Insulin Therapy

NURS 108ECC- Spring, 2008

Majuvy L. Sulse MSN, RN, CCRN

Insulin

Exogenous substance Purified insulin prep from beef and pork Human insulin preparation (synthetic)-

more rapid onset of action, shorter peak action Preferred for pregnant women Clients beginning insulin therapy clients going for intermittent use only

Uses of Insulin therapy Type 1 diabetes Meet metabolic demands Oral agents are unable to maintain satisfactory blood

glucose levels

Types

Types differ in regard to onset, peak action, and duration

Available in 100 units/ml or 500 units/ml (500 unit/ml & Lispro needs Rx)

Combinations are tailored according to blood glucose level, lifestyle, eating & activity patterns.

Rapid ActingShort ActingIntermediate actingLong ActingCombination therapy

RAPID-ACTING INSULINS

Humalog (insulin Lispro, aspart or Novolog), in which a chemical change has been made to the insulin molecule. This gives the insulin a very desirable property of extremely rapid absorption. Onset is 15 minutes

Peak action of Lispro insulin is about 60-90 minutes after injection, and insulin levels fall off rapidly after 3 to 4 hours.

This allows the insulin, if given before the meal, to control the post-meal rise of glucose much better, and to reduce the chance of hypoglycemia (because insulin levels drop faster). This may well be its greatest advantage.

It can essentially substitute for any short-acting insulin.

SHORT-ACTING INSULINS

These include Humulin R (HR), and Novolin Toronto (also known as regular) insulins.

Rapid-acting insulins start being absorbed in 30-60 minutes

Peak action within 2 to 3 hours of injection in most individuals.

Duration of action is approximately 4 to 6 hours Short-acting insulins are often used before eating to control the large rise of blood glucose that often occurs after a meal. Ideally, short-acting insulin is taken approximately 30-45 minutes before the meal, as it takes up to 2 hours to see its main effect. However, most people take their insulin just before eating.

INTERMEDIATE-ACTING INSULINS

Includes NPH and Lente, start being absorbed 2-3 hours after injection

Peak action after 6-8 hours. Duration of action may be as much as 12-

16 hours after injection. Used in the morning, its greatest action would be in the afternoon. One of the best uses is injection at bedtime to control the morning glucose of the next day.

LONG-ACTING INSULINS

Mainly includes the UltraLente insulin. Onset-2 hours Peak effect occurring after 16-20 hours Duration of action may be 24 hours, and vary

occasionally longer. It is not a popular insulin. It is mainly used in individuals in whom intermediate-acting insulins taken at bedtime act too quickly, resulting in hypoglycemic reactions during the night.

By using a human UltraLente, one can slow down the peak action by an hour or two, often preventing hypoglycemia at night, but controlling the fasting sugar of the next day.

LONG-ACTING INSULINS

Insulin Gargline (Lantus)-long acting insulin analog is used for once daily subcutaneous injection at bedtime to provide basal insulin coverage

Cannot be mixed/diluted with other types of insulin. Mixing may result in a cloudy solution and an unpredictable alteration in both the onset of action and time to peak effect

Pharmacokinetics of Insulin

Injection site-rotation of sites Absorption rate-

larger doses prolongs absorption, longer duration of action provides less consistent

absorption Injection into scar tissue delays absorption

Injection depth- Time of injection- Mixing of insulins-mixing different types can change the

timing of peak insulin action

Method of administration

Subcutaneous IV- as a drip or IVP MDI-multiple daily insulin injections-uses

immediate and long acting insulin as basal component together with frequent blood glucose monitoring

Insulin pump-continuous subcutaneous injection in the abdominal wall via a small plastic tube to a catheter into subcutaneous tissue-tight glucose control, flexibility & close to normal lifestyle

Insulin Pump

Release an additional bolus from the same cartridge and via the same infusion set at mealtimes and to correct the blood sugar

Increase or reduce the basal insulin supply as needed for a certain period of time without having to reprogram the basal rate for every hour,

Program / adjust the basal rate himself/herself. The insulin pump does not measure blood sugar

and also does not react automatically to fluctuations in blood sugar. The pump user must handle blood sugar monitoring himself/herself and make any adjustments to the insulin dosage

Features of an Insulin Pump

Method of administration

New Technology Nasal spray administered via a nebulizer Inhalation- regular insulin (U-500) delivered

in an inhaler during inspiration Transdermal also being tested

Problems associated with Insulin Therapy

Hypoglycemia Allergic reaction-itching, burning, redness around site Lipodystrophy-

lipohypertrophy –increased fat deposits in the skin Lipoatrophy-loss of fatty tissue

Somogyi effect-treat with less insulin Dawn Phenomenon-hyperglycemia on awakening due to

release of growth hormones or cortisol levels-treat with increase insulin for the overnight period or adjust insulin administration (intermediate) to be given at 10 pm

Patient Diabetic Teaching

MedicationStorageDose preparationSyringesBlood glucose monitoring

Patient Diabetic Teaching

Medication Recognize characteristics, purpose, and

action, dosage, duration, and adverse effects of medication

Inform the generic and brand names of insulin Evaluate client’s ability to self administer

medications Instruct what to do if medication is missed Instruct client how to mix medications

Patient Diabetic Teaching

Storage-Store new vials of insulin in the refrigerator. The vials you will use within 30 days can be stored at

normal room temperature. In case you don't finish a vial within 30 days, keep it in

the refrigerator. 30 minutes before having a shot, remove the vial from

the refrigerator so the shot will hurt less. Put it back in the refrigerator until you use it next time. Never store your insulin in the glove compartment of

your car; extremes temperatures can spoil your insulin. If it is very cold try to keep your insulin in a pocket close

to your body. In hot weather use special bags with an ice pack; insulin

must be kept cool but not frozen.

Patient Diabetic Teaching

Dose PreparationInspect the bottle before each use for

changes that may signify loss in potency (clumping, precipitation, frosting, or change in color & clarity)

Rapid & short acting should be clear; all others cloudy

Mixing Different types of Insulin

Wash hands Gently rotate NPH insulin bottle Wife off top of vial with alcohol swabs Draw back amount of air into the syringe that equals total

dose Inject air equal to NPH dose into NPH vial Inject air equal to regular dose into regular vial Invert regular insulin vial and withdraw regular insulin

dose Carefully withdraw NPH dose

Patient Diabetic Teaching

Syringes-marked in insulin units

Differs in unit increments Insulin syringes comes in

1 ml, 0.5ml, and 0.3 ml reuse of syringes for same

client does not increase rate of infection at site

Patient Diabetic Teaching

Injection Rotating sites-abdomen, arms, thigh, buttocks 90 or 45 degree angle subcutaneously

90 degree angle if able to grasp a fold of skin 45 degree if individual is thin to avoid IM injections

Aspiration for blood is not necessary

Sites of Administration

Blood Glucose monitoring

Cornerstone in diabetes managementDetects hyper and hypoglycemic episodesEnables patient to make decisions

regarding diet, exercise and medicationsFrequency of testing depends

Pt. glycemic goals Type of diabetes Pt ability to perform test Willingness to test

Patient Teaching Guide

Wash hands in warm waterLet hands hang in dependent position or

warm hands in warm water if unable to obtain adequate blood sample

Use side of finger rather than the centerDeep punctures unnecessary and causes

pain & bruising