diabetes treatments: options for insulin delivery bonnie pepon, rn, bsn, cde certified diabetes...
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Diabetes Treatments: Diabetes Treatments: Options for Insulin Options for Insulin
DeliveryDelivery
Bonnie Pepon, RN, BSN, CDECertified Diabetes Educator
Conemaugh Diabetes Institute
DiabetesDiabetes
21 million people in the U.S. have diabetes
$132 billion each year◦Type 1 diabetes – no insulin production◦Type 2 diabetes – some insulin production
Classes of MedicationsClasses of Medications
• Sulfonylureas
• Meglitinides
• Biguanides
• Alpha Glucosidase Inhibitors
• Thiazolidinediones-TZD’s
• Incretin Mimetics
• DPP IV Inhibitors
SulfonylureasMost common drugs in this class:
• Glipizide (Glucotrol, Glucotrol XL)• Glyburide (Micronase, Diabeta,
Glynase)• Glimepiride (Amaryl)
How do they work?
• Stimulate the pancreas to make more insulin
• Work for up to 24 hours• Lowers fasting and post prandial blood
sugar
Advantages:
• May decrease AIC 1.5-2%• Inexpensive
Side effects:
• Weight gain (4.5-11 lbs.)• Low blood sugar
How to take:
• Take glipizide 30 min before the first meal of the day
• All others take with first meal of the day
MeglitinidesMost common drugs in this class:
• Repaglinide(Prandin) • Nateglinide (Starlix)
How do they work?
• Stimulate the pancreas to make more insulin
• Work only for about 4 hours after meals
• Only effects post prandial sugars – NOT FASTING!
Advantages:
• May decrease A1C by 1-2%
Side effects:
• Weight gain• Low blood sugar
How to take:
• Take up to 30 minutes before meals • No meal= No pill
BiguanidesMost common drugs in this class:
• Metformin (Glucophage, Glucophage XR)• Liquid Form (Riomet)
How do they work?
• Helps your body produce less glucose from the liver
• Helps insulin work better• Reduces glucose absorption in the
intestines• Takes up to 2 weeks to see maximum
effect
Advantages: • Can decrease AIC 1.5-2%• Does not cause low blood sugar or
weight gain• May also lower triglycerides and
cholesterol
Side effects: • Nausea and Diarrhea
How to take:
• Take with breakfast and supper
Alpha Glucosidase InhibitorsMost common drugs in this class:
• Acarbose (Precose)• Miglitol (Glyset)
How do they work?
• Slows the digestion of carbs in the small intestine, thus decreasing the post prandial blood sugar spike
Advantages:
• May decrease A1C by 0.5 to 1%• Does not cause low blood sugar or
weight gain
Side effects:
• Gas and diarrhea
How to take:
• Take with first bite of food of 3 largest meals of the day
Insulin Sensitizers-TZD’SMost common drugs in this class:
• Rosiglitazone (Avandia)• Pioglitazone (Actos)
How do they work?
• Helps insulin work better• Enhances glucose uptake by the muscle
tissue • Reduces glucose production by the liver• Takes up to 3 months to see maximum
effect
Advantages: • May decrease A1C by 0.5-1%• Does not cause low blood sugar• May decrease triglycerides and increase
HDL
Side effects: • Swelling in legs and weight gain (caution in heart failure)
• If on oral contraceptive, may increase risk of pregnancy
• Liver damage (<1% chance)• Liver function is monitored every 2
months for the first year
Combination DrugsCombination Drugs
• Glucovance (glyburide/metformin)
• Metaglip (glipizide/metformin)
• Avandamet (avandia/metformin)
• Duetact (amaryl/actos)New Ones:• Fortamet (metformin SR)• Glumetza (metformin SR)• Actoplus (actos/metformin)• Avandryl (avandia/glimepiride)
Incretin Mimetics: Gut HormonesIncretin Mimetics: Gut Hormones
◦Byetta (Exenatide) approved for type 2
◦Symlin (Pramlintide) approved for type 1 and type 2 using mealtime insulin
Byetta How do they work?
• Prevents stored sugar from entering the blood stream• Stimulates insulin release • Slows gastric emptying• Lowers post prandial blood sugar spike• Makes you feel full• Reduces food intake and appetite
Advantages: • May decrease A1C by 1% after 6 months• Promotes weight loss (5-6 lbs)
Dosing: • Comes in a prefilled pen that lasts one month• 5 mcg twice a day for 1 month, then increase to 10mcg
twice a day• Give within 60 minutes of morning and evening meal• Do NOT give after a meal• If you miss a meal, skip the dose
Side effects: • Nausea (will go away with time and dose titration)• Vomiting and diarrhea• Low blood sugar• May need to decrease dose of sulfonylurea to avoid low
blood sugar
Symlin
How do they work?
• Slows gastric emptying• Lowers the post prandial blood sugar
spike• Makes you feel full• Reduces food intake and appetite• Slows production of glucose from liver
Advantages: • May lower A1C by 0.6% in Type 2 after 6 months
• Promotes weight loss (4 lbs)
Side effects: • Nausea (will decrease over time)• Loss of appetite• Vomiting• Hypoglycemia (3 hours after dose)• Decrease amount of rapid acting insulin
by 50%
DPP IV InhibitorsDPP IV Inhibitors
Januvia (Sitagliptin)
Oral active, selective inhibitor for the DPP-4 enzyme
A1C effect-decreased by 0.65-0.8%
Can be administered with or without food
Not for type 1 diabetes
Rapid Acting InsulinInsulin Onset of
actionPeaks Duration
Humalog or lispro
5 to 15 minutes
30 to 60 minutes
3 to 5 hours
Novolog or aspart
Apidra or glulisine
Short Acting InsulinHumulin R or Novolin R
30 minutes
2 to 3 hours
3 to 6 hours
Clear in appearanceAvailable in vials and pens
Intermediate Acting InsulinInsulin Onset of
actionPeaks Duration
Humalin N (NPH) or Novolin N (NPH)
2 to 4 hours
4 to 12 hours
12 to 18 hours
Cloudy in appearanceAvailable in vials and pens
Long Acting InsulinLevimir (detemir)
1 to 2 hours
6 to 8 hours
6 to 23 hours
Lantus (glargine)
1 hour no peak 24 hours
Clear in appearanceAvailable in vials and pensCannot be mixed in the same syringe with any other type of insulin
Syringe/Needle/VialSyringe/Needle/VialInsulin comes in U–100 in the
U.S.◦orange cover and black scale◦100 units of insulin per milliliter of
fluid in the vial
U–500 available◦high insulin resistance using more
than 200 units a day
Outside the U.S.: U-40◦red cover and red scale
Syringe/Needle/VialSyringe/Needle/Vial
Most common method of delivery
Syringes (range of sizes) needle gauge needle length syringe capacity
3/10cc, 1/2cc, 1cc
Insulin NeedlesInsulin Needles Syringes available
1/2 in or 12.7 mm 5/16 or 8mm
Pen needles available ½ in 5/16 in 3/16 in
Gauges available 31, 30, 29, 28
Insulin DevicesInsulin Devices
Syringes
◦Syringes are most widely available◦Can be adjusted to 1 or ½ units◦Can use most types of insulin◦Require good vision to measure a dose
Insulin DevicesInsulin Devices
Pens
◦Easy to set the correct dose by a dial◦Can be adjusted with ½ units or 1 unit◦Can use most types of insulin◦Very convenient and accurate for the vision
impaired and those on the go
Insulin DevicesInsulin Devices
Pumps
◦Results in better diabetes control◦More flexible eating schedule◦Dose adjusted by 1/10 to 1/20 units◦Requires higher level of involvement & more
advanced diabetes education and skills
Insulin SyringesInsulin Syringes
Multiple manufacturers◦BD, Monoject, SureComfort,
Ulticare Precision Sure Dose, UltiGuard, Medicore, Aimsco
Injection aides◦Inject-Ease by BD and Palco,
Instaject (can be combined with a lancet device), NeedleAid, NovoPen 3 Penmate
Insulin PensInsulin Pens
Uses an insulin needle ◦available in different sizes and gauges◦units can be counted as dialed by a click◦plunger is pushed in and held for several
seconds before removing the needle
Insulin PensInsulin Pens
Storage in refrigerator until the pen is started◦storage life ranges from 7 to 42 days
Pre-filled pens◦28 days: Humalog/Novolog/Novolin R◦14 days: Novolin N◦10 days: Novalin 70/30
Insulin Pens: Insulin Cartridges
1.5 mlInsulin Days
Humalog 28 days
Novolin R 30 days
Novolin 70/30 and Novolin N
7 days
3 mlNovolin R/Novolog/Lantus
28 days
Novolin N 14 days
Novolin 70/30 10 days
Levemir 42 days
Pre-mixed InsulinInsulin Onset of
actionPeaks Duration
Humalog mix 75/25 or 50/50
30 minutes
2 to 4 hours
22 to 24 hours
Humulin mix 70/30 or 50/50
Novolog mix 70/30
Novolin mix 70/30
Helpful for those with poor eyesight, dexterity problems or those who have trouble mixing from 2 different vials
Inhaled InsulinInhaled Insulin
Delivers rapid acting dry powder insulin
Absorbed through the lungs into the bloodstream◦1mg and 3mg blister packets◦Cannot be used for smokers, children, pregnant
women or anyone with lung problems
Will be taken off the market in January 2008
Insulin InfuserInsulin Infuser
Minimize needle sticks by creating a portal to inject insulin into
A small tube is inserted into the fatty tissue of the injection site
It is taped in place for 2-3 daysInsulin injected into the tube via pen or
syringe instead of the skin
Insulin Delivery SystemsInsulin Delivery SystemsIn the FutureIn the Future
Oral insulinTransdermal insulinBuccal insulinArtificial pancreasImplantable insulin pump
Case StudyCase Study
45 year old African-American maleDiagnosed with Type 2 DM Initial glucose 280mg/dl, A1C–9.9%
◦ Started on nutrition and physical activity◦ 3 months later still having symptoms◦ PMH –hypertension, obesity, high lipids◦ Smoker, occasional alcohol, no drug use
What therapy should be started?