BC ADM Insulin Therapy 5 — Questions and Answers
Question 1: A patient with CKD stage 4 (eGFR 22 mL/min) requires insulin dose adjustment because:
- The kidneys produce insulin resistance factors that decrease as renal function declines
- Reduced renal insulin clearance prolongs insulin action and increases hypoglycemia risk (Correct answer)
- Uremia accelerates insulin degradation requiring higher doses
- Renal impairment reduces carbohydrate absorption, necessitating lower doses
Correct answer: Reduced renal insulin clearance prolongs insulin action and increases hypoglycemia risk
The kidneys clear approximately 30–40% of circulating insulin; as renal function declines, insulin half-life is prolonged, increasing hypoglycemia risk and requiring dose reduction.
Question 2: Which technique most effectively prevents insulin leakage after subcutaneous pen injection?
- Withdraw the needle immediately after pushing the plunger
- Hold the pen in place for 10 seconds after delivering the full dose before withdrawing (Correct answer)
- Inject at a 90-degree angle regardless of body habitus
- Apply pressure to the site with an alcohol swab immediately after withdrawal
Correct answer: Hold the pen in place for 10 seconds after delivering the full dose before withdrawing
Keeping the needle in place for at least 10 seconds after dose delivery allows the insulin to disperse and prevents backflow through the needle track.
Question 3: Intravenous insulin infusion protocols in the ICU are preferred over subcutaneous insulin primarily because IV administration:
- Has a higher insulin bioavailability than subcutaneous injection
- Allows precise, titratable glucose control with rapid dose adjustments (Correct answer)
- Eliminates the need for blood glucose monitoring
- Prevents insulin antibody development in critically ill patients
Correct answer: Allows precise, titratable glucose control with rapid dose adjustments
IV insulin has immediate onset and offset, enabling precise glycemic control with rapid titration in response to the rapidly changing metabolic state of critically ill patients.
Question 4: A patient is prescribed concentrated insulin glargine U-300. Compared to U-100 glargine, which statement is accurate?
- U-300 glargine has a shorter duration of action than U-100 glargine
- U-300 glargine has a flatter, more prolonged action profile than U-100 glargine (Correct answer)
- The same volume is injected regardless of concentration
- U-300 glargine requires twice-daily dosing for full coverage
Correct answer: U-300 glargine has a flatter, more prolonged action profile than U-100 glargine
U-300 glargine forms a more compact subcutaneous depot that dissolves more slowly, yielding a flatter pharmacodynamic profile and longer duration (up to 36 hours) than U-100 glargine.
Question 5: The extended-release insulin icodec (once-weekly basal insulin) achieves its prolonged half-life primarily through:
- Covalent binding to albumin that slowly releases free insulin over 7 days
- A unique hexameric structure that resists subcutaneous protease degradation
- Strong reversible binding to albumin via a fatty acid chain, reducing free insulin fraction (Correct answer)
- Encapsulation in a biodegradable polymer that releases insulin continuously
Correct answer: Strong reversible binding to albumin via a fatty acid chain, reducing free insulin fraction
Insulin icodec contains a C20 fatty di-acid moiety that allows strong, reversible albumin binding, dramatically reducing free insulin and extending its half-life to ~196 hours.
Question 6: A patient switches from NPH insulin given twice daily to insulin detemir. The diabetes care specialist should counsel that detemir:
- Should always be given once daily at bedtime only
- May require twice-daily dosing due to its shorter duration compared to other basal analogs (Correct answer)
- Provides identical 24-hour coverage with once-daily dosing for all patients
- Has no dose-dependent duration and must be given three times daily
Correct answer: May require twice-daily dosing due to its shorter duration compared to other basal analogs
Insulin detemir's duration is dose-dependent and shorter than glargine or degludec; many patients, especially those on lower doses, require twice-daily administration for adequate 24-hour coverage.
Question 7: During sick-day management for a patient with type 1 diabetes, insulin should be:
- Held until oral intake resumes to prevent hypoglycemia during illness
- Continued or increased as needed, with frequent glucose and ketone monitoring (Correct answer)
- Reduced by 50% when the patient cannot eat normal meals
- Switched from rapid-acting to regular insulin only during illness
Correct answer: Continued or increased as needed, with frequent glucose and ketone monitoring
Counter-regulatory hormones during illness increase insulin requirements; insulin should be continued with supplemental correction doses, guided by frequent glucose and ketone checks to prevent DKA.
BC ADM Insulin Therapy 5
A patient with CKD stage 4 (eGFR 22 mL/min) requires insulin dose adjustment because: