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Insulin therapy regimen
- 2. Indications for insulin therapy • Type 1 diabetes • Women with gestational diabetes • In type 2 diabetes, inadequately controlled on OADs • type 2 diabetes in special situations- – Pancreatitis – DKA – during surgery – acute infections
- 3. Types of InsulinTypes of Insulin 1. Rapid-acting (insulin Aspart) 2. Short-acting humulin 3. Intermediate-acting 4. Premixed 5. Long-acting lantus-(glargine).levemir(detemir) (Analogs) (Regular) (NPH) (70/30)
- 7. Twice daily regimens • Intermediate acting insulin(NPH)and short acting (regular) insulin • 2/3 of insulin – morning(ratio 1:2) • 1/3 of insulin - evening
- 8. MULTIPLE –INJECTION REGIMENS • Short acting- before meal • Intermediate or long acting –once or twice daily • Advantage:- – allows greater freedom with regard to meal timing . – More variable day to day physical activity
- 9. Dawns phenomenon • Early morning hyperglycemia without nocturnal hypoglycemia. • It is due to counter regulatory hormones • No need of insulin dose change. – Solution • Give long acting insulin not before 11 :00 p.m • May need to increase dose of night time insulin
- 10. Continuous subcutaneous insulin infusion (CSII) • Very effective insulin regimen for type 1 DM • Sophisticated device • requires education of the patient and frequent interactions with diabetes management team • Advantages: – programmed dose – basal infusion rates altered during exercise – different doses of insulin can be matched based on meals • Disadvantages--- – infection – hyperglycemia – DKA • Short acting insulin analogues are used. • SMBG
- 11. Insulin devices • Insulin syringes—10ml insulin vials 30 unit—0.3 ml,50 unit-0.5 ml,100 unit-1ml Needl es -8mm to 13mm Use each syringe only once. • Insulin pen-insulin catridge-3ml-300units fits into the device Disposable, reusable • Insulin pumps-reservoir of insulin-infusion set worn outside the body—abdomen Only short or rapid acting insulin are used—mimics physiological pattern • Inhaled insulin
- 12. After injection
- 15. Side-effects of Insulin TherapySide-effects of Insulin Therapy • Hypoglycemia(predominantly seen in type 1 patients) • Weight gain • Peripheral edema(salt and water retention in short term) • Insulin antibodies(with animal insulin ) • Local allergy • Lipohypertrophy or lipoatrophy at site of injection
Editor's Notes
- People with type 1 diabetes require insulin for survival – they cannot be managed on oral agents. There is some limited evidence suggesting that the use of metformin within the first trimester of pregnancy is safe. However, there is no evidence for other oral glucose-lowering agents. Therefore the use of oral agents is not recommended during pregnancy. Ideally, women with type 2 diabetes on oral glucose-lowering medicines should be transferred to insulin therapy prior to conception. Oral glucose-lowering medicines should not be recommenced until after the birth and the woman is no longer breast feeding. People with type 2 diabetes may require short-term insulin therapy during periods where their blood glucose levels remain high – such as around a surgical event or illness. Insulin may also be needed in the long term due to steady beta cell loss. The UKPDS showed that approximately 50% of people with type 2 diabetes require insulin therapy to supplement or replace oral glucose-lowering medicines within 5 to 10 years of diagnosis. This is known as secondary failure.
- Key Points The effects of rapid-acting insulin analogues occur within roughly 10 to 15 minutes, peak at 1 to 1.5 hours, and last between 4 and 5 hours. Examples of rapid-acting insulin analogues include insulin aspart, lispro, and glulisine. The effects of short-acting human insulin occur within 30 to 60 minutes, peak at 2 to 4 hours, and last 5 to 8 hours.
- Key Points Intermediate-acting human insulin begins to exert its effect with 1 to 3 hours, peak at 5 to 8 hours, and can last up to 18 hours. Examples include NPH and lente insulin. Premixed insulin comes in a vial or cartridge and contains a fixed ratio of rapid- or short-acting to intermediate-acting insulin. Examples include 75% NPL with 25% lispro, 70% APS with 30% aspart, and 70% NPH with 30% regular insulin or NPH.
- Key Points The onset of action for long-acting human insulin is 3 to 4 hours, the peak occurs at 8 to 15 hours, and the effects last 22 to 26 hours. Examples include ultralente insulin. Long-acting insulin analogues begins to exert its effect within 1.5 to 3 hours. The peak of action for insulin detemir is dose dependent, and insulin glargine has no peak. Both last up to 24 hours.
- Key Points The disadvantages of insulin therapy include weight gain of roughly 2 to 4 kilograms, which is probably proportional to the correction of glycemia and owing predominantly to the reduction of glycosuria. This weight gain could adversely affect cardiovascular health. Insulin therapy is also associated with hypoglycemia; however, rates are much lower than in type 1 diabetes. In clinical trials aimed at normoglycemia and achieving a mean HbA1c of approximately 7%, severe hypoglycemic episodes (defined as requiring help from another person to treat) occurred at a rate of 61 per 100 patient-years in a type 1 diabetes trial (i.e., the DCCT intensive-therapy group), but occurred at a rate of just 1 to 3 per 100 patient-years in trials with type 2 diabetics. Reference: Nathan DM et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. Diabetes Care 2006;29(8):1963-72.