NR601 FINAL EXAM STUDY GUIDE
I I I I
Week I5: IGlucose Imetabolism Idisorders
Types Iof IDM
1. Type I1- Isevere Iinsulin Ideficiency Iresulting Iin Ireduction Ior Iabsence Iof Ifunctioning Ibeta Icells Iin
Ithe Ipancreatic Iislets Iof ILangerhans. IThis Ileads Ito Ihyperglycemia Idue Ito Ialtered Imetabolism Iof
Ilipids, Icarbs, Iand Iproteins. IInitial Is/s Iof Ihyperglycemia. ISubjective Ifindings- Ipolyuria, Ipolydipsia,
Inocturnal Ienuresis Iand Ipolyphagia Iwith Iparadoxical Iweight Iloss, Ivisual Ichanges Iand Ifatigue.
IObjective-dehydration(poor Iskin Iturgor Iand Idry Imucous), Iwt Iloss Idespite Inormal/increase
Iappetite, Ireduction Iin Imuscle Imass. IDKA-fatigue, Icramping, Iabnormal Ibreathing
2. Type I2- IType I2 IDM Iis Icharacterized Iby Ithe Iabnormal Isecretion Iof Iinsulin, Iresistance Ito Ithe Iaction
Iof Iinsulin Iin Ithe Itarget Itissues, Iand/or Ian Iinadequate Iresponse Iat Ithe Ilevel Iof Ithe Iinsulin Ireceptor.IA
Ipatient Imay, Ihowever, Ipresent Iwith Ipruritus, Ifatigue, Ineuropathic Icomplaints Isuch Ias Inumbness
Iand Itingling, Ior Iblurred Ivision.
3. Prediabetic- Ifasting Iglucose I consistently Ielevated Iabove Ithe Inormal Irange Ibut Iless Ithan I100-125.
IImpaired Iglucose Itolerance I(IGT) Istate Iof Ihyperglycemia Iwhere I2 Ihr Ipost Iglucose Iload Iglycemic
Ilevel Iis I140-199
Diagnostic Icriteria- Ithere Iare I4 Ilab-based Icriteria Ito Iconfirm IDM: IA1C, Irandom Iplasma Iglucose, Ifasting
Iplasma Iglucose, Iand I2-hr Ipost Iload Iplasma Iglucose
• AIC Iof I6.5 Ior Ihigher=diabetes
• Random Iplasma Iglucose Ilevel Iof I200 IWITH Iclassic Isymptoms Iof Ihyperglycemia Ior Ia
Ihyperglycemic Icrisis
• Fasting Iplasma Iglucose Ilevel Iof I126 Ior Ihigher Ion ITWO Ioccasions(fasting Iis Idefined Ias Ino Icaloric
Iintake Ifor Iat Ileast I8 Ihrs
• 2-hour Ipost Iload Iplasma Iglucose Ilevel Iof I200 Ior Ihigher Iduring Ian IOGTT, Ifollowing Iconsumption IofIa
Iglucose Iload Icontaining Ithe Iequivalent Iof I75g Iof Ianhydrous Iglucose Idissolved Iin Iwater I(OGTT Iis
Ialso Iused Ito Iscreen Ifor Idiabetes Iduring Ipregnancy)
*** IIn Ithe Iabsence Iof Iunequivocal Ihyperglycemia Iresults Ishould Ibe Iconfirmed Iby Irepeat Itesting Ion Ia
Inew Iblood Isample Iwithout Idelay, Ipreferably Iusing Ithe Isame Itype Iof Itest.***
• *All Iabove-but Iconfirmation Iof Itype I2 Idiabetes Imellitus Irequires: Itwo Ifasting Iblood Iglucoses
≥126 Img/dL Ior Itwo Irandom Iblood Iglucoses I≥200 Img/dL.
• You Ido Inot Iscreen Ifor Itype I1 Idiabetes Ibut Iyou Ido Iscreen Ifor Itype I2 Iif Ian Iindividual Iis Ioverweight
Ior Iobese, Iregardless Iof Iage, Iand Ifor Iall Iadults Iaged I45 Iyears Iand Iolder. ITests Ishould Ibe IrepeatedIat
Ia Iminimum Iof I3 Iyear Iintervals
Initial ITreatment-
Type I1- IFIRST ILINE: IINSULIN. IThe Iinitial Igoal Iof Itreatment Ifor Itype I1 IDM Iis Ito Inormalize Ithe
Ielevated Iblood Iglucose Ilevel. IThis Iis Ibest Iaccomplished Iby Iintensive Iinsulin Iregimens Ito Iachieve
Ithe Ifollowing Igoals: Iplasma Iglucose Ilevels Iof I80 Ito I130 Img/dL Ibefore Imeals, Ipeak Ipostprandial
1
, (1–2 Ihours Iafter Ithe Ibeginning Iof Ia Imeal) Iglucose Ilevels Iof Iless Ithan I180 Img/dL, Iand Ian IA1C
Ibelow I7% Ifor Iadults Iwith Itype I1 IDM. IA Icomprehensive Itreatment Iplan Irequires Iexogenous
Iinsulin, Ifrequent Iself-monitoring Iof Iblood Iglucose I(SMBG), Imedical Inutrition Itherapy, Iregular
Iexercise, Icontinuing Ieducation Iin Iprevention Iand Itreatment Iof Idiabetic Icomplications, Iand Ithe
Iperiodic Ireassessment Iof Itreatment Igoals. I(Type I1A: Iinsulin I dependent, IType I1B: Ivariably Iinsulin
Idependent). IThe IADA IStandards Iof Imedical Icare Iin Idiabetes Istates Ithat Ithe Imajority Iof Ipatients
Iwith Itype I1 IDM, Ishould Ibe Itreated Iwith Imultiple Idaily Iinjections Iof Iprandial Iinsulin Iand Idaily
Ibasal Iinsulin Ior Iwith Ia Icontinuous Isubcutaneous Iinsulin Iinfusion Ipump. IINITIATION IOF IINSULIN
ITHERAPY IIN INEWLY IDIAGNOSED ITYPE I1 IDM, ISHOULD IBE IMANAGED IBY IOR IIN ICLOSE
ICOLLABORATION IWITH IAN IENDOCRINOLOGIST.
Type I2-FIRST ILINE: ILIFESTYLE IMANAGEMENT. IInterventions Ishould Iinclude Itreatments Idirected
Iat Iboth Irisk Ireduction Iand Iglycemic Icontrol. ILifestyle Imanagement Iis Ian Iimportant Ipart Iof
Itreatment Iand Icomprises Inutrition Itherapy, Iactivity Iprescriptions Ifor Iexercise, Idecreased
Iprolonged Isitting, Iand Iin Iolder Iadults, Itraining Iin Ibalance Iand Iflexibility. ILifestyle Imanagement
Ishould Ifocus Ion Imental Ihealth, Isleep, Iand Ismoking Icessation. IObesity Imanagement Ihas Ibecome
Ia Ihigh-level Itarget Iin Ithe Itreatment Iof Ipts Iwith Itype I2 IDM. IADA Istates Ithat Ievery Ipatient Ishould
Ireceive Idiabetes Iself-management Ieducation Iand Idiabetes Iself-management Isupport Iat Ithe Itime
Iof Idiagnosis.
Pharmacological Itherapy Ifor Itype I2 IDM Iis Irequired Iwhen Ilifestyle Imanagement Idoes Inot Iresult Iin
Iadequate Iblood Iglucose Icontrol. IDrug Itherapy Ishould Ialways Ibe Iconsidered Ian Iadjunctive
Itherapy Ito Ilifestyle Imanagement, Ias Ithe Ilatter Iis Itypically Iinitiated Ifirst. IThe IADA Iand IAACE
Irecommend Imetformin Iif Ithere Iare Ino Icontraindications, Isuch Ias Irenal Idisease Ior Iabnormal
Icreatinine Iclearance, Iacute Imyocardial Iinfarction, Ior Isepticemia.
The IAACE Irecommends Iadding Ia Isecond Iagent Ito Ilifestyle Itreatment Iand Imetformin Iif Ithe IA1C Iis
Imore Ithan I7.5% Iat Ithe Itime Iof Idiagnosis Ior Iafter I3 Imonths Iof Imonotherapy Iwithout Iachievement
Iof Ithe Ipatient’s Iblood Iglucose Igoals. IMetformin Ican Ibe Iused Ias Ia Imonotherapy Iunless Ithe Ipatient
Ihas Icontraindications Ior Iintolerance. IAlthough Imetformin Iis Ithe Ifirst-line Imedication
Irecommended Iby Ithe IADA Iand Ithe IAACE Ifor IDM Itype I2, Iit Ishould Ibe Iused Ionly Iin Ipatients Iwith
Iadequate Irenal Ifunction Iand Ishould Inot Ibe Iused Iin Ipatients Iwith Ian IeGFR Ibelow I45 ImL/min/1.73
2
Im .
• Immediately Iupon Idiagnosis Iof Itype I2 IDM, Ibegin Ilifestyle Itherapy Iwith Imedically Iassisted
Iobesity Itreatment.
• If Iglycemic Igoals Iare Istill Inot Imet I3 Imonths Ilater, Ibegin Isingle-agent Ior Idual Itherapy Iwith Ioral
Iantidiabetic Iagents, Idepending Ion Iwhether IA1C Iis Iless Ithan Ior Igreater Ithan I7.5%.
• If Iglycemic Igoals Iare Inot Imet Iin I3 Imonths, Iinitiate Itriple Itherapy.
• If Iafter I3 Iadditional Imonths I(or Iat Ithe Itime Iof Idiagnosis) IA1C Iis I9.0% Ior Ihigher Iand Ithe Ipatient
Iis Isymptomatic, Iadd Iinsulin Itherapy.
• A1c-Gyycemic Ilevel Iover I2-3months Iand Iis Ihelpful Iis Idocumenting Icontrol Iand
Icontinuing Icare.
• A1c Iless Ithan I7% Iindicate Istrong Icontrol
• 6.5%or Iless Idecrease Ioccurrence Iof Icomplications Iachieved Iw/o Ihypoglycemia Ior Iother
Iadverse Ieffect.
2
, Medication ISide IEffects
-Type I1:
Hypoglycemia Iis Ia Icommon Ioccurrence Iin Ipatients Iwith Itype I1 IDM Iand Ioccurs Ifor Ia Ivariety Iof Ireasons:
Iexcessive Iexogenous Iinsulin, Imissed Imeals Ior Iinadequate Ifood Iintake, Iexcessive Iexercise, Ialcohol
Iingestion, Idrug Iinteractions, Ior Idecreases Iin Iliver Ior Ikidney Ifunction. ISigns Iand Isymptoms: Idiaphoresis,
Itachycardia, Ihunger, Ishakiness, Ialtered Imentation I(ranging Ifrom Ian Iinability Ito Iconcentrate Ito Ifrank
Icoma), Islurred Ispeech, Iand Iseizures. IThe IADA Iclassifies Ihypoglycemia Ias Ia Iplasma Iglucose Ilevel Iof I< I54 Ias
Iserious, Iclinically Isignificant Ihypoglycemia. IA Iblood Iglucose Ilevel Iof I70 Iis Iconsidered Ia Ithreshold Ilevel
Ithat Irequires Iintervention. IExamples Iof Iappropriate Ifoods: I#1 Ichoice: Ipure Iglucose, I½ Icup Ifruit Ijuice, I6oz
Iregular Isoda I(not Idiet Ior Isugarless), I1 Icup Imilk, Ior Iglucose Itabs. ICandy Iis Ionly Ia Ilast Iresort. IRecheck
Iglucose I15 Iminutes Iafter Itreatment. IAdditional Icarbs Ican Ibe Igiven Iif Iglucose Iis Istill Iless Ithan I70
-Type I2:
Metformin Ican Icause: Ihypoglycemia Iesp Iin Iolder Iadults, Iadverse Ireactions Isuch Ias IGI Idisturbances Iand
Imetallic Itaste, Iand Iis Icontraindicated Iin Irenal Idisease Iso Iassess Irenal Ifunction Iprior Ito Iprescribing.
- Metformin Ialso Ihas Ia Iboxed Iwarning Iin Iits IFDA-approved Iprescribing Iinformation Ifor Ilactic
Iacidosis, Ialthough Ithis Iside Ieffect Iis Ivery Irare. IMetformin Ishould Ibe Idiscontinued I24 Ito I48 Ihours
Ibefore Idiagnostic Iand Isurgical Iprocedures Idue Ito Ithe Irisk Iof Idecreased Ikidney Ifunction, Iand Iits
Iadministration Ishould Inot Ibe Iresumed Ifor Iat Ileast I6 Ihours Iafter Ithese Iprocedures Ior Iuntil Ithe
Ipatient Iis Iadequately Ihydrated. IInitial Idosing Iis I500 Img Ionce Ia Iday Iwith Ibreakfast Ior Idinner Ifor I1
Iweek, Ithen Itwice Idaily Iwith Ibreakfast Iand Idinner. ISeveral Iweeks Iof Itherapy Imay Ibe Ineeded Ito
Iachieve Imaximum Ieffects Iof Ithe Igiven Idose. ICommon Iadverse Ireactions Iinclude Idiarrhea,
Inausea, Ianorexia, Iand Iabdominal Idiscomfort, Iwhich Iusually Iresolve Iwith Ia Igradual Iincrease Iof
Idosage. IMetformin Ihas Ibeen Ishown Ito Icause Idecreased Ivitamin IB12 Iabsorption, Iand Ipatients Ion
Ilong-term Imetformin Itherapy Ishould Iundergo Iperiodic Itesting Ifor IB12 Ideficiency, Iespecially Iif Ithe
Ipatient Icomplains Iof Iperipheral Ineuropathy. IAt Ithe Imaximum Idose, Ithe Imonthly Icost Iof
Imetformin Iin Ithe IUnited IStates Iis Iapproximately I$4 Ion Imany Igeneric Iformularies. IMetformin Iis
Icurrently Ifound Iin I20 Icombination Iformulations Iwith Iother Imedications.
*For Iother Inoninsulin Iagent Iadverse Ireactions Isee Ipg I929 IDunphy Ibook*
SINGLE-DOSE THERAPY
Single Injection
• Intermediate or long-acting insulin with or without regular insulin in the
morning or Intermediate or long-acting insulin at bedtime
• Recommend at a minimum SMBG in the morning and at bedtime
CONVENTIONAL SPLIT-DOSE THERAPY
Two Injections
• Mixture of NPH and regular insulin in the morning and evening
• Recommend at a minimum SMBG before each dosing and at bedtime
INTENSIVE INSULIN THERAPY
3
I I I I
Week I5: IGlucose Imetabolism Idisorders
Types Iof IDM
1. Type I1- Isevere Iinsulin Ideficiency Iresulting Iin Ireduction Ior Iabsence Iof Ifunctioning Ibeta Icells Iin
Ithe Ipancreatic Iislets Iof ILangerhans. IThis Ileads Ito Ihyperglycemia Idue Ito Ialtered Imetabolism Iof
Ilipids, Icarbs, Iand Iproteins. IInitial Is/s Iof Ihyperglycemia. ISubjective Ifindings- Ipolyuria, Ipolydipsia,
Inocturnal Ienuresis Iand Ipolyphagia Iwith Iparadoxical Iweight Iloss, Ivisual Ichanges Iand Ifatigue.
IObjective-dehydration(poor Iskin Iturgor Iand Idry Imucous), Iwt Iloss Idespite Inormal/increase
Iappetite, Ireduction Iin Imuscle Imass. IDKA-fatigue, Icramping, Iabnormal Ibreathing
2. Type I2- IType I2 IDM Iis Icharacterized Iby Ithe Iabnormal Isecretion Iof Iinsulin, Iresistance Ito Ithe Iaction
Iof Iinsulin Iin Ithe Itarget Itissues, Iand/or Ian Iinadequate Iresponse Iat Ithe Ilevel Iof Ithe Iinsulin Ireceptor.IA
Ipatient Imay, Ihowever, Ipresent Iwith Ipruritus, Ifatigue, Ineuropathic Icomplaints Isuch Ias Inumbness
Iand Itingling, Ior Iblurred Ivision.
3. Prediabetic- Ifasting Iglucose I consistently Ielevated Iabove Ithe Inormal Irange Ibut Iless Ithan I100-125.
IImpaired Iglucose Itolerance I(IGT) Istate Iof Ihyperglycemia Iwhere I2 Ihr Ipost Iglucose Iload Iglycemic
Ilevel Iis I140-199
Diagnostic Icriteria- Ithere Iare I4 Ilab-based Icriteria Ito Iconfirm IDM: IA1C, Irandom Iplasma Iglucose, Ifasting
Iplasma Iglucose, Iand I2-hr Ipost Iload Iplasma Iglucose
• AIC Iof I6.5 Ior Ihigher=diabetes
• Random Iplasma Iglucose Ilevel Iof I200 IWITH Iclassic Isymptoms Iof Ihyperglycemia Ior Ia
Ihyperglycemic Icrisis
• Fasting Iplasma Iglucose Ilevel Iof I126 Ior Ihigher Ion ITWO Ioccasions(fasting Iis Idefined Ias Ino Icaloric
Iintake Ifor Iat Ileast I8 Ihrs
• 2-hour Ipost Iload Iplasma Iglucose Ilevel Iof I200 Ior Ihigher Iduring Ian IOGTT, Ifollowing Iconsumption IofIa
Iglucose Iload Icontaining Ithe Iequivalent Iof I75g Iof Ianhydrous Iglucose Idissolved Iin Iwater I(OGTT Iis
Ialso Iused Ito Iscreen Ifor Idiabetes Iduring Ipregnancy)
*** IIn Ithe Iabsence Iof Iunequivocal Ihyperglycemia Iresults Ishould Ibe Iconfirmed Iby Irepeat Itesting Ion Ia
Inew Iblood Isample Iwithout Idelay, Ipreferably Iusing Ithe Isame Itype Iof Itest.***
• *All Iabove-but Iconfirmation Iof Itype I2 Idiabetes Imellitus Irequires: Itwo Ifasting Iblood Iglucoses
≥126 Img/dL Ior Itwo Irandom Iblood Iglucoses I≥200 Img/dL.
• You Ido Inot Iscreen Ifor Itype I1 Idiabetes Ibut Iyou Ido Iscreen Ifor Itype I2 Iif Ian Iindividual Iis Ioverweight
Ior Iobese, Iregardless Iof Iage, Iand Ifor Iall Iadults Iaged I45 Iyears Iand Iolder. ITests Ishould Ibe IrepeatedIat
Ia Iminimum Iof I3 Iyear Iintervals
Initial ITreatment-
Type I1- IFIRST ILINE: IINSULIN. IThe Iinitial Igoal Iof Itreatment Ifor Itype I1 IDM Iis Ito Inormalize Ithe
Ielevated Iblood Iglucose Ilevel. IThis Iis Ibest Iaccomplished Iby Iintensive Iinsulin Iregimens Ito Iachieve
Ithe Ifollowing Igoals: Iplasma Iglucose Ilevels Iof I80 Ito I130 Img/dL Ibefore Imeals, Ipeak Ipostprandial
1
, (1–2 Ihours Iafter Ithe Ibeginning Iof Ia Imeal) Iglucose Ilevels Iof Iless Ithan I180 Img/dL, Iand Ian IA1C
Ibelow I7% Ifor Iadults Iwith Itype I1 IDM. IA Icomprehensive Itreatment Iplan Irequires Iexogenous
Iinsulin, Ifrequent Iself-monitoring Iof Iblood Iglucose I(SMBG), Imedical Inutrition Itherapy, Iregular
Iexercise, Icontinuing Ieducation Iin Iprevention Iand Itreatment Iof Idiabetic Icomplications, Iand Ithe
Iperiodic Ireassessment Iof Itreatment Igoals. I(Type I1A: Iinsulin I dependent, IType I1B: Ivariably Iinsulin
Idependent). IThe IADA IStandards Iof Imedical Icare Iin Idiabetes Istates Ithat Ithe Imajority Iof Ipatients
Iwith Itype I1 IDM, Ishould Ibe Itreated Iwith Imultiple Idaily Iinjections Iof Iprandial Iinsulin Iand Idaily
Ibasal Iinsulin Ior Iwith Ia Icontinuous Isubcutaneous Iinsulin Iinfusion Ipump. IINITIATION IOF IINSULIN
ITHERAPY IIN INEWLY IDIAGNOSED ITYPE I1 IDM, ISHOULD IBE IMANAGED IBY IOR IIN ICLOSE
ICOLLABORATION IWITH IAN IENDOCRINOLOGIST.
Type I2-FIRST ILINE: ILIFESTYLE IMANAGEMENT. IInterventions Ishould Iinclude Itreatments Idirected
Iat Iboth Irisk Ireduction Iand Iglycemic Icontrol. ILifestyle Imanagement Iis Ian Iimportant Ipart Iof
Itreatment Iand Icomprises Inutrition Itherapy, Iactivity Iprescriptions Ifor Iexercise, Idecreased
Iprolonged Isitting, Iand Iin Iolder Iadults, Itraining Iin Ibalance Iand Iflexibility. ILifestyle Imanagement
Ishould Ifocus Ion Imental Ihealth, Isleep, Iand Ismoking Icessation. IObesity Imanagement Ihas Ibecome
Ia Ihigh-level Itarget Iin Ithe Itreatment Iof Ipts Iwith Itype I2 IDM. IADA Istates Ithat Ievery Ipatient Ishould
Ireceive Idiabetes Iself-management Ieducation Iand Idiabetes Iself-management Isupport Iat Ithe Itime
Iof Idiagnosis.
Pharmacological Itherapy Ifor Itype I2 IDM Iis Irequired Iwhen Ilifestyle Imanagement Idoes Inot Iresult Iin
Iadequate Iblood Iglucose Icontrol. IDrug Itherapy Ishould Ialways Ibe Iconsidered Ian Iadjunctive
Itherapy Ito Ilifestyle Imanagement, Ias Ithe Ilatter Iis Itypically Iinitiated Ifirst. IThe IADA Iand IAACE
Irecommend Imetformin Iif Ithere Iare Ino Icontraindications, Isuch Ias Irenal Idisease Ior Iabnormal
Icreatinine Iclearance, Iacute Imyocardial Iinfarction, Ior Isepticemia.
The IAACE Irecommends Iadding Ia Isecond Iagent Ito Ilifestyle Itreatment Iand Imetformin Iif Ithe IA1C Iis
Imore Ithan I7.5% Iat Ithe Itime Iof Idiagnosis Ior Iafter I3 Imonths Iof Imonotherapy Iwithout Iachievement
Iof Ithe Ipatient’s Iblood Iglucose Igoals. IMetformin Ican Ibe Iused Ias Ia Imonotherapy Iunless Ithe Ipatient
Ihas Icontraindications Ior Iintolerance. IAlthough Imetformin Iis Ithe Ifirst-line Imedication
Irecommended Iby Ithe IADA Iand Ithe IAACE Ifor IDM Itype I2, Iit Ishould Ibe Iused Ionly Iin Ipatients Iwith
Iadequate Irenal Ifunction Iand Ishould Inot Ibe Iused Iin Ipatients Iwith Ian IeGFR Ibelow I45 ImL/min/1.73
2
Im .
• Immediately Iupon Idiagnosis Iof Itype I2 IDM, Ibegin Ilifestyle Itherapy Iwith Imedically Iassisted
Iobesity Itreatment.
• If Iglycemic Igoals Iare Istill Inot Imet I3 Imonths Ilater, Ibegin Isingle-agent Ior Idual Itherapy Iwith Ioral
Iantidiabetic Iagents, Idepending Ion Iwhether IA1C Iis Iless Ithan Ior Igreater Ithan I7.5%.
• If Iglycemic Igoals Iare Inot Imet Iin I3 Imonths, Iinitiate Itriple Itherapy.
• If Iafter I3 Iadditional Imonths I(or Iat Ithe Itime Iof Idiagnosis) IA1C Iis I9.0% Ior Ihigher Iand Ithe Ipatient
Iis Isymptomatic, Iadd Iinsulin Itherapy.
• A1c-Gyycemic Ilevel Iover I2-3months Iand Iis Ihelpful Iis Idocumenting Icontrol Iand
Icontinuing Icare.
• A1c Iless Ithan I7% Iindicate Istrong Icontrol
• 6.5%or Iless Idecrease Ioccurrence Iof Icomplications Iachieved Iw/o Ihypoglycemia Ior Iother
Iadverse Ieffect.
2
, Medication ISide IEffects
-Type I1:
Hypoglycemia Iis Ia Icommon Ioccurrence Iin Ipatients Iwith Itype I1 IDM Iand Ioccurs Ifor Ia Ivariety Iof Ireasons:
Iexcessive Iexogenous Iinsulin, Imissed Imeals Ior Iinadequate Ifood Iintake, Iexcessive Iexercise, Ialcohol
Iingestion, Idrug Iinteractions, Ior Idecreases Iin Iliver Ior Ikidney Ifunction. ISigns Iand Isymptoms: Idiaphoresis,
Itachycardia, Ihunger, Ishakiness, Ialtered Imentation I(ranging Ifrom Ian Iinability Ito Iconcentrate Ito Ifrank
Icoma), Islurred Ispeech, Iand Iseizures. IThe IADA Iclassifies Ihypoglycemia Ias Ia Iplasma Iglucose Ilevel Iof I< I54 Ias
Iserious, Iclinically Isignificant Ihypoglycemia. IA Iblood Iglucose Ilevel Iof I70 Iis Iconsidered Ia Ithreshold Ilevel
Ithat Irequires Iintervention. IExamples Iof Iappropriate Ifoods: I#1 Ichoice: Ipure Iglucose, I½ Icup Ifruit Ijuice, I6oz
Iregular Isoda I(not Idiet Ior Isugarless), I1 Icup Imilk, Ior Iglucose Itabs. ICandy Iis Ionly Ia Ilast Iresort. IRecheck
Iglucose I15 Iminutes Iafter Itreatment. IAdditional Icarbs Ican Ibe Igiven Iif Iglucose Iis Istill Iless Ithan I70
-Type I2:
Metformin Ican Icause: Ihypoglycemia Iesp Iin Iolder Iadults, Iadverse Ireactions Isuch Ias IGI Idisturbances Iand
Imetallic Itaste, Iand Iis Icontraindicated Iin Irenal Idisease Iso Iassess Irenal Ifunction Iprior Ito Iprescribing.
- Metformin Ialso Ihas Ia Iboxed Iwarning Iin Iits IFDA-approved Iprescribing Iinformation Ifor Ilactic
Iacidosis, Ialthough Ithis Iside Ieffect Iis Ivery Irare. IMetformin Ishould Ibe Idiscontinued I24 Ito I48 Ihours
Ibefore Idiagnostic Iand Isurgical Iprocedures Idue Ito Ithe Irisk Iof Idecreased Ikidney Ifunction, Iand Iits
Iadministration Ishould Inot Ibe Iresumed Ifor Iat Ileast I6 Ihours Iafter Ithese Iprocedures Ior Iuntil Ithe
Ipatient Iis Iadequately Ihydrated. IInitial Idosing Iis I500 Img Ionce Ia Iday Iwith Ibreakfast Ior Idinner Ifor I1
Iweek, Ithen Itwice Idaily Iwith Ibreakfast Iand Idinner. ISeveral Iweeks Iof Itherapy Imay Ibe Ineeded Ito
Iachieve Imaximum Ieffects Iof Ithe Igiven Idose. ICommon Iadverse Ireactions Iinclude Idiarrhea,
Inausea, Ianorexia, Iand Iabdominal Idiscomfort, Iwhich Iusually Iresolve Iwith Ia Igradual Iincrease Iof
Idosage. IMetformin Ihas Ibeen Ishown Ito Icause Idecreased Ivitamin IB12 Iabsorption, Iand Ipatients Ion
Ilong-term Imetformin Itherapy Ishould Iundergo Iperiodic Itesting Ifor IB12 Ideficiency, Iespecially Iif Ithe
Ipatient Icomplains Iof Iperipheral Ineuropathy. IAt Ithe Imaximum Idose, Ithe Imonthly Icost Iof
Imetformin Iin Ithe IUnited IStates Iis Iapproximately I$4 Ion Imany Igeneric Iformularies. IMetformin Iis
Icurrently Ifound Iin I20 Icombination Iformulations Iwith Iother Imedications.
*For Iother Inoninsulin Iagent Iadverse Ireactions Isee Ipg I929 IDunphy Ibook*
SINGLE-DOSE THERAPY
Single Injection
• Intermediate or long-acting insulin with or without regular insulin in the
morning or Intermediate or long-acting insulin at bedtime
• Recommend at a minimum SMBG in the morning and at bedtime
CONVENTIONAL SPLIT-DOSE THERAPY
Two Injections
• Mixture of NPH and regular insulin in the morning and evening
• Recommend at a minimum SMBG before each dosing and at bedtime
INTENSIVE INSULIN THERAPY
3
