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Pharmacological management Insulin

Pharmacological management Insulin. 60. 40. Insulin. 20. 0. Insulin. A hormone secreted by the beta cells Secreted in response to glucose or other stimuli, such as amino acids

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Pharmacological management Insulin

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  1. Pharmacological managementInsulin Slides current until 2008

  2. 60 40 Insulin 20 0 Insulin • A hormone secreted by the beta cells • Secreted in response to glucose or other stimuli, such as amino acids • Normal response characterized by low basal levels of insulin, with surges of insulin triggered by a rise in blood glucose Slides current until 2008 Breakfast Lunch Supper

  3. Insulin action • Increases glucose uptake, particularly in muscle, liver and adipose tissue • Suppresses glucose output from the liver • Increases formation of fat • Inhibits breakdown of fats • Promotes amino-acid uptake and prevents protein breakdown Slides current until 2008

  4. Indications for insulin therapy • Type 1 diabetes • Women with diabetes who become pregnant or are breastfeeding • Transiently in type 2 diabetes in special situations • In type 2 diabetes, inadequately controlled on glucose-lowering medicines (secondary failure) Slides current until 2008

  5. Insulin therapy • Insulin therapy aims to replicate the normal physiological insulin response • Insulin regimens should be individualized • type of diabetes • willingness to inject • lifestyle • blood glucose monitoring • age • dexterity • glycaemic targets Slides current until 2008

  6. Insulin types and action Slides current until 2008

  7. International labeling www.idf.org Slides current until 2008

  8. Variability in insulin absorption Slides current until 2008

  9. Factors affecting absorption • Lipohypertrophy • Dose of injection • Site and depth of injection • Exercise • Ambient and body temperature • Insulin type • Incomplete re-suspension Slides current until 2008

  10. ACTIVITY • What is the most common insulin regimen used in your country? • How well do you think it works? • How do people accept insulin? Slides current until 2008

  11. 60 40 Insulin 20 0 Insulin regimens: once a day insulin Endogenous insulin Soluble insulin Intermediate-acting insulin Breakfast Lunch Supper Slides current until 2008

  12. 60 40 Insulin 20 0 Twice a day insulin Endogenous insulin Soluble insulin Intermediate-acting insulin Breakfast Lunch Supper Slides current until 2008

  13. 60 40 Insulin 20 0 Three times a day insulin Endogenous insulin Soluble insulin Intermediate-acting insulin Breakfast Lunch Supper Slides current until 2008

  14. 60 40 Insulin 20 0 Basal-bolus regimen Endogenous insulin Rapid-acting insulin analogue Intermediate-acting insulin Breakfast Lunch Supper Slides current until 2008

  15. 60 40 Insulin 20 0 Long-acting insulin analogues Endogenous insulin Rapid-acting insulin analogue Long-acting insulin analogue Breakfast Lunch Supper Slides current until 2008

  16. Commencing insulin therapy • Insulin should never be used as a threat • Fear of injecting is common; needle phobia is rare • Healthcare professional’s attitude is key to acceptance • People should be praised and encouraged to promote a positive attitude • Blood test is more painful than insulin injection • Forget the oranges; just do it! Slides current until 2008

  17. Commencing insulin therapy • Starting dose will depend on many factors • age • weight • type and duration of diabetes • glycaemic targets • In type 2 diabetes, consider continuing maximum tolerated oral glucose-lowering medicines • 10 units of intermediate-acting insulin once a day Slides current until 2008

  18. Injecting insulin • Should be given into subcutaneous tissue • Skin of a very thin person may have to be gently pinched • Insulin at room temperature less painful • Needle can be inserted at 45-90º • 45º for very thin people • 90º for overweight people or when using short needle • Swabbing with alcohol is not necessary Slides current until 2008

  19. Insulin devices Syringe and needle • Usually disposable, intended for one injection only • May need to use doses divisible by 5 or 10 if visually impaired Pens • Easy to use • Loading pen may be difficult for elderly • Disposable pens Slides current until 2008

  20. Insulin devices Pumps • Insulin delivered every few minutes over 24 hours • Require large commitment Inhaled insulin • For bolus doses only • Large device • Unknown long-term effects on lungs Slides current until 2008

  21. Adjusting insulin – what are the targets? • Treatment targets should be individualized, especially for very young and very old • Absence of hypoglycaemia *CDA 2003, *1ADA 2004, *2 IDF 2005 Slides current until 2008

  22. FINFAT: start small dose intermediate- acting insulin at night Aim for target fasting levels first Adjust by 2-4 units or 10% Second injection only added once fasting targets reached Starting insulin in type 2 diabetes Slides current until 2008

  23. Pattern management Watch levels for 2-3 days Address hypoglycaemia first Aim for target fasting levels next Adjust by 2-4 units or 10% Wait 2-3 days Adjusting insulin Slides current until 2008

  24. Adjusting insulin • Flexible dose guideline • Eating more • Exercising more • Insulin to carbohydrate ratio • Evaluate with next blood glucose • Tailored to individual needs Slides current until 2008

  25. Which insulin to adjust when? Slides current until 2008

  26. Insulin practicalities • Timing • Soluble insulin: 30-45 minutes pre-meal • Short-acting insulin analogues: no more than 15 minutes pre-meal and can be given post-meal • Intermediate- or long-acting insulins do not have to be given in relation to a meal Slides current until 2008

  27. Insulin practicalities Storage • One month in fridge or at room temperature once the vial has been opened • Must never be frozen • Store away from source of heat • If refrigeration not available store in clay pot or hole in ground • May be damaged by direct sunlight or vigorous shaking Slides current until 2008

  28. Precautions • Insulin strength may differ (U40, U100, U500) • Ensure that the syringe matches the strength! • Long-acting insulin analogues are clear in appearance • Identify and differentiate insulin type Slides current until 2008

  29. Mixing insulins • NPH and soluble insulins can be mixed without changing properties • Check with the manufacturer before mixing any other insulins • Pre-drawn syringes can be kept in fridge (2-80 C or 36-460 F)for one month Slides current until 2008

  30. Side effects • Hypoglycaemia • Weight gain • Lipohypertrophy • Lipoatrophy • Insulin oedema • Allergic reaction Slides current until 2008

  31. Example 1 Insulin: NPH 25 units, Reg. 10 units before breakfast NPH 15 units, Reg. 10 units before supper Slides current until 2008

  32. Insulin: rapid-acting before each meal and NPH at bedtime Example 2 Slides current until 2008

  33. ACTIVITY What would you advise if…. • The insulin had been taken and the restaurant meal was late • Regular insulin should be taken before a meal but the pre-meal blood glucose is 3.5 mmol/L (63 mg/dl) • A tennis match is scheduled an hour after lunch • A person wakes up nauseated and does not want to eat • Blood glucose levels do not coincide with how a person feels Slides current until 2008

  34. Summary • All people with type 1 diabetes must be treated with insulin • The majority of people with type 2 diabetes will need insulin within 5 to 10 years of diagnosis • Insulin therapy should not be used as a threat • Insulin regimens should be individualized • Insulin should be adjusted to achieve blood glucose as close to target range as possible Slides current until 2008

  35. Review question • One advantage that rapid-acting insulin has over regular insulin is that it: • Must be given immediately after the meal • Does not have to be kept in the fridge • Does not need a basal insulin to be given as well • Has a short and predictable action time Slides current until 2008

  36. Review question 2. Which of the following does not affect the absorption of insulin? • The temperature of the insulin • The temperature of the area to be injected • The amount of insulin to be injected • The type of injection device, i.e. pen or syringe Slides current until 2008

  37. Review question 3. Jonathan says his doctor has suggested he take insulin four times a day. He asks if this is not going to be too much insulin. What is your best response? • It is not possible to take too much insulin, you just have to eat more • The action of insulin taken four times a day is closest to the action of endogenous insulin • Taking insulin four times a day will be very difficult, and the results will not be much better • Your doctor feels that taking insulin four times a day will make you pay more attention to your diabetes Slides current until 2008

  38. Review question 4. Suleen has been on insulin twice a day – a mixture of intermediate and soluble in the morning, and again before dinner. Her records show that her fasting levels are 10-12mmol/L (180-216mg/dl), but the rest of the day, her levels are less than 8.5mmol/L (153mg/dl). What change(s) would you suggest to her insulin regimen to improve her levels? • Suggest she eats less at dinner and more at lunch • Suggest she increases her soluble before dinner • Suggest she increases her intermediate before dinner • Suggest she moves her intermediate to bedtime and decrease her soluble in the morning Slides current until 2008

  39. Review question 5. The goal of bedtime insulin in the person with type 2 diabetes who is on oral blood glucose-lowering medicines is to: • Provide insulin to cover the bedtime snack • Reduce the fasting glucose level • Reduce the number of oral blood glucose-lowering medicines • Prevent hypoglycaemia during the night Slides current until 2008

  40. Answers • d • d • b • d • b Slides current until 2008

  41. References • Klingensmith GJ, Ed. Intensive Diabetes Management, 3rd ed. Virginia: American Diabetes Association, 2003. • Colwell JA. Hot Topics Diabetes.Philadelphia: Hanley & Belfus, 2003. • American Diabetes Association. Insulin Administration. Diabetes Care 2004; 27(Suppl 1): S106-109. • Davidson MB. Diabetes Mellitus Diagnosis and Treatment. 4th ed. Philadelphia: W.B. Saunders Company, 1998. • Ilkova H, Glaser B, Tunckale A, Bagriacik N, Cerasi E. Induction of long-term glycemic control in newly diagnosed type 2 diabetic patients by transient intensive insulin treatment. Diabetes Care 1997; 20: 1353-6. • Nathan DM. Initial management of glycemia in Type 2 diabetes mellitus. N Engl J Med 2002; 347: 1342-9. • Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian Journal of Diabetes 2003; 27(suppl 2). • Olsson P-O, Hans A, Henning VS. Miscibility of human semisynthetic regular and lente insulin and human biosynthetic, regular and NPH insulin. Diabetes Care 1987; 10: 473-7. • IDF Clinical Guidelines Task Force. Global Guidelines for Type 2 diabetes. Brussels: International Diabetes Federation, 2005. Slides current until 2008

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