent hypoglycemia
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Quick Review 1
1. Why should -blockers be used with caution in diabetic patients?
2. What effect does insulin have on serum potassium (K+) levels?
3. What would you suspect in a patient with hypoglycemia and a lab work-up that reveals an absence
of C-peptide?
4. Describe the process by which glucose stimulates insulin release in the cells of the pancreas.
5. What disease results when a type 1 diabetic does not take sufficient insulin?
6. What disease results when a type 2 diabetic has severely elevated blood sugar due to poor control
of their diabetes?
7. How is long term glycemic control measured in patients with diabetes mellitus? (LP p286)
8. Insulin is normally administered subcutaneously. In what circumstance would you administer IV
regular insulin? (LP p288)
9. What are the counter-regulatory hormones that prevent the human body from becoming too
hypoglycemic and, in certain circumstances, may cause hyperglycemia in diabetics? (LP p288)
10. To what type of receptor does insulin bind in order to exert its effects?
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Insulin Preparations and Treatment
1. What is the goal of insulin therapy?
Normalize blood glucose and mimic insulin physiology
2. What are the short-acting insulin preparations that have an effect within 15 minutes of
administration? (LP p289)
• Regular insulin
• Insulin lispro
• Insulin aspart
• Insulin glulisine
3. Distinguish between the various insulin preparations and their action times: (LP p288)
4. Insulin aspart, lispro and glulisine all have about the same as regular
insulin.
5. NPH Insulin is less ________________ which causes delayed absorption. (LP p289)
6. What are the long-acting insulin preparations, which offer once daily administration? (LP p290)
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7. What are some of the ways exogenous insulin preparations are used to control blood glucose levels?
8. How are combination insulin preparations dosed?
2/3 daily dose:
1/3 daily dose: evening
9. What is an example of basal-bolus insulin administration?
10. What are some other important considerations with insulin therapy?
• Timing
• Meals
•
11. Which insulin dose should be adjusted if a patient wakes up hyperglycemic?
12. Which insulin dose should be adjusted if a patient is hyperglycemic at suppertime?
13. Which insulin dose should be adjusted if a patient is hyperglycemic at bedtime?
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14. What meal considerations affect adjusting insulin?
15. A sick patient may need insulin.
16. Describe the Dawn Phenomenon.
• Hyperglycemia in the morning
• A normal rise in blood glucose in the night
• Need an increase in insulin dose to keep blood sugar from rising
17. Describe the Somogyi Effect.
• Hyperglycemia in the morning
• Low blood glucose overnight
• Rebound
• Need less insulin overnight
18. How do you determine whether a patient is experiencing the Somogyi Effect and Dawn
Phenomenon?
• Somogyi Effect –
• Dawn Phenomenon –
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Quick Review 2
1. Which insulin can be given IV?
• Regular insulin (Humulin)
• Insulin lispro (Humalog)
• Insulin (Novolog)
• Insulin (Apidra)
2. What are the two long acting insulin preparations? (LP p290)
3. In which type of diabetes is insulin required for treatment?
4. It is determined that a patient needs to be started on insulin and a total daily dosage is calculated.
Assuming that the patient is going to be started on a mixture of NPH and R insulin, what percentage
of the total daily insulin is typically dosed in the morning before breakfast, and what percent is
dosed in the evening before dinner?
Total Daily Dose = _________________________________
(100kg Person: 50 units Insulin, divided throughout the day)
_______Morning ________Evening
2/3 NPH 1/3 R 1/2 NPH 1/2 R
5. If a patient is on an insulin dosing schedule of NPH + R in the morning and evening, what dose
should be adjusted based on the following findings:
Hypoglycemia prior to
breakfast
Hyperglycemia at
lunch
Hyperglycemia at
dinner
Hypoglycemia at
bedtime
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6. As a general rule when increasing a patient’s insulin dose at a clinic visit, what is the most you
usually would increase the total daily dose of insulin at the visit?
7. When dosing insulin glargine as basal insulin and insulin lispro with meals, what is the usual ratio of
total daily glargine dose to total daily lispro dose?
insulin glargine
insulin lispro, the insulin lispro divided based upon meal size
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End of Session Quiz – Insulin and Diabetes Mellitus
1. Differentiate the basic typical characteristics of type 1 and type 2 diabetes mellitus: (LP p286)
Type 1 Type 2
Age of Onset
Appearance
Prevalence
Genetics
Defect
2. What is the goal of insulin therapy? (LP p287)
3. What are the symptoms of hypoglycemia? (LP p288)
4. Identify each of the following insulin preparations as either short-acting, intermediate-acting, or
long-acting: (LP p289)
Regular insulin -
Insulin aspart -
Insulin glulisine -
Insulin glargine -
Insulin detemir -
NPH insulin -
5. How would you distinguish Somogyi Effect from Dawn Phenomenon?
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6. If you determined that the type 1 diabetes mellitus patient’s morning hyperglycemia was due to
Somogyi effect, then what modifications in therapy would be necessary?
7. How can a patient cut down on lipodystrophy secondary to insulin injection? (LP p288)
8. What are the counter regulatory hormones that raise serum blood sugar?
9. Which insulin can be administered IV?
10. What type of cell receptor is activated by insulin?
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