QuestionSBA
QuestionChoice
As his morning blood glucose level is persistently high, adjustments should be made to his long acting evening insulin dose instead of just giving a PRN short acting insulin
34446
b
Biphasic insulin detemir (Levemir Penfill) 15 units SC and soluble insulin (Actrapid ®) 2 units SC
QuestionChoice
Decreasing the insulin dose to 13 units would be inappropriate as this could worsen his glycaemic control
34447
c
Decrease Biphasic insulin detemir (Levemir Penfill) to 13 units SC BD
QuestionChoice
As his morning blood glucose level is high, the evening insulin dose should be increased, usually by 10% to 20%. As he normally takes 15 units of insulin in the evening, a 10% to 20% increase to 16.5 to 18 units should be made
34448
d
Increase evening Biphasic insulin detemir (Levemir Penfill) to 22 units SC
QuestionChoice
The patient has poorly controlled hyperglycaemia, with high levels of blood glucose in the morning. After ruling our DKA with serum and urinary ketones, a dose adjustment should be considered if glucose levels remain high. As his morning blood glucose level is high, the evening insulin dose should be increased, usually by 10% to 20%. As he normally takes 15 units of insulin in the evening, a 10% to 20% increase to 16.5 to 18 units should be made
34445
a
Increase evening Biphasic insulin detemir (Levemir Penfill) to 17 units SC
QuestionChoice
Increasing to 22 units is more than 20% of his usual dose. Variable rate insulin infusion is considered in a hyperglycaemic patients who are nil by mouth and who have failed to respond to adjustments of their usual insulin regime
34449
e
Stop biphasic insulin detemir (Levemir Penfill) SC and start variable rate insulin infusion
QuestionComment
where on the BNF can i find this?

59427
User
subscriber
Axillary RNA
Concept
Chapter
#### Monitoring

The BNF advises to monitor lung function (in patients with a history of obstructive airway disease).

#### Overdoses

Overdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).
Non-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.

Management
 - Airway protection 
 - Activated charcoal within 1 hour
 - IV Fluids
 
IV glucagon is the first-line management.
 
For symptomatic bradycardia, IV atropine may be used.

2618
2832
Insulin Titration
Topic
9
Internal Medicine
6900
Case Presentation:




A 25-year-old lady was admitted to the Respiratory Ward following an exacerbation of asthma. PMH Type 1 diabetes mellitus, Asthma. DH Salbutamol 200micrograms INH PRN, Fluticasone 50 micrograms BD INH 12-hrly, Biphasic insulin detemir (Levemir Penfill) 15 units SC 12-hrly.


 **On Examination**

HR 90/min and regular


BP 125/85 mmHg


RR 25/min


O2 sats 96% on room air


Temperature 37.5oC.


 **Investigations**

||||
|---------------------------|:-------:|--------------------|
|Sodium|140 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Urea|6 mmol/L|2.5 - 7.8|
|Creatinine|85 µmol/L|60 - 120|


Urinary ketones negative.


Average capillary blood glucose readings are 15 mmol/L prior to breakfast and 5.8 mmol/L prior to evening meal (normal range 3.5-5.5 mmol/L).


VBG Ketones 0.3 mmol/L (<0.6mmol/L)


Question:
Select the most appropriate decision option with regard to the evening dose of insulin based on these data.
a