Diabetes Task Force In-Service
Randa Abdelal, PharmD
Pharmacy Clinical Coordinator
Saint Peter’s University Hospital
November, 2008

Insulin Resistance and Type II Diabetes
Normal Conditions: Insulin signaling results in glucose transporter
(GLUT-4) translocation from intracellular storage sites to the cell
membrane (muscle, adipose tissue).
Type I Diabetes – insulin dependent, the lack of insulin due to the
destruction of pancreatic ß-cells
Insulin Resistance – the inability of maximal concentrations of insulin to
appropriately stimulate muscle glucose transport and other physiological
responses.
Type II Diabetes – insulin independent, a global disorder of insulin signal
transduction that ultimately dysregulates gene expression and cell function
in wide range of tissues.
Complications: neuropathy, nephropathy, retinopathy, and CVD

Diseases associated with partial
failure of insulin/IGF-signaling
Dyslipidemia
• Hypertension
• Female infertility
• Glucose intolerance
Might progress to type 2 diabetes

Factors Affecting Insulin Secretion

Normal Insulin Profiles

Normal Insulin Profiles

Insulin Preparations - Regular Insulin
e.g. -Humulin R
-Novolin R

Rapid acting analogue insulin
(Novolog)

Rapid Acting Analogues

Intermediate acting insulin
Humulin N
Novolin N

Long acting analogue insulin
Glargine (Lantus)
Detemir (Levemir)

Premixed short and intermediate
insulin combinations
e.g. Humulin 70/30
Novolin 70/30 †
Humalog Mix 75/25
NovoLog Mix 70/30 †
† Note difference between :
Novolin 70/30 (70% NPH/30% regular)
and
NovoLog Mix 70/30
(70% aspart protamine/30% rapid-
acting aspart)

Graph showing duration and peak times of some insulins

Insulins Commonly Used in the United States
insulin glulisine Apidra analog Sanofi-Aventis clear

Human & Analog Insulin: Time of Action
(rapid)
(short)
(intermediate)
(long)

Premixed analogue combinations
Mix
Novolog Mix &

Basal bolus using rapid and long acting analogue

Basal bolus using short and intermediate insulin

Discontinued Insulin Formulations

When to Give Insulin
Generally:
Before meals or snacks.
For blood glucose levels significantly
above target range.
For moderate, large, or increasing
ketones, as per DMMP(Diabetes Medical Management Plan)

Insulin Characteristics
Discontinued In 2005
Discontinued In 2005

Continued….

Dosing Of Insulin
For many patients; insulin doses vary
depending upon:
Blood glucose readings
Food availability/preference
Physical activity level
Age/body weight

General insulin storage requirements are as follows:
1. Never freeze. (Frozen insulin should be thrown away.)
2. Never use insulin beyond the expiration date stamped on the vial, pen, or cartridge that is
supplied from the drug manufacturer.
3. Never expose insulin to direct heat or light.
4. Inspect insulin prior to each use. Any insulin that has clumps or solid white particles
should not be used. Insulin that is supposed to be clear should not have any cloudy
appearance.
5. Check storage guidelines specific to the insulin formulation. This is usually in the product
package insert.
6. Unopened, not-in-use insulin should be stored in a refrigerator at a temperature of 2-8º C.
7. Opened, in-use insulin should be stored at room temperature below 25º C.
9. When storing pre-filled insulin syringes, store them with the needle pointing up.

Insulin Vials Storage:
2-8 C < 25 C
Apidra 28 days Until Expiration Date Stamp 28 days

Oral Hypoglycemic Agents:
A. Sulfonylureas
Glipizide (Glucotrol®)
Tolbutamide (Orinase®)
B. Meglitinides
Repaglinide (Prandin®)
C. Biguanides
Metformin (Glucophage®)
D. Thiazolidinediones
Rosiglitazone (Avandia®)
Pioglitazone (Actos®)
E. Synthetic Incretin
Exenatide (Byetta®)
F. Other NON-traditional
hypoglycemic Agents

A. SULFONYLUREAS

Sulfonylurea- First Generation:

Sulfonylurea-Second Generation:

B. MEGLITINIDES

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C. BIGUANIDES

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D. Thiazolidinediones
The U.S. Food and Drug Administration (FDA) is aware of a potential safety issue related to Avandia (rosiglitazone), a drug
approved to treat type 2 diabetes. Safety data from controlled clinical trials have shown that there is a potentially
significant increase in the risk of heart attack and heart-related deaths in patients taking Avandia. However, other
published and unpublished data from long-term clinical trials of Avandia, including an interim analysis of data from the
RECORD trial (a large, ongoing, randomized open label trial) and unpublished reanalyses of data from DREAM (a previously
conducted placebo-controlled, randomized trial) provide contradictory evidence about the risks in patients treated with
Avandia.

Continued….

Continued….

E. Synthetic Incretin
In October 2007, FDA warned healthcare professionals about
reports of acute pancreatitis in patients taking the antidiabetic
drug Byetta (exenatide).

Continued…..

* Other Hypoglycemic Agents

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References:
2008 Certification Handbook for Diabetes Educators available online at :http://www.ncbde.org/documents/HB2008Final.pdf
USA Insulin Formulations available online at: http://www.diabetes.org/uedocuments/rg05insulins.pdf
D I A B E T E S F O R E C A S T | J A N U A R Y 2 0 0 5 available online at: http://www.diabetes.org/uedocuments/rg05insulins.pdf
Consensus Guidelines 2000-available online at: http://www.diabetesguidelines.com/health/dwk/pro/guidelines/ispad/ispad.asp
http://dhs.wisconsin.gov/rl_dsl/Publications/GudStrgInsulin.pdf; Updated February 16, 2007