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0_diabetes presentation final for Hyderabad.pptx
- 1. TYPES OF INSULIN THERAPY DRMEHR UN NISA YASIR Assistant Professor Pediatric endocrine fellow NICH
- 2. Learning Goals • Overviewof Insulin • Types of Insulin in pediatric use • Different types of Insulin regimens • To calculate Insulin doses • Types of insulin delivery devices • Injection Sites • Storage of Insulin • Side effects and complications
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- 4. Insulin • A hormoneproduced in the pancreas by the islets of Langerhans, which regulate the amount of glucose in the blood. • All people with type 1 diabetes need insulin to survive. • Many people with type 2 diabetes need insulin to achieve good blood glucose control.
- 5. Discovery of Insulin •In 1921, a young surgeon named Frederick Banting and his assistant Charles Best figured out how to remove insulin from a dog’s pancreas. Initially it looked like “thick brown muck”. • In January 1922, Leonard Thompson, a 14- year-old boy dying from diabetes in a Toronto hospital, became the first person to receive an injection of insulin.
- 6. Insulin Analogs • In1990 - Insulin Lispro : Genetically modified rapid acting insulin analog was synthesized. • Now 3 rapid-acting insulin analogs are available Lispro, Aspart & Glulisine. •In 2000 - Insulin Glargine – genetically modified long acting insulin was introduced.
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- 8. Regular Insulin (Shortacting) • Soluble, Clear • Identical to human insulin • Used in basal-bolus regimens with intermediate- acting or basal long-acting insulin. • Or it also combined with Intermediate-acting insulin in a twice daily regimen. action time Onset of Action 30 min- 1hr Peak of Action 2 - 4 hours Duration of action 5-8 hours
- 9. Rapid-acting insulins (Aspart, Lispro,Glulisine ) • Its a modified human insulin by changing A.A sequence or by addition of F.F.A which increases its absorption. • Used with MDI regimen. • Given before meals or immediately before meals/snacks. In erratic eaters can be given after the meal. • Reduces postprandial hyperglycemia and nocturnal hypoglycemia. • It is used in insulin pumps. Onset of Action 15-35min Peak of Action 1-3 hrs Duration of action 3-5 hrs
- 10. Ultra-rapid-acting insulin (Faster Aspart:Fiasp) •Faster onset and offset, replicating physiologic insulin action. • FDA approved for children 2 years old. ≥ • When Faster-aspart combined with insulin degludec provides effective glycemic control. Onset of Action 10-20 min Peak of Action 1-3 hours Duration of action 3-5 hours
- 11. Intermediate Acting Insulin •For over half a century, NPH (Neutral Protamine Hagedorn) was the primary form of basal insulin. • Cloudy • It has to be resuspended prior to injection. Insufficient resuspension leads to day-to-day variability of the glucose. • Its action profile requires twice daily injection with fixed meal schedule. • It is limited in their ability to achieve optimal glycemia and patients are prone to nocturnal hypoglycemia. 01/02/2025 03:31 AM Presentation • Department • Author Slide 11 action time Onset of Action 2-4hrs Peak of Action 4-12hrs Duration of action 12-24hrs
- 12. Long acting insulins Glargine( Lantus ) • rDNA origin Terminal GLycine has two additional ARGINine hence the name. • As efficacious as twice daily NPH. • Can be given once or twice daily with MDI regimen. • Can be given any time during the day but nocturnal hypoglycemia occurs less often with breakfast injection. • When switching to glargine as basal insulin, the total dose of basal insulin needs to be reduced by 20% to avoid hypoglycemia. Onset of Action 2-4 hrs Peak of Action 8-12 hrs Duration of action 22-24 hrs
- 13. Long acting insulins:Detemir (Levemir) • The FFA chain stabilizes the hexamers and slowing dissociation. • Administered once or twice daily based on clinical needs. • Transitioning to detemir from NPH, require same doses or may require increase in detemir dose. • In a pediatric study, 70% of the participants used detemir twice daily. • Reduces the risk for nocturnal hypoglycemia as compared to NPH. Onset of Action 1-2 hours Peak of Action 4-7 hrs Duration of action 22-24 hrs
- 14. Premixed Human Insulin •Premixed combinations of short and intermediate acting insulin (biphasic) • Cloudy (needs re-suspending) • Several different combinations (eg. 10, 20, 25, 30, 40, 50) • e.g. 30/70 Mixture = 30% fast acting + 70% intermediate acting 01/02/2025 03:31 AM Presentation • Department • Author Slide 14 action time Onset of Action 30 min Peak of Action 4-12 hrs Duration of action 8-24 hrs
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- 17. Insulin degludec/insulin aspart Ryzodeg– Novo Nordisk • Approved for children( ≥1 year old) by FDA. • It is an Ultra-long-acting analog. • It forms multihexamers after S/C which results in a slow release of monomers. • Monomers binds to albumin which slows the clearance from the body extending the action for up to 42 h or longer. • Dose adjustments are made every 3–4 days without insulin stacking.
- 18. Insulin glargine 300u/ml (Toujeo- Sanofi) • FDA approved for children ≥6 years. • It is a more concentrated formulation (300 units/ml). • Prolonged duration of action (>24 h). • It is particularly for those with high basal insulin needs.
- 19. Ultra long actinginsulin (Icodec) • Used as once weekly basal analog. • Half-life is about 8 days • Currently not approved for pediatric use.
- 20. Biosimilar Insulins In contrastto generic drugs these insulin demonstrate slight differences in their available counterparts. • Glargine biosimilars (Basaglar): FDA approved in 4 yrs old ≥ • Abasaglar approved in 2 years old ≥ • lispro biosimilar insulin for children with diabetes • Admelog FDA and approved in 4 years old ≥
- 21. EXUBERA® (Inhaled Human Insulin) •Human insulin inhaled powder is the fastest acting exogenous insulin absorbed quickly from the lungs eliminating the delays after subcutaneous injection. • Approved in adults but is not yet approved for children. • A clinical trial for pediatric use is on going.
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- 23. Starting a patienton insulin Influencing factors: •Age •Weight •Stage of puberty •Duration and phase of diabetes •Nutritional intake and distribution • Exercise patterns • Daily routine • Results of BG monitoring and glycated hemoglobin • Intercurrent illness • Menstrual cycles
- 24. Starting dose • Duringpartial remission phase total insulin dose<0.5IU/kg/day • Prepubertal children 0.7 IU -1.0 IU/kg /day • During puberty 1.2 IU-2 IU/kg/day • Prandial insulin are approximately 55% to 70% of total daily dose. • Long-acting analog are approximately 30%–45% of total daily dose.
- 25. Insulin Twice aDay Regimen
- 26. Weight = 36kg Total dose = 36 units (1 IU/kg/day ) • Morning 2/3rd 24 units NPH 2/3rd : 16 Regular 1/3rd : 8 • Evening 1/3rd 12 units NPH 2/3rd : 8 Regular 1/3rd : 4
- 27. Two Injections PerDay 12/22/2023 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 Breakfast Lunch Evening Meal Sleep Insu lin in blo od time
- 28. Multiple Dose InsulinInjections
- 29. “Act Like aPancreas” • GOAL: mimic the function of the pancreas with basal and bolus insulins • Basal Insulin: required during fasting in order to cover blood sugar release by liver for energy. • Bolus insulin: required to cover ingested carbohydrates and blood sugars out of goal range. 33 ©2011
- 30. Weight = 36kg Total dose = 36 units (1IU/kg/day) • Long Acting 50% (at night/morning) 18 • Pre Breakfast Rapid acting 6 • Pre Lunch Rapid acting 6 • Pre Dinner Rapid acting 6
- 31. 4 Injections PerDay 3 Short + 1 long Acting (Basal Bolus) 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 Breakfast Lunch Evening Meal Sleep time Insu lin in bloo d
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- 34. Pens – Advantages •Improved dose accuracy • More convenient • Easy to use • Portable • Painless dosing • May reduce barriers to patient self-management • Preferred to syringes by patients 01/02/2025 03:31 AM Presentation • Department • Author Slide 34
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- 36. Insulin Injection Sites Pictureof lipohypertrophy
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- 38. Storage of Insulin •Before use • store in fridge (2-8o C) • In-use vials • insulin can be stored at room temperature (below 25 or 30C) for up to 10 days and 8 weeks based on manufacturer’s guidelines. 01/02/2025 03:31 AM Presentation • Department • Author Slide 38
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- 40. Side Effects ofInsulin • Hypoglycaemia • Allergic reactions • Injection site problems: Lipodystrophy • Weight gain 01/02/2025 03:31 AM Presentation • Department • Author Slide 40
- 41. Complications of InsulinTherapy • Lipo-hypertrophy • Lipo-atrophy • Abscess/ bruises • Idiosyncratic skin reaction 01/02/2025 03:31 AM Presentation • Department • Author Slide 41
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Editor's Notes
- #11 Isophane or NPH is the most commonly used intermediate insulin. NPH stands for Neutral Protamine Hagedorn, and protamine is the retarding agent that alters the speed of absorption and action of the insulin.
- #14 Premixed human insulin is a combination of a short acting plus an intermediate acting insulin. The name of the insulin will indicate the ratio of short acting to intermediate acting insulin. About 60% of patients requiring insulin are using premixed insulin, and the majority of those are using 30/70 mix. The benefit of premixed insulin is that patients do not need to mix the two types of insulin in a syringe themselves thereby reducing the risk of dosing errors and enabling the use of injection devices.
- #31 There may be a need for injecting isophane bd, rather than od when using quick acting analogues in a basal bolus regimen
- #34 Patients who have to take insulin injections every day for the rest of their lives appreciate the benefits of the modern insulin devices. In a study of the acceptability of a disposable device, 9 out of 10 patients who were offered a choice preferred pens to syringes (Coscelli et al. 1995). The convenience of the insulin devices helps patients to maintain their lifestyle and might lead to better patient self-management to the insulin therapy as it is less of an obstacle to take the injections at the right time.
- #38 Insulin cartridges, disposable pens and vials not in use should be stored in the fridge. Injecting cold insulin may be more uncomfortable than injecting insulin at room temperature. Insulin pens and cartridges in use may be kept at room temperature (max 25 C) for up to 4 weeks. They should not be kept in the fridge when in use. Some insulin vials, when in use, may be kept out of the fridge (max 25 C) for up to 6 weeks.
- #40 Hypoglycaemia is very common. It is important for patients to monitor their blood glucose. If patients use the same site for injection it may become lumpy; insulin will not be absorbed at the correct rate. In order to avoid this, patients are advised to rotate their injection sites. Allergic reaction to insulin is extremely rare, usually it will be a reaction to one or more of the excipients. If this occurs – contact Medical Information at 0845 600 5055.