Insulin Ce


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Insulin Ce

  1. 1. INSULINS Rabia Tahir, Pharm.D. New York Harbor Healthcare System
  2. 2. HISTORY of INSULIN <ul><li>Diabetes -> 3500 years. </li></ul><ul><ul><li>“ Control” only by diet in past. </li></ul></ul><ul><li>Insulin discovered in 1921. </li></ul><ul><li>Insulin used in 1 st diabetic patient in 1922. </li></ul><ul><li>1 st protein -> chemically synthesized in 1963. </li></ul>
  3. 3. INSULIN INDICATIONS <ul><li>Type I Diabetes </li></ul><ul><ul><li>Absolute deficiency of insulin </li></ul></ul><ul><li>Type II Diabetes </li></ul><ul><ul><li>Insulin resistance </li></ul></ul><ul><ul><li>Relative insulin deficiency </li></ul></ul>
  4. 4. INSULIN INDICATIONS <ul><li>Insulin may be provided in two ways </li></ul><ul><ul><li>Basal supplement with an intermediate to long-acting preparation to suppress hepatic glucose production and maintain near normoglycemia in the fasting state. </li></ul></ul><ul><ul><li>Premeal bolus dose of rapid-acting or short-acting insulin to cover the extra requirements after food is absorbed. </li></ul></ul>
  5. 5. TYPES of INSULIN <ul><li>20 types available </li></ul><ul><li>Which one should be used? </li></ul><ul><ul><li>Individuals lifestyle </li></ul></ul><ul><ul><li>Physicians preference </li></ul></ul><ul><ul><li>Patients blood sugar level </li></ul></ul>
  6. 6. TYPES of INSULIN <ul><li>Which one should be used? </li></ul><ul><ul><li>Source of insulin </li></ul></ul><ul><ul><ul><li>Obtained from pork pancreas or is made chemically identical to human insulin by recombinant DNA technology. </li></ul></ul></ul><ul><ul><ul><li>Beginning in January 2006, pork insulin for human use will no longer be manufactured or marketed in the U.S..  </li></ul></ul></ul><ul><ul><li>How soon it starts working -> onset. </li></ul></ul><ul><ul><li>When it starts working the hardest -> peak. </li></ul></ul><ul><ul><li>How long it lasts in body -> duration. </li></ul></ul>
  7. 7. TYPES of INSULIN <ul><li>Insulin onset, peak, and duration of effect must match meal patterns and exercise schedules -> achieve near normal blood glucose values throughout the day. </li></ul><ul><li>Four basic forms </li></ul><ul><ul><li>Rapid-acting insulins </li></ul></ul><ul><ul><li>Short-acting insulins </li></ul></ul><ul><ul><li>Intermediate-acting insulins </li></ul></ul><ul><ul><li>Long-acting insulins </li></ul></ul>
  8. 8. RAPID-ACTING INSULINS <ul><li>Type Onset (h) Peak (h) Duration (h) Appearance </li></ul><ul><li>insulin lispro 15-30 min 1-2 3-4 Clear </li></ul><ul><li>HUMALOG </li></ul><ul><li>insulin aspart 15-30 min 1-2 3-5 Clear </li></ul><ul><li>NOVOLOG </li></ul><ul><li>insulin glulisine 15-30 min 1-2 3-4 Clear </li></ul><ul><li>APIDRA </li></ul><ul><li>NOVOLOG (insulin aspart) -> formulary </li></ul>
  9. 9. RAPID-ACTING INSULINS <ul><li>Administrative Options </li></ul><ul><ul><li>HUMALOG (insulin lispro) </li></ul></ul><ul><ul><ul><li>Pen, U-100 vial, or 1.5 ml or 3 ml pen cartridge </li></ul></ul></ul><ul><ul><li>NOVOLOG (insulin apart) </li></ul></ul><ul><ul><ul><li>Pen, U-100 vial, 3 ml pen cartridge </li></ul></ul></ul><ul><ul><li>APIDRA (insulin glulisine) </li></ul></ul><ul><ul><ul><li>U-100 Vial </li></ul></ul></ul>
  10. 10. RAPID-ACTING INSULINS <ul><li>Within 10 minutes of meal. </li></ul><ul><li>Better efficacy in post prandial blood glucose. </li></ul><ul><li>Minimizes delayed postmeal hypoglycemia. </li></ul><ul><li>Normally used in regimens with intermediate or long-acting insulin. </li></ul><ul><li>Rapid-acting insulin can be mixed with NPH and lente -> the mixture should be injected within 15 minutes prior to a meal. </li></ul>
  11. 11. SHORT-ACTING INSULINS <ul><li>Type Onset (h) Peak (h) Duration (h) Appearance </li></ul><ul><li>Regular 0.5-1.0 2-3 3-6 Clear </li></ul><ul><li>HUMULIN R </li></ul><ul><li>NOVOLIN R </li></ul><ul><li>NOVOLIN R -> formulary </li></ul>
  12. 12. SHORT-ACTING INSULINS <ul><li>Administrative Options </li></ul><ul><ul><li>HUMULIN R </li></ul></ul><ul><ul><ul><li>U-100 vial, 10 ml vial or U-500, 20 ml vial </li></ul></ul></ul><ul><ul><li>NOVOLIN R </li></ul></ul><ul><ul><ul><li>Insulin pen, U-100 vial, or 3 ml pen cartridge, and Innolet </li></ul></ul></ul>
  13. 13. SHORT-ACTING INSULINS <ul><li>Relatively slow onset of action when given SQ. </li></ul><ul><li>Requires injection 30 minutes prior to meal to achieve optimal post prandial glucose control and to prevent delayed postmeal hypoglycemia. </li></ul><ul><li>Eating within a few minutes after or before injecting is discouraged because it substantially reduces the ability of that insulin to prevent a rapid rise in blood glucose and may increase the risk of delayed hypoglycemia. </li></ul>
  14. 14. INTERMEDIATE-ACTING INSULIN <ul><li>Type Onset (h) Peak (h) Duration (h) Appearance </li></ul><ul><li>NPH 2-4 4-6 8-12 Cloudy </li></ul><ul><li>HUMULIN N </li></ul><ul><li>NOVOLIN N </li></ul><ul><li>Lente 3-4 6-12 12-18 Cloudy </li></ul><ul><li>HUMULIN L </li></ul>
  15. 15. INTERMEDIATE-ACTING INSULIN <ul><li>Administrative Options </li></ul><ul><ul><li>HUMULIN N </li></ul></ul><ul><ul><ul><li>U-100 vial, prefilled pen </li></ul></ul></ul><ul><ul><li>NOVOLIN N </li></ul></ul><ul><ul><ul><li>U-100 vial, prefilled pen, and Innolet </li></ul></ul></ul><ul><ul><li>HUMULIN L </li></ul></ul><ul><ul><ul><li>U-100 vial </li></ul></ul></ul>
  16. 16. LONG-ACTING INSULIN <ul><li>Type Onset (h) Peak (h) Duration (h) Appearance </li></ul><ul><li>Glargine 4-5 − 22-24 Clear </li></ul><ul><li>LANTUS </li></ul>
  17. 17. LONG-ACTING INSULIN <ul><li>Administrative Options </li></ul><ul><ul><li>LANTUS </li></ul></ul><ul><ul><ul><li>U-100 vial </li></ul></ul></ul>
  18. 18. LONG-ACTING INSULIN <ul><li>LANTUS </li></ul><ul><ul><li>‘ peakless’’ analog -> less nocturnal hypoglycemia than NPH when given at bedtime </li></ul></ul><ul><ul><li>Usually given once a day only </li></ul></ul>
  19. 19. PREMIXED INSULIN <ul><li>Fixed ratio insulins are dosed according to patient needs </li></ul><ul><li>15 minutes before meals </li></ul><ul><li>Premixed insulin analogs </li></ul><ul><ul><li>HUMALOG Mix 75/25 (75% neutral protamine lispro, 25% lispro) </li></ul></ul><ul><ul><ul><li>U-100 vial, prefilled pen </li></ul></ul></ul><ul><ul><li>NOVOLOG Mix 70/30 (70% aspart protamine suspension, 30% aspart) </li></ul></ul><ul><ul><ul><li>U-100 vial, prefilled pen, 3 ml pen cartridge </li></ul></ul></ul>
  20. 20. PREMIXED INSULIN <ul><li>NPH-regular combinations </li></ul><ul><ul><li>HUMULIN 70/30 </li></ul></ul><ul><ul><ul><li>Vial, prefilled pen </li></ul></ul></ul><ul><ul><li>NOVOLIN 70/30 </li></ul></ul><ul><ul><ul><li>Vial, pen cartridge, Innolet </li></ul></ul></ul><ul><ul><li>HUMULIN 50/50 </li></ul></ul><ul><ul><ul><li>Vial </li></ul></ul></ul>
  21. 23. ADVERSE EFFECTS of INSULIN <ul><li>Hypoglycemia causes </li></ul><ul><ul><li>Missing or delaying meals. </li></ul></ul><ul><ul><li>Taking to much insulin. </li></ul></ul><ul><ul><li>Exercising or working more than normal. </li></ul></ul><ul><ul><li>An infection or illness (diarrhea and vomiting). </li></ul></ul><ul><ul><li>Interactions with other drugs that lower blood glucose -> oral antidiabetic agents, salicylates, sulfa ab’s, certain antidepressants . </li></ul></ul><ul><ul><li>Consumption of alcoholic beverages. </li></ul></ul>
  22. 24. ADVERSE EFFECTS of INSULIN <ul><li>Hypoglycemia S&S </li></ul><ul><ul><li>Mild to moderate </li></ul></ul><ul><li>Sweating - Drowsiness </li></ul><ul><li>Dizziness - Sleep disturbances </li></ul><ul><li>Palpitation - Anxiety </li></ul><ul><li>Tremor - Blurred vision </li></ul><ul><li>Hunger - Slurred speech </li></ul><ul><li>Restlessness - Depressed mood </li></ul><ul><li>Tingling in hands, feet, lips, or tongue - Irritabilty </li></ul><ul><li>Lightheadedness - Abnormal behavior </li></ul><ul><li>Inability to concentrate - Unsteady movement </li></ul><ul><li>Headache - Personality changes </li></ul>
  23. 25. ADVERSE EFFECTS of INSULIN <ul><li>Hypoglycemia S&S </li></ul><ul><ul><li>Severe </li></ul></ul><ul><li>Disorientation </li></ul><ul><li>Unconsciousness </li></ul><ul><li>Seizures </li></ul><ul><li>Death </li></ul>
  24. 26. ADVERSE EFFECTS of INSULIN <ul><li>Hypoglycemia Treatment (< 50mg/dl). </li></ul><ul><ul><li>Mild to moderate </li></ul></ul><ul><ul><ul><li>Rule of 15 -> 15g carbohydrate every 15 min until BG is greater than 70mg/dl, then follow simple meal. </li></ul></ul></ul><ul><ul><li>Severe or continuing </li></ul></ul><ul><ul><ul><li>Unable to take sugar by mouth or are unconscious may need Dextrose 50% 50 ml infusion or Glucagon 1mg IM, SQ, or IV. </li></ul></ul></ul>
  25. 27. ADVERSE EFFECTS of INSULIN <ul><li>Allergic reaction </li></ul><ul><ul><li>Generalized reaction </li></ul></ul><ul><ul><ul><li>Uncommon but life threatening -> itchy rash over entire body, SOB, wheezing, confusion, low BP, tachycardia, sweating. </li></ul></ul></ul><ul><ul><li>Local reaction </li></ul></ul><ul><ul><ul><li>At injection site and is common -> itching, redness, hardness, or swelling. </li></ul></ul></ul>
  26. 28. ADVERSE EFFECTS of INSULIN <ul><li>Lipodystrophy </li></ul><ul><ul><li>Change in fat below injection site </li></ul></ul><ul><ul><ul><li>Lipoatrophy </li></ul></ul></ul><ul><ul><ul><li>Lipohypertrophy </li></ul></ul></ul><ul><ul><li>Avoid injections in areas of skin that have theses reactions. </li></ul></ul>
  27. 29. MIXING INSULINS <ul><li>Formulations and particle size distribution vary with insulin products. </li></ul><ul><li>Mixing -> physiochemical changes can occur either immediately or over time. </li></ul><ul><li>Serum insulin concentrations tend to reach a single peak. </li></ul>
  28. 30. MIXING INSULINS GUIDELINES <ul><li>Pt’s well controlled on mixed insulin regimen -> maintain their standard procedure. </li></ul><ul><li>No other medication or diluents should be mixed with insulin. </li></ul><ul><li>Glargine (LANTUS) should not be mixed with any insulin. </li></ul><ul><li>Use of commercially available premixed insulins may be used if insulin ratio is appropriate to Pt insulin requirement. </li></ul><ul><li>NPH and short-acting insulin when mixed can be used immediately or stored for future use. </li></ul>
  29. 31. MIXING INSULINS GUIDELINES <ul><li>Rapid-acting insulin can be mixed with NPH, lente, and ultralente. </li></ul><ul><li>When rapid acting insulin is mixed with either an intermediate or long-acting insulin -> mixture should be injected within 15 min before meal. </li></ul><ul><li>Mixing of short-acting and lente insulins is not recommended except for Pt already adequately controlled on such mixture. </li></ul><ul><li>Phosphate-buffered insulins (NPH) should not be mixed lente insulins. </li></ul>
  30. 32. INSULIN STORAGE <ul><li>Unopened vials, cartridges and pens. </li></ul><ul><ul><ul><li>If refrigerated use until expiration date (standard) </li></ul></ul></ul><ul><ul><ul><li>If room temperature (below 30 º C) use within 28 days </li></ul></ul></ul><ul><li>Opened </li></ul><ul><ul><ul><li>Vials within 28 days at room temperature or refrigerated </li></ul></ul></ul><ul><ul><ul><li>Pen and pen cartridges within 28 days at room temperature ( do not refrigerate) </li></ul></ul></ul><ul><li>Do not use if insulin has been frozen or exposed to high temperatures (<2 º C or > 30 º C). </li></ul><ul><li>Excess agitation should be avoided. </li></ul>
  31. 33. INSULIN ADMINISTRATION <ul><li>Check vial before use to inspect for changes -> loss of potency. </li></ul><ul><li>Vial and pens should be rolled in palms of hands before drawing with needle -> except with rapid and short acting insulin. </li></ul><ul><li>If mixing insulins -> clear insulin should be drawn into syringe first. </li></ul>
  32. 34. INSULIN DELIVERY DEVICES <ul><li>Insulin pens </li></ul><ul><ul><li>Pens with cartridges -> users turn a dial to select the desired dose of insulin -> press a plunger on the end to deliver insulin. </li></ul></ul><ul><ul><li>Needle should be embedded within skin for 5 seconds after complete depression of plunger. </li></ul></ul><ul><ul><li>Air bubbles in pen reduces rate of insulin flow. </li></ul></ul><ul><ul><li>Avoid leaving needle on pen between injections and prime needle with 2 units of insulin. </li></ul></ul>
  33. 35. INSULIN DELIVERY DEVICES <ul><li>Jet injectors </li></ul><ul><ul><li>Option for people who do not want to use needles. </li></ul></ul><ul><ul><li>Use high pressure air to send a fine spray of insulin through the skin as a fine stream. </li></ul></ul><ul><ul><li>Have no needles -> advantage in patients unable to use syringes or with needle phobias. </li></ul></ul><ul><ul><li>More rapid absorption of short-acting insulins </li></ul></ul><ul><ul><li>Costly and may traumatize skin. </li></ul></ul>
  34. 36. INJECTION SITE <ul><li>Subcutaneous tissue of upper arm. </li></ul><ul><li>Anterior and lateral aspects of the thigh, buttocks, and abdomen. </li></ul><ul><li>IM not recommended. </li></ul><ul><li>Rotation of injection site recommended. </li></ul><ul><ul><li>Prevent lipohypertrophy and lipoatrophy. </li></ul></ul><ul><ul><li>Rotating within one area is recommended. </li></ul></ul>
  35. 37. INJECTION SITE <ul><li>Variable absorption between sites. </li></ul><ul><ul><li>Abdomen > arms >thighs > buttocks </li></ul></ul><ul><li>Exercise increases rate of absorption. </li></ul><ul><li>Areas of lipohypertrophy have slower absorption. </li></ul><ul><li>IM > SC absorption. </li></ul>
  36. 38. PREVENTING PAINFUL INJECTIONS <ul><li>Inject insulin at room temp. </li></ul><ul><li>Make sure no air bubbles remain in syringe before injection. </li></ul><ul><li>Wait for topical alcohol to evaporate before injection. </li></ul><ul><li>Relax muscle at injection site at time of injection </li></ul><ul><li>Penetrating skin quickly. </li></ul><ul><li>Not changing direction of needle during insertion or withdrawal. </li></ul>
  37. 39. CONCLUSION <ul><li>Insulin type and species </li></ul><ul><li>Injection technique </li></ul><ul><li>Site of injection </li></ul><ul><li>Individual Pt response differences </li></ul><ul><ul><li>Onset </li></ul></ul><ul><ul><li>Peak </li></ul></ul><ul><ul><li>Duration </li></ul></ul>