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Slides current until 2008

Pharmacological management

Insulin

Section 3 | Part 2 of 3

Curriculum Module III-3 | Insulin

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Insulin managementCurriculum Module III-3

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Insulin

A hormone secreted by the beta cells

Secreted in response to glucose or otherstimuli, such as amino acids

Normal response characterized by low basallevels of insulin, with surges of insulintriggered by a rise in blood glucose

Insulin

60

0

20

40

Breakfast Lunch Supper

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Insulin action

1. Increases glucose uptake,particularly in muscle, liver andadipose tissue

2. Suppresses glucose output fromthe liver

3. Increases formation of fat

4. Inhibits breakdown of fats

5. Promotes amino-acid uptake and

prevents protein breakdown

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Indications for insulin therapy

Type 1 diabetes

Women with diabetes who become

pregnant or are breastfeeding

Transiently in type 2 diabetes inspecial situations

In type 2 diabetes, inadequatelycontrolled on glucose-loweringmedicines (secondary failure)

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Insulin therapy

Insulin therapy aims to replicate thenormal physiological insulin response

Insulin regimens should be individualized

type of diabetes willingness to inject

lifestyle

blood glucose monitoring age

dexterity

glycaemic targets

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

Rapid

lisproaspart

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International labeling

www.idf.org

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Variability in insulin absorption

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Factors affecting absorption

Lipohypertrophy

Dose of injection

Site and depth of injection

Exercise

Ambient and body

temperature

Insulin type

Incomplete re-suspension

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What is the most commoninsulin regimen used in yourcountry?

How well do you think it works?

How do people accept insulin?

ACTIVITY

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Insulin regimens: once a day insulin

Soluble insulinIntermediate-actinginsulin

Insu

lin

60

0

20

40


Endogenous insulin

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Twice a day insulin

Soluble insulinIntermediate-acting insulinI

nsulin

60

0

20

40Endogenous insulin


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Three times a day insulin

Soluble insulinIntermediate-acting insulin

Insulin

60

0

20



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Rapid-actinginsulin analogue

Intermediate-acting insulin

Basal-bolus regimen

Insulin

60

0

20



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Long-actinginsulin analogue

Long-acting insulin analogues

Rapid-actinginsulin analogueInsulin

60

0

20

40 Endogenous insulin


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Commencing insulin therapy

Insulin should never be used as a threat

Fear of injecting is common; needlephobia is rare

Healthcare professionals attitude is key toacceptance

People should be praised and encouragedto promote a positive attitude

Blood test is more painful than insulininjection

Forget the oranges; just do it!

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Commencing insulin therapy

Starting dose will depend on manyfactors

age

weight

type and duration of diabetes

glycaemic targets

In type 2 diabetes, consider continuingmaximum tolerated oral glucose-lowering medicines

10 units of intermediate-actinginsulin once a day

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Injecting insulin

Should be given into subcutaneoustissue

Skin of a very thin person may have to

be gently pinched Insulin at room temperature less

painful

Needle can be inserted at 45-90

45 for very thin people

90 for overweight people or whenusing short needle

Swabbing with alcohol is not necessary

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Insulin devices

Syringe and needle

Usually disposable, intended forone injection only

May need to use doses divisibleby 5 or 10 if visually impaired

Pens

Easy to use

Loading pen may be difficult forelderly

Disposable pens

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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

l

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HbA1C Pre-meal 2 hourspost-meal

Target for

most peoplewith diabetes

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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

I li t

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Adjusting insulin

Pattern management

Watch levels for 2-3 days

Address hypoglycaemia first

Aim for target fasting levelsnext

Adjust by 2-4 units or 10%

Wait 2-3 days

I li t

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Adjusting insulin

Flexible dose guideline

Eating more

Exercising more

Insulin to carbohydrate ratio

Evaluate with next bloodglucose

Tailored to individual needs

I li t

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Which insulin to adjust when?

Blood glucose Insulin to be changed

Fasting Bedtime or supper intermediate- orlong-acting

Post-breakfast Morning short- or rapid-acting insulin

Pre-lunch Morning intermediate-acting insulin

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

Pre-supper (dinner) Morning intermediate-acting insulin

Post-supper (dinner) Supper-time short- or rapid-actinginsulin

During the night Supper-time or bedtime intermediate-acting

I li t

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Insulin practicalities

Timing

Soluble insulin: 30-45 minutespre-meal

Short-acting insulin analogues: nomore than 15 minutes pre-mealand can be given post-meal

Intermediate- or long-actinginsulins do not have to be given inrelation to a meal

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Storage

One month in fridge or at roomtemperature once the vial has

been opened Must never be frozen

Store away from source of heat

If refrigeration not available storein clay pot or hole in ground

May be damaged by directsunlight or vigorous shaking

Insulin practicalities

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Insulin strength may differ (U40,U100, U500)

Ensure that the syringe matchesthe strength!

Long-acting insulin analogues are

clear in appearance Identify and differentiate insulin

type

Precautions

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Mixing insulins

NPH and soluble insulins can bemixed without changing properties

Check with the manufacturerbefore mixing any other insulins

Pre-drawn syringes can be kept in

fridge (2-80 C or 36-460 F)for onemonth

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Side effects

Hypoglycaemia

Weight gain

Lipohypertrophy

Lipoatrophy

Insulin oedema Allergic reaction

Blood glucose lowering medicines

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Blood glucose-lowering medicinesCurriculum Module IV-1

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Insulin: NPH 25 units, Reg. 10 units beforebreakfast

NPH 15 units, Reg. 10 units beforesupper

Pre-breakfastmmol/L(mg/dl)

Pre-lunch Pre-supper

2 hourspost-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

Blood glucose lowering medicines

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Blood glucose-lowering medicinesCurriculum Module IV-1

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Example 2

Insulin: rapid-acting before each meal andNPH at bedtime

Pre-breakfastmmol/L(mg/dl)

Pre-lunch Pre-supper

2 hourspost-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)

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What would you advise if.

1. The insulin had been taken and therestaurant meal was late

2. Regular insulin should be taken before ameal but the pre-meal blood glucose is3.5 mmol/L (63mg/dl)

3. A tennis match is scheduled an hour afterlunch

4. A person wakes up nauseated and doesnot want to eat

5. Blood glucose levels do not coincide withhow a person feels

ACTIVITY

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Summary

All people with type 1 diabetes must betreated with insulin

The majority of people with type 2

diabetes will need insulin within 5 to 10years of diagnosis

Insulin therapy should not be used as athreat

Insulin regimens should be individualized Insulin should be adjusted to achieve

blood glucose as close to target range aspossible

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Review question

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

a. Must be given immediately after themeal

b. Does not have to be kept in thefridge

c. Does not need a basal insulin to begiven as well

d. Has a short and predictable actiontime

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Review question

2. Which of the following does notaffectthe absorption of insulin?

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

injected

c. The amount of insulin to be

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

pen or syringe

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Review question

3. Jonathan says his doctor has suggested he takeinsulin four times a day. He asks if this is notgoing to be too much insulin. What is your bestresponse?

a. It is not possible to take too much insulin,

you just have to eat moreb. The action of insulin taken four times a

day is closest to the action of endogenousinsulin

c. Taking insulin four times a day will be very

difficult, and the results will not be muchbetter

d. Your doctor feels that taking insulin fourtimes a day will make you pay moreattention to your diabetes

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Review question

4. Suleen has been on insulin twice a day a mixtureof intermediate and soluble in the morning, andagain before dinner. Her records show that herfasting levels are 10-12mmol/L (180-216mg/dl), butthe rest of the day, her levels are less than

8.5mmol/L (153mg/dl). What change(s) would yousuggest to her insulin regimen to improve herlevels?

a. Suggest she eats less at dinner and more atlunch

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

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Review question

5. The goal of bedtime insulin in the personwith type 2 diabetes who is on oral bloodglucose-lowering medicines is to:

a. Provide insulin to cover the bedtimesnack

b. Reduce the fasting glucose level

c. Reduce the number of oral bloodglucose-lowering medicines

d. Prevent hypoglycaemia during the night

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Answers

1. d

2. d

3. b

4. d

5. b

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References

1. Klingensmith GJ, Ed. Intensive Diabetes Management, 3rd ed. Virginia: American DiabetesAssociation, 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 glycemiccontrol in newly diagnosed type 2 diabetic patients by transient intensive insulintreatment. Diabetes Care 1997; 20: 1353-6.

6. Nathan DM. Initial management of glycemia in Type 2 diabetes mellitus. N Engl J Med2002; 347: 1342-9.

7. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. CanadianDiabetes Association 2003 Clinical Practice Guidelines for the Prevention and Managementof 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 lenteinsulin 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.

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