Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Appropriate Use of Basal Insulins EDUCATIONAL OBJECTIVES: At the conclusion of the activity, the learner will be better able to: 1. Review guideline recommendations for basal insulin use, including when to start basal insulin therapy; 2. Describe potential barriers to early initiation of insulin therapy; 3. Discuss aspects of currently available basal insulin products, including pharmacokinetic parameters, dosing and administration, and adverse effects; and 4. Design an evidence-based medication regimen for a patient that involves appropriate timing and use of basal insulin. POST-TEST/RATIONALE 1. Which of the following is an appropriate indication for insulin replacement therapy? A. B. C. D. An individual in hyperglycemic crisis (e.g., diabetic ketoacidosis) A person with a hemoglobin A1c greater than 9.0% who is symptomatic A hospitalized individual receiving enteral nutrition All of the above*** Correct Answer: D Insulin replacement therapy is indicated in a variety of situations, including for patients who have markedly elevated hemoglobin A1c who are symptomatic, for patients experiencing hyperglycemic crises, and for patients who are hospitalized and unable to take oral medications. 2. According to the American Diabetes Association recommendations for antihyperglycemic therapy in type 2 diabetes, which of the following is a true benefit of using basal insulin as a second-line add-on therapy to background metformin when compared to other drug classes? A. B. C. D. The addition of basal insulin has the highest level of efficacy*** The addition of basal insulin has the lowest risk of hypoglycemia The addition of basal insulin has a neutral effect on weight None of the above Correct Answer: A According to the American Diabetes Association recommendations for antihyperglycemic therapy in type 2 diabetes, the addition of basal insulin as a second-line add-on therapy to metformin has the highest level of efficacy, a relatively high risk of hypoglycemia, and is associated with weight gain. 3. All of the following are key patient barriers to the use of insulin therapy EXCEPT: A. Fear of injections B. Fear of weight gain C. Fear of hyperglycemia*** D. Fear of a loss of independence Correct Answer: C There are a variety of patient barriers to starting insulin. Some of the most common barriers include fear of injections, fear of weight gain, fear of hypoglycemia, and a fear that starting insulin injections will lead to a loss of independence. 4. All of the following are appropriate strategies to overcoming key barriers to insulin therapy, EXCEPT: A. B. C. D. Avoid using insulin as a “threat” Use insulin pens and regimens that offer maximum regimen flexibility Give an injection in the office or clinic to dispel injection fears Wait to use insulin until all other treatment approaches have failed*** Correct Answer: D A variety of approaches can be used to minimize and overcome barriers to insulin therapy. Some approaches that can be helpful include: avoiding using insulin as a “threat,” using insulin pens and regimens that offer maximum flexibility, giving patients a limited trial of insulin, and giving patients an injection in the office or clinic to dispel injection fears. 5. Which of the following basal insulin products is considered an “ultra-long-acting” basal insulin? A. B. C. D. Insulin degludec*** U-100 insulin glargine Insulin detemir NPH insulin Correct Answer: A There are a variety of insulin products available that can be used to cover basal insulin needs. The 2 insulin products that last longer than 24 hours and are considered “ultra-long-acting” basal insulins are U-300 insulin glargine and insulin degludec. 6. All of the following statements about the concentrated insulin products U-300 insulin glargine and U-200 insulin degludec are true, EXCEPT: A. These concentrated insulins are only available in pre-filled pens to minimize the risk of dosing errors B. Due to their longer duration of action, these concentrated insulins are associated with higher rates of hypoglycemia than U-100 insulin glargine*** C. These concentrated insulin products allow for a smaller volume of insulin injection than U-100 insulin products D. When administering a dose of insulin with concentrated insulins, the dose is simply dialed on the insulin pen (i.e., no dose conversion is needed) Correct Answer: B The concentrated ultra-long-acting basal insulins (U-300 insulin glargine and U-200 insulin degludec) are only available in pre-filled insulin pens to minimize the risk of dosing errors. When administering a dose, the dose is dialed on the insulin pen and no dose conversion is needed. These concentrated insulin products allow for a smaller total volume of insulin with a given dose, and they have the potential advantage of slightly lower rates of hypoglycemia compared to U-100 insulin glargine. 7. According to the prescribing information for U-300 insulin glargine, if a patient is currently taking 10 units of U-100 insulin glargine once daily, what is the recommended starting dose if she is switched to U-300 insulin glargine? A. B. C. D. 8 units of U-300 insulin glargine 10 units of U-300 insulin glargine*** 12 units of U-300 insulin glargine 11 units of U-300 insulin glargine Correct Answer B: According to the manufacturer, when converting a patient from U-100 to U-300 insulin glargine, the conversion can be made in a 1:1 ratio. If a patient is receiving 10 units of U-100 insulin glargine, he or she can be started on 10 units of U-300 insulin glargine. It is important to monitor the patient’s response and titrate the insulin to individualized needs. 8. Which of the following basal insulins is formulated in an acidic solution and, when injected, forms microprecipitates in the subcutaneous tissue that allows for delayed absorption and a protracted duration of action? A. B. C. D. Insulin detemir Insulin degludec Insulin glargine*** Insulin glulisine Correct Answer: C Insulin glargine is formulated in an acidic solution. Once injected, insulin glargine microprecipitates in the subcutaneous tissue. These microprecipitates then slowly dissolute and are absorbed into the circulation. This process allows for delayed absorption and a protracted duration of action. 9. TG is a 65-year-old man with type 2 diabetes. He weighs 100 kg. According to the American Diabetes Association recommendations for the initiation of basal insulin, which of the following options is an appropriate starting dose of basal insulin? A. B. C. D. 10 units per day 5 units per day 20 units per day Both A and C would be appropriate options*** Correct Answer: D According to the American Diabetes Association Standards of Care, an appropriate starting dose of basal insulin is 10 units per day or 0.1 to 0.2 units/kg/day. Therefore, a reasonable starting dose of basal insulin for TG would be 10 to 20 units/day. 10. After starting TG on 10 units of insulin daily, which of the following would be an appropriate plan for titrating his basal insulin therapy according to the American Diabetes Association standards of care? A. Instruct TG to monitor his morning fasting blood glucose (FBG) and adjust his basal insulin dose to reach his FBG target*** B. Instruct TG to monitor his postprandial glucose (PPG) and adjust his basal insulin dose to reach his PPG target C. Tell TG his insulin dose will be assessed when he is back in the office in 3 months D. All of the above Correct Answer: A According to the American Diabetes Association Standards of Care, basal insulin should be adjusted by 10% to 15% or 2 to 4 units once or twice weekly to reach the FBG target. The basal insulin dose should also be decreased in response to recorded hypoglycemic events. Basal insulin should not be titrated to address PPBG. Basal insulin should be actively titrated to achieve FBG goals and avoid clinical inertia.