Pre-Mixed Insulin Combinations
1st number = percentage of intermediate-acting insulin
2nd number = percentage of short/rapid-acting insulin
Novolog 70/30 Aspart protamine / Aspart
Humalog 75/25 - Lispro protamine / Lispro
Humalog 50/50 - Lispro protamine / Lispro
Humulin 70/30 - NPH / Regular
Novolin 70/30 - NPH / Regular
Pre-mixed insulins have been around for a long time, so let’s review them! These products have a protamine component that is intermediate-acting and serves as the basal insulin, combined with a regular version that is shorter-acting and serves as the prandial insulin. They are normally dosed twice per day. When looking at the ratio, always remember that the first number is the basal percentage and second number is the prandial percentage. The main benefits of these products is that it cuts down on the number of injections per day (2 per day, compared to 4 per day with a basal daily + prandial TID). This can also make it cheaper for patients since they pay 1 copayment instead of having 2 different prescriptions. The major downside is that there is very little flexibility in dosing. The ratios are set so you can’t increase the basal without increasing the prandial (& vice versa), and most patients will not fit perfectly into those ratios since everyone’s insulin requirements are different. This can make it difficult to get optimal glycemic control. I generally do not use these products with my patients, but again it is patient-specific so there may be some instances that these would be the ideal fit for a patient.
Jarred Prudencio, PharmD - https://www.instagram.com/ambcarerx
#Insulin #Combinations #PreMixed #Pharmacology #BrandNames
Insulin Dosing Basics - Initiating Insulin for T2DM and Converting Insulin Products
Insulin dosing can be complex and is super patient-specific, but here are the very basics! For type 2 diabetes, we initiate basal insulin at 10 units/day usually, or weight-based. Before initiating bolus insulin for type 2 diabetes, be sure to think about whether a GLP1 could provide enough control or if bolus insulin is truly needed. When titrating insulin doses if patients experience unexplained hypoglycemia, decrease the dose by 10-20%. Lastly, when converting from short to rapid insulin or from NPH to basal insulin, decrease the dose by 20% to account for lack of cross tolerance. This is important because we are seeing a movement away from using short and NPH insulin since rapid and basal insulins more closely mimic physiologic insulin, so you're bound to run into patient cases where converting is needed.
Jarred Prudencio, PharmD - https://www.instagram.com/ambcarerx
#Insulin #Basics #Dosing #Conversion #Initiating #Prescribing #Pharmacology
FIASP - Insulin Aspart vs Novolog
Have you heard about Fiasp, a new version of insulin aspart that is the fastest-acting insulin currently on the market? Fiasp is insulin aspart like Novolog, but it is formulated with Vitamin B3 & L-Arginine, which makes it absorb very quickly. Why does this matter? The fast onset more closely matches the endogenous insulin kinetics, and can be very helpful with administration. Normal rapid-acting insulins are supposed to be injected 5-15 minutes PRIOR to eating, which can be difficult and many patients end up injecting immediately before eating or after they already started eating. Though it still works, it's not ideal for glycemic control and can also cause hypoglycemia if not timed correctly. Fiasp is built to absorb very quickly, which is why it can be taken immediately prior to eating, or within 20 minutes after starting a meal. A study has shown Fiasp to have a greater A1c reduction compared to Novolog as well due to these kinetics.
Jarred Prudencio, PharmD - https://www.instagram.com/ambcarerx
#FIASP #Aspart #FastActing #Insulin #Pharmacology #EBM #Endocrinology
GLP-1 Agonists
Adlyxin (Lixisenatide) Daily
Bydureon (Exenatide ER) Weekly
Ozempic (Semaglutide) Weekly
Trulicity (Dulaglutide) Weekly
Victoza (Liraglutide) Daily
GLP-1 Agonists are commonly used medications to treat Type 2 Diabetes. They are subcutaneous injections, so many patients mistaken these medications for insulin. However, GLP-1's are very different. They work primarily on lowering post-prandial blood glucose due to the incretin effect. Some additional benefits include weight loss and carrying only a low risk of hypoglycemia. Common side effects include GI upset (since it works in the GI tract) and injection site pain.
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Depending on the product, it can be injected once daily or just once weekly! There is an ORAL GLP1 that is currently being studied (semaglutide), and we hope to see that come to market in the future. Notice that the MOA seems very similar to DPP4s from one of my previous posts. That's because they work in the same pathway, so it's important NOT to use them together since there’s no added benefit.
#GLP1 #Agonists #Pharmacology #Dosing #Diabetes #DM2 #Endocrinology
Jarred Prudencio, PharmD - https://www.instagram.com/ambcarerx
DKA DIAGNOSTIC CRITERIA:
1. Serum glucose >250 mg/dL
2. Arterial pH <7.3
3. Serum bicarbonate <18 mEq/L
4. At least moderate ketonuria or ketonemia.
10% to 30% of DKA cases occur in patients with type 2 diabetes, in situations of extreme physiologic stress or acute illness.
Infection is a very common trigger for DKA in patients who have new-onset diabetes and previously established diabetes. If there is any suspicion of infection, antibiotics should be administered promptly.
2.6% to 3.2% of DKA admissions are Euglycemic Diabetic ketoacidosis (EDKA).
Pregnancy is a risk factor for EDKA because of the physiologic state of hypoinsulinemia and increased starvation.
Alcoholic ketoacidosis may have a similar presentation to EDKA, with anorexia, vomiting, dyspnea, and significant anion gap metabolic acidosis and ketonemia.
Common, early signs of ketoacidosis include nausea, vomiting, abdominal pain, and hyperventilation.
Patients with DKA usually present with a serum anion gap greater than 20 mEq/L (normal 3 to 10 mEq/L). However, the increase in anion gap is variable, being determined by several factors: the rate and duration of ketoacid production, the rate of metabolism of the ketoacids and their loss in the urine, and the volume of distribution of the ketoacid anions.
Continue insulin infusion until ketoacidosis is resolved, serum glucose is below 200 mg/dL, and subcutaneous insulin is begun.
Treatment with IV fluid resuscitation should continue until the anion gap closes and acidosis has resolved.
#DKA #EDKA #Insulin #diabeticketoacidosis #aniongap #TDD
Insulin Degludec (Tresiba) vs Insulin Glargine (Lantus, Basaglar, or Toujeo)
Insulin degludec (Tresiba) is an ultra-long acting insulin that lasts up to 42 hours. Insulin glargine (Lantus, Basaglar, Toujeo) has been the standard basal insulin but degludec is become more and more frequently used. Major reasoning is that since it lasts longer, degludec never needs to be dosed BID while some patients do require BID dosing with glargine if it does not last the full 24 hours. Additionally, results from the DEVOTE trial demonstrated that degludec was noninferior in terms of CV outcomes and A1c lowering, but had significantly less incidence of severe hypoglycemia.
Jarred Prudencio, PharmD - https://www.instagram.com/ambcarerx
#Insulin #Degludec #Glargine #Comparison #Pharmacology #DEVOTE #Diabetes
Insulin Calculations for Type 1 Diabetes
Insulin-to-Carb Ratio (ICR) 500/TDD = #g of carbs covered by I unit of rapid-acting insulin
Insulin Sensitivity Factor (ISF) 1800/TDD = #mg/dL of glucose lowered by 1 unit of rapid-acting insulin
Here's the 2 primary calculations used in dosing insulin for patients with type 1 diabetes. The ICR tells us how many grams of carbs are covered by 1 unit of mealtime insulin, while the ISF tells us how much of a blood sugar drop can be expected by 1 unit of mealtime insulin. This can be utilized in 2 main ways. One way is for patients to calculate how many carbs they will eat in a meal, use the ICR to calculate how many units needed to cover the meal, then check BG and add on any additional units of insulin to "correct" the BG back down to goal. Another way is for patients who have a fairly standard mealtime insulin dose, but will be eating additional carbs in a meal. They would calculate how many additional carbs (more than usual), then add the insulin to their normal mealtime dose. They will also add an additional amount with the ISF if needed.
Jarred Prudencio, PharmD - https://www.instagram.com/ambcarerx
#Insulin #Calculation #ICR #ISF #CarbRatio #SensitivityFactor #Type1 #Diabetes #DM1 #Pharmacology #Endocrinology
In ARDS, we know that the lungs are so diffusely injured that the remaining total area of relatively spared lung may be reduced to the size of a baby’s lungs, hence the “Baby Lung” concept. Despite this, it is also important to realize that in ARDS, lung injury may be diffuse, but not necessarily uniformly distributed, and we often see heterogenous patterns of lung injury mixed with regions of relative lung sparing. In that sense, both lungs may have multiple “Baby Lungs” with different baseline volumes (FRC) that depend on the area of lung spared in those regions. This is where the concept of Lung Strain and Lung Stress come into play.
Lung Strain is Tidal Volume/FRC. Consider a patient in ARDS where 6 ml/kg corresponds to 400 ml tidal volume. If a spared region has an FRC of 400 ml, strain is calculated as 1; however, if a neighboring region has an FRC of only 100 ml, then lung strain is 4! 4 times the amount of strain! Likewise, stress and strain are directly correlated to one another. Therefore, even at low tidal volumes and plateau pressures <30, we may be providing lung protective ventilation to one region of spared lung while causing significant lung strain and lung stress to another.
Keep this in mind, and always shoot for the minimum in terms of low tidal volumes. 6 ml/kg is what has been classically taught, but if you can get away with 3-4 ml/kg, the risk of lung strain is even further minimized. Same with lung stress; we are taught to keep plateau pressures < 30; but shooting for the lowest possible plateau pressure is likely the best way to minimize lung stress. Ultimately, the goal is to minimize the risk of Ventilator-Induced Lung Injury (Barotrauma, Volutrauma) and promote Lung rest and recovery.
#pathophysiology #diagnosis #management #ards #foamed #criticalcare #treatment #respiratory #clinical
