pharmacological management insulin

Slides current until 2008

Pharmacological managementInsulin

Insulin managementCurriculum Module III-3

Slide 2 of 41


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

Insu

lin

60

0

20

40

Breakfast Lunch Supper


Slide 3 of 41


Insulin action

1. Increases glucose uptake, particularly in muscle, liver and adipose tissue

2. Suppresses glucose output from the liver

3. Increases formation of fat

4. Inhibits breakdown of fats

5. Promotes amino-acid uptake and prevents protein breakdown


Slide 4 of 41


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)


Slide 5 of 41


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


Slide 6 of 41


Insulin types and actionOnset (hrs) Peak (hrs) Duration (hrs)

Rapidlispro aspart

<¼ ¾-2½ 3½-4½

Shortsolubleregular

½-1 2-4 6-8

IntermediateNPHlente

1-21-3

6-12 6-12

18-24 18-24

Long actingultralente glarginedetemir

4-63-41-2

8-20 3-243-8

24 or more≥24 or more 12-24 (dose-dependent)


Slide 7 of 41


International labeling

www.idf.org


Slide 8 of 41


Variability in insulin absorption


Slide 9 of 41


Factors affecting absorption

• Lipohypertrophy

• Dose of injection

• Site and depth of injection

• Exercise

• Ambient and body temperature

• Insulin type

• Incomplete re-suspension


Slide 10 of 41


• What is the most common insulin regimen used in your country?

• How well do you think it works?

• How do people accept insulin?

ACTIVITY


Slide 11 of 41


Insulin regimens: once a day insulin

Soluble insulin

Intermediate-acting insulin

Insu

lin

60

0

20

40


Endogenous insulin


Slide 12 of 41


Twice a day insulin

Soluble insulin

Intermediate-acting insulinIn

sulin

60

0

20

40Endogenous insulin



Slide 13 of 41


Three times a day insulin

Soluble insulin


Insu

lin

60

0

20

40 Endogenous insulin



Slide 14 of 41


Rapid-acting insulin analogue


Basal-bolus regimenIn

sulin

60

0

20




Slide 15 of 41


Long-acting insulin analogue

Long-acting insulin analogues

Rapid-acting insulin analogue

Insu

lin

60

0

20




Slide 16 of 41


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!


Slide 17 of 41


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


Slide 18 of 41


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


Slide 19 of 41


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


Slide 20 of 41


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


Slide 21 of 41


HbA1c Pre-meal 2 hours post-meal

Target for most people with diabetes

<7% 4-7mmol/L*

90-130 mg/dl*1

5-10mmol/L*

<180mg/dl*1

IDF Global guideline for Type 2 diabetes*2

<6.5% <6.0mmol/L

<110mg/dl

<8.0mmol/L

<145mg/dl

Adjusting insulin – what are the targets?

*CDA 2003, *1ADA 2004, *2 IDF 2005

• Treatment targets should be individualized, especially for very young and very old

• Absence of hypoglycaemia


Slide 22 of 41


Starting insulin in type 2 diabetes

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


Slide 23 of 41


Adjusting insulin

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


Slide 24 of 41


Adjusting insulin

• Flexible dose guideline

• Eating more

• Exercising more

• Insulin to carbohydrate ratio

• Evaluate with next blood glucose

• Tailored to individual needs


Slide 25 of 41


Which insulin to adjust when?

Blood glucose Insulin to be changed

Fasting Bedtime or supper intermediate- or long-acting

Post-breakfast Morning short- or rapid-acting insulin

Pre-lunch Morning intermediate-acting insulin

Post-lunch Morning intermediate-acting insulin or lunchtime short- or rapid-acting insulin

Pre-supper (dinner) Morning intermediate-acting insulin

Post-supper (dinner) Supper-time short- or rapid-acting insulin

During the night Supper-time or bedtime intermediate-acting


Slide 26 of 41


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


Slide 27 of 41


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

Insulin practicalities


Slide 28 of 41


• 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

Precautions


Slide 29 of 41


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


Slide 30 of 41


Side effects

• Hypoglycaemia

• Weight gain

• Lipohypertrophy

• Lipoatrophy

• Insulin oedema

• Allergic reaction

Insulin managementCurriculum Module IV-1

Slide 31 of 41ACTIVITY


Insulin: NPH 25 units, Reg. 10 units before breakfast

NPH 15 units, Reg. 10 units before supper

Pre-breakfastmmol/L (mg/dl)

Pre-lunch Pre-supper

2 hours post-supper

Day 1 10.4 (187) 6.5 (117) 7.0 (126) 9.2 (165)

Day 2 9.6 (172) 5.4 (97) 6.8 (122) 10.2 (183)

Day 3 11.0 (198) 6.2 (112) 6.5 (117) 8.8 (158)

Example 1

Insulin managementCurriculum Module IV-1

Slide 32 of 41ACTIVITY


Example 2

Insulin: rapid-acting before each meal and NPH at bedtime

Pre-breakfast mmol/L (mg/dl)

Pre-lunch Pre-supper

2 hours post-supper

Day 1 7.0 (126) 6.5 (117) 15.1 (272) 10.3 (185)

Day 2 6.7 (120) 5.4 (97) 14.6 (263) 12.2 (219)

Day 3 6.5 (117) 6.2 (112) 12.5 (225) 11.8 (212)


Slide 33 of 41


What would you advise if….

1. The insulin had been taken and the restaurant meal was late

2. Regular insulin should be taken before a meal but the pre-meal blood glucose is 3.5 mmol/L (63 mg/dl)

3. A tennis match is scheduled an hour after lunch

4. A person wakes up nauseated and does not want to eat

5. Blood glucose levels do not coincide with how a person feels

ACTIVITY


Slide 34 of 41


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


Slide 35 of 41


Review question

1. One advantage that rapid-acting insulin has over regular insulin is that it:

a. Must be given immediately after the meal

b. Does not have to be kept in the fridge

c. Does not need a basal insulin to be given as well

d. Has a short and predictable action time


Slide 36 of 41


Review question

2. Which of the following does not affect the absorption of insulin?

a. The temperature of the insulinb. The temperature of the area to be

injectedc. The amount of insulin to be

injectedd. The type of injection device, i.e.

pen or syringe


Slide 37 of 41


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?

a. It is not possible to take too much insulin, you just have to eat more

b. The action of insulin taken four times a day is closest to the action of endogenous insulin

c. Taking insulin four times a day will be very difficult, and the results will not be much better

d. Your doctor feels that taking insulin four times a day will make you pay more attention to your diabetes


Slide 38 of 41


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?

a. Suggest she eats less at dinner and more at lunch

b. Suggest she increases her soluble before dinnerc. Suggest she increases her intermediate before

dinnerd. Suggest she moves her intermediate to bedtime

and decrease her soluble in the morning


Slide 39 of 41


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:

a. Provide insulin to cover the bedtime snack

b. Reduce the fasting glucose level

c. Reduce the number of oral blood glucose-lowering medicines

d. Prevent hypoglycaemia during the night


Slide 40 of 41


Answers

1. d

2. d

3. b

4. d

5. b


Slide 41 of 41


References

1. Klingensmith GJ, Ed. Intensive Diabetes Management, 3rd ed. Virginia: American Diabetes Association, 2003.

2. Colwell JA. Hot Topics Diabetes. Philadelphia: Hanley & Belfus, 2003.

3. American Diabetes Association. Insulin Administration. Diabetes Care 2004; 27(Suppl 1): S106-109.

4. Davidson MB. Diabetes Mellitus Diagnosis and Treatment. 4th ed. Philadelphia: W.B. Saunders Company, 1998.

5. 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.

6. Nathan DM. Initial management of glycemia in Type 2 diabetes mellitus. N Engl J Med 2002; 347: 1342-9.

7. 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).

8. 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.

9. IDF Clinical Guidelines Task Force. Global Guidelines for Type 2 diabetes. Brussels: International Diabetes Federation, 2005.

pharmacological management insulin

Documents

insulin types

surges of insulin

insulin therapytype

low basal levels of

amino acidsnormal response

special situationsin

beta cells