This document provides information on insulin therapy. It discusses what insulin is, how it is secreted normally, and its actions in the body. Insulin deficiency results in hyperglycemia and other metabolic defects. The discovery of insulin by Banting and Best in 1921 revolutionized the treatment of diabetes. Insulin comes in various forms including rapid-acting, short-acting, intermediate-acting, long-acting, and premixed varieties. Common insulin regimens include split-mixed, basal, basal-plus, and basal-bolus. Early initiation of insulin in type 2 diabetes has clinical benefits beyond glycemic control. Barriers to insulin therapy include fear of hypoglycemia and the inconvenience of injection schedules. Pro
Intensive insulin therapy is best defined as a comprehensive system of diabetes management with the patient and management team as partners. The system is directed at improvement of glycemia and patient well-being.
Definition of diabetes - introduction - classification of diabetes - etiology of diabetes type 1 and type 2- risk factors for diabetes - diagnosis of diabetes - clinical manifestations of diabetes type 1 and type 2- investigations for diabetes - treatment of diabetes - non-pharmacological treatment and pharmacological treatment - pharmacotherapy of type 1 and type 2 - acute complications of diabetes and treatment
Intensive insulin therapy is best defined as a comprehensive system of diabetes management with the patient and management team as partners. The system is directed at improvement of glycemia and patient well-being.
Definition of diabetes - introduction - classification of diabetes - etiology of diabetes type 1 and type 2- risk factors for diabetes - diagnosis of diabetes - clinical manifestations of diabetes type 1 and type 2- investigations for diabetes - treatment of diabetes - non-pharmacological treatment and pharmacological treatment - pharmacotherapy of type 1 and type 2 - acute complications of diabetes and treatment
Controlling blood sugar (glucose) levels is the major goal of diabetes treatment, in order to prevent complications of the disease.
Type 1 diabetes is managed with insulin as well as dietary changes and exercise.
Type 2 diabetes may be managed with non-insulin medications, insulin, weight reduction, or dietary changes.
Medications for type 2 diabetes are designed to
increase insulin output by the pancreas,
decrease the amount of glucose released from the liver,
increase the sensitivity (response) of cells to insulin,
decrease the absorption of carbohydrates from the intestine, and
slow emptying of the stomach, thereby delaying nutrient digestion and absorption in the small intestine.
Diabetes mellitus (DM) has routinely been described as a metabolic disorder characterized by hyperglycemia that develops as a consequence of defects in insulin secretion, insulin action, or both.
Such a deficiency results in increased concentrations of glucose in the blood, which in turn damage many of the body's systems, in particular the blood vessels and nerves.
1. Microvascular (due to damage to small blood vessels).
2. Macrovascular (due to damage to larger blood vessels).
Insulin Initiation : When We should Start with Basal Insulin?mataharitimoer MT
Insulin Initiation : When We should Start with Basal Insulin?
Dr. Agus Taolin , SpPD, FINASIM | PAPDI CABANG BOGOR
Disampaikan pada acara PIT VI IDI Kota Bogor | 9 Nopember 2013
Controlling blood sugar (glucose) levels is the major goal of diabetes treatment, in order to prevent complications of the disease.
Type 1 diabetes is managed with insulin as well as dietary changes and exercise.
Type 2 diabetes may be managed with non-insulin medications, insulin, weight reduction, or dietary changes.
Medications for type 2 diabetes are designed to
increase insulin output by the pancreas,
decrease the amount of glucose released from the liver,
increase the sensitivity (response) of cells to insulin,
decrease the absorption of carbohydrates from the intestine, and
slow emptying of the stomach, thereby delaying nutrient digestion and absorption in the small intestine.
Diabetes mellitus (DM) has routinely been described as a metabolic disorder characterized by hyperglycemia that develops as a consequence of defects in insulin secretion, insulin action, or both.
Such a deficiency results in increased concentrations of glucose in the blood, which in turn damage many of the body's systems, in particular the blood vessels and nerves.
1. Microvascular (due to damage to small blood vessels).
2. Macrovascular (due to damage to larger blood vessels).
Insulin Initiation : When We should Start with Basal Insulin?mataharitimoer MT
Insulin Initiation : When We should Start with Basal Insulin?
Dr. Agus Taolin , SpPD, FINASIM | PAPDI CABANG BOGOR
Disampaikan pada acara PIT VI IDI Kota Bogor | 9 Nopember 2013
All diabetics irrespective of other treatment require some control of their eating and exercise patterns
Dibetics must watch their
- total caloric intake
-types of nutrients and eating schedule
50% of patients may require only diet Another 25% would need to augment their natural insulin with drugs
while the remainder will need insulin
Diet recommendations include
- discouraging fats
encouraging complex carbohydrate and fibre
The recommended diabetic diet except in a few respects is now similar to the normal healthy diet that everyone should eat. i.e regular meals, low in fats, low simple sugars, low in sodium and high in complex carbohydrate (starch) and fibre
Diet recommendations include
- discouraging fats
encouraging complex carbohydrate and fibre
The recommended diabetic diet except in a few respects is now similar to the normal healthy diet that everyone should eat. i.e regular meals, low in fats, low simple sugars, low in sodium and high in complex carbohydrate (starch) and fibre
Diet recommendations include
- discouraging fats
encouraging complex carbohydrate and fibre
The recommended diabetic diet except in a few respects is now similar to the normal healthy diet that everyone should eat. i.e regular meals, low in fats, low simple sugars, low in sodium and high in complex carbohydrate (starch) and fibre Diet recommendations include
- discouraging fats
encouraging complex carbohydrate and fibre
The recommended diabetic diet except in a few respects is now similar to the normal healthy diet that everyone should eat. i.e regular meals, low in fats, low simple sugars, low in sodium and high in complex carbohydrate (starch) and fibre
Infertility is defined as the inability of a couple to conceive after at least one year of regular unprotected intercourse.
Male infertility refers to a male's inability to cause pregnancy in a fertile female.
IDD situation in our country has improved
A good number of thyroid disorder patients are either undiagnosed and or untreated
Thyroid disorder in pregnancy- Rate high
As a sound thyroid functioning status is crucial for growth, development in children; reproduction, psychological and general wellbeing in adults, we must be proactive in screening, diagnosing and treating our patients.
Over the past several years it has been proved that maternal thyroid disorder influence the outcome of mother and fetus, during and also after pregnancy. The most frequent thyroid disorder in pregnancy is maternal hypothyroidism. It is associated with fetal loss, placental abruptions, pre-eclampsia, preterm delivery and reduced intellectual function in the offspring.1 In pregnancy, overt hypothyroidism is seen in 0.2% cases2 and sub clinical hypothyroidism in 2.3% cases3. Fetal loss, fetal growth restriction, pre-eclampsia and preterm delivery are the usual complications of overt hyperthyroidism (low TSH and high T3, T4) seen in 2 of 1000 pregnancies whereas mild or sub clinical hyperthyroidism (suppressed TSH alone) is seen in
1.7% of pregnancies and not associated with adverse outcomes4. Autoimmune positive euthyroid pregnancy shows doubling of incidence of miscarriage and preterm delivery. Worldwide more than 20 million people develop neurological sequel due to intra uterine, iodine deprivation5. Other problems of thyroid disorders in pregnancy are post partum thyroiditis, thyroid nodules and cancer, hyper emesis gravidarum etc. Debates and disputes persist regarding several protocol and management plan in this specific spectrum of diseases.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
2. What is Insulin?
(1)
• Polypeptide hormone
• Beta-cells of islets of Langerhans
in pancreas
• Profound effects on
• carbohydrate, fat & protein
metabolism
• To some extent on water &
electrolyte balance
• 2 chains
• 2 bonds
• Secreted as basal
& meal related (2)
• Meal related in 2
phases
3. What is Insulin?
(2)
• Insulin deficiency results in
• Elevated plasma glucose -Hyperglycemia
• Elevated plasma lipid - Hypertriglyceridemia
• Altered protein metabolism - Metabolic &
Immune defects
• Insulin replacement in diabetes tends to
restore normalcy
4. Insulin Secretion
B L S HS
Bolus
Basal
Bolus Bolus
Basal Basal
Normally secreted as basal (between meals & night
time) & Meal-related peaks (1st
& 2nd
phase)
5. Actions of Insulin
(1)
• Integrated action on carbohydrate, protein
and fat metabolism
• Dominant effect on glucose homoeostasis
predominantly exerted in 3 tissues
Liver
Skeletal muscle
Fat
6. Actions of Insulin
(2)
In Liver
• Inhibition of glycogenolysis & gluconeogenesis
• Stimulation of glycogenesis & storage
In skeletal muscle & adipocytes
• Stimulation of glucose uptake, utilization &
storage
• Increases glucose transport
• Activation/inactivation of enzymes responsible for
storage & metabolism of glucose
7. Insulin:
The Definitive Therapy for Diabetes
• DM
• Impaired insulin secretion (insulin deficiency)
• Impaired insulin action (insulin resistance)
• Insulin can overcome both the defects
• Hence: Insulin-the definitive therapy for all types
of diabetes
Insulin- a valuable therapeutic tool for early
intervention, to attain and maintain target levels of
blood glucose control.
8. Discovery of insulin (1)
“One of the greatest milestones in history of
medicine”.
9. Discovery of insulin (2)
Experiments in Toronto
University
F Banting, surgeon
C Best, medical college
student
30 July 1921
Banting & Best- extracted
insulin from dog & proved
that it controls symptoms of
diabetes in dogs – 1921
Banting & Macleod-Nobel
Prize for Medicine &
Physiology in 1923
10. 1923 – Nobel prise to Banting and
Macleod
FG
Banting
JJR
Macleod
CH Best JB Collip
11. Discovery of Insulin (3)
• 1st
patient to receive pancreatic extract (insulin)-14-yr
old Leonard Thompson.
• 1st
attempt (11th
Jan 1922)- failed but the 2nd
attempt (3rd
May 1922) succeeded in reducing urine glucose
excretion.
First patient to
benefit from insulin
–saved from death
Leonard Thompsom-1908-1935
•Grew cheerful, started
eating more, gained
weight, & cheeks started
swelling out
12. Discovery of Insulin (4)
Description of Structure
• 1955- Frederick Sanger
identified the amino acid
sequence of insulin:
• Insulin is a protein,
consisting of
• Alpha (21) and beta
(30) chains
• Half life time in blood is 4-
5 min.
B-chain
A-chain
Connecting peptide
s-
s
s-s
s-s
Another Nobel Prize in insulin history – 1958
14. Manufacture of Insulin
(1)
• 1923-Eli Lilly started manufacturing
• 1923- Novo started manufacturing
• ‘Most developments in insulin therapy have originated
from the laboratories of Novo-Nordisk’
• NPH insulin
• highly purified insulin
• monocomponent insulin
• semisynthetic insulin
• biosynthetic human insulin
• Insulin analogues: Insulin Aspart, Premixed analogue & Insulin
Detemir
Insulin
15. Manufacture of insulin (2)
• Currently NN- human insulin from yeast
(Saccharomyces cerevisiae) using rDNA
technology.
• Eli Lilly-human insulin using E. coli, a gram-
negative bacterium.
17. Types of insulin
Type of Insulin
& Brand Names
Onset Peak Duration
Role in Blood Sugar
Management
Rapid-Acting
Lispro 15-30 min. 30-90 min 3-5 hours Covers insulin needs for
meals eaten at the same
time as the injection.Aspart 10-20 min. 40-50 min. 3-5 hours
Glulisine 20-30 min. 30-90 min. 1-2½ hours
Short-Acting
Regular
30 min- 60
min
2-5 hours 5-8 hours
Covers insulin needs for
meals eaten within 30-60
minutes
Intermediate-Acting
NPH (N) 1-2 hours 4-12 hours 18-24 hours
Covers insulin needs for
about half the day or
overnight.
18. Types of insulin
Name of
Insulin
Onset Duration
Role in Blood
Sugar
Management
Long-Acting
Long-acting
insulin covers
insulin needs
for about one
full day.
Degludec 30-90 min No peak:
insulin is
delivered at
a steady
level.
Longer than 24
hours
Glargine 30-90 min Up to 24 hours
Detemir 1-120 min 20-24 hours
19. Types of insulin
Type of Insulin Onset Peak Duration
Role in Blood Sugar
Management
Pre-Mixed*
30/70 30 min. 2-4 hours 14-24 hours These products are
generally taken two
or three times a day
before mealtime.50/50 30 min. 2-5 hours 18-24 hours
25/75 15 min.
30 min.-2½
hours
16-20 hours
Inhaler
Exubera Banned
Afrezza With in min 12 to 15 min 2-3 hours Post prandial effects.
*Premixed insulins are a combination of specific proportions of intermediate-
acting and short-acting insulin in one bottle or insulin pen (the numbers the brand
name indicate the percentage of each type of insulin).
20. Common Insulin Regimens (1)
Split Mix Regimens
Two injections (intermediate + soluble) per day
* before breakfast & before bedtime
Proportion/dosage of insulins titrated based on BG
profile
Drawback
Mixing insulins is tedious and problematic
Inaccuracy of dose
Not preferred –more problems for patients
21. Common Insulin Regimens (2)
Basal insulin
Usually given at night
Proportion/dosage of insulin titrated based on FBG
Drawback
Expensive
Fasting blood glucose is primary targeted
May be with sensitizer and or secretagogue
22. Common Insulin Regimens (3)
Basal Plus
Basal insulin at night
Any rapid acting insulin premeal.
May be useful during early years of T2DM and in
uncomplicated well motivated patients.
May be needed to shifted to Basal bolus regimen
Not preferred –more problems for patients
23. Common Insulin Regimens (4)
Basal Bolus
Basal insulin at night and one rapid acting insulin
immediately before each major meal (3 times).
Basal insulin is titrated following FBG
Rapid acting insulin is titrated by post meal BGs
Drawback
Expensive
4 times needle prick a day.
Most preferred –most fexible
25. Common Insulin Regimens
(5)
Continuous subcutaneous insulin infusion
(CSII):
Recommended for adults and children 12 years and older with
T2DM provided:
To achieve target HbA1c levels with MDIs result in the person experiencing
disabling hypoglycaemia or
HbA1c levels have remained high (8.5% or above) on MDI therapy despite
a high level of care.
27. Indications of insulin
Continuous Use
* Type 1 Diabetes
* Type 2 Diabetes with OHA failure
- Primary - Secondary
Intermittent Use
* Type 2 diabetes during
- major surgery
- pregnancy, labour and delivery
- myocardial infarction
- acute infections
- Hypergycemic emergencies: DKA & HHS
* GDM
Life-saving in T1DM
Essential in T2DM
28. Starting dose of insulin
• T1DM: 1 -0.2-1 U/kg / day1
• T2DM: 0.2-0.3 U/kg / day
In split mixed regimen- 2/3 as intermediate
acting & 1/3 as short- acting 2
In basal bolus regimen: ½ basal at bed time
and ½ bolus in 3 divided doses.
Dosage is individualized and titrated soon
1
Goodman & Gillman’s The pharmacological basis of therapeutics ed. 9th
.pg. 1501
2
Harrison’s Principles of Internal Medicine (15th
Edition) pg. 2131
29. Current recommendations for the treatment of type 2
diabetes
Diet/exercise
Start metformin
Start insulin
Add incretin
therapy
Diabetes Disease Progression
An alternative
approach
30. Why Early insulin initiation?
Clinical & Pharmacological Reasons(4)
Insulin
Improves beta-cell function
(reduces glucotoxicity &
lipotoxicity)
Reverses insulin resistance Improves Quality of Life
Beneficial effects on
lipids
Insulin provides
4 benefits beyond
glycemic control
35. Insulin administration
Sites
• Abdomen (fastest absorption & most preferred)
• Buttocks
• Upper arm
• Thigh-lateral & anterior aspects (slowest)
• Rotate the site of injection around a selected
area
(Intermediate)
36. Side effects of Insulin
5 Side effects
1. Hypoglycemia
2. Allergic Reactions –
• Local redness, itching – self limiting, disappears with
continuation of therapy
• Systemic allergy – angioedema, anaphylaxis; rare,
requires desensitization
1. Insulin lipoatrophy
2. Insulin lipohypertrophy
3. Insulin Edema & weight gain
37. Barriers to Insulin therapy (1)
Hypoglycemia
Requires
specialist
Daily inj
Compliance
Dose titration
difficult
Patient
Runs Away
Serious
illness
Cost
Insulin therapy in type 2 diabetes
Insulin therapy in type 2 diabetes
Insulin therapy in type 2 diabetes
Insulin therapy in type 2 diabetes
38. Barriers to insulin therapy (2)
• Fear of hypoglycemia
• Inconvenient timing of injection
• Complicated regimen
• to be taken 30 minutes before meal
• lifestyle to fit therapy
• Hyperglycemia immediately after meal
• Hypoglycemia before next meal
• Fear of injection
DIPPAP 2 - 53%
Patient survey – ORG-MARG
2002 – 34%
DIPPAP 2 – 35%
39. Storage of Insulin (1)
• Vials, Penfills & Pens not in use
stored between 2° & 8°C
• Storage in or near freezing compartment is to be
avoided (more important-suspensions)
• Too high temp- gradual decrease in biological potency
• In use stored at room temperature (25°C) up to 6wks
(Vials) & up to 4 wks (Penfills & Devices)
• Pens/ Penfills- in use- should not be kept in refrigerator
40.
41. Storage of Insulin (2)
Storage of patient supplies of insulin in
warm climates is not an important
practical issue, & should not interfere
with supplies of vital insulin to pts. in
developing countries.
In this session on Insulin therapy we will try address all issues related to insulin usage in diabetes with particular focus on usage of insulin in type 2 diabetes
We all know that insulin is a Polypeptide hormone
produced by the Beta-cells of islets of Langerhans in pancreas
It exerts profound effects on
carbohydrate, fat & protein metabolism
To some extent on water & electrolyte balance
Insulin deficiency that occurs in diabetes results in
Elevated plasma glucose -Hyperglycemia
Elevated plasma lipid - Hypertriglyceridemia
Altered protein metabolism resulting in Metabolic & Immune defects
HENCE Insulin replacement in diabetes tends to restore normalcy.
Here we look at the secretion of insulin which occurs as basal & meal-related secretion. We have discussed this in the previous session also hence no elaboration is required
Insulin is the definitive therapy for diabetes – we say this because type 2 Diabetes is associated with 2 defects –impaired insulin secretion & impaired insulin action & now there is enough data to show that Insulin can overcome both these defects
Hence: Insulin is the definitive therapy for all types of diabetes. Moreover experts have said that insulin is a valuable therapeutic tool….
The discovery of insulin is an important event not only in the history of diabetes but also in the history of medicine. Discovery of insulin is therefore described as one of the greatest milestones in history of medicine “One of the greatest milestones in history of medicine”
In 1921 Banting and Best started working on the extraction of insulin from the pancreas of dogs. They were successful to prove that the extract could lower blood glucose in dogs. After improving the extraction procedure the team obtained more pure and potent extract with hypoglycemic action. In January 1922 the first injection of insulin was given to a 14-year old boy.
… this boy is the first patient to receive the pancreatic extract i.e. insulin in the year 1922 he was a type 1 diabetic by name Leonard Thompson. The first attempt to inject failed but the in the 2nd attempt on May 3rd 1922, this extract when injected succeeded in reducing the urine glucose excretion in the boy. As time passed this boy grew cheerfully and starting eating more, gained more weight & his cheeks started swelling out. This is the first patient to benefit from insulin and to be saved from death by insulin injections. This was just the beginning & since then millions of such patients have benefited from insulin ..
One another milestone in the history of insulin is the description of the structure of insulin by Fredrick Sanger in the year 1955. Fredrick Sanger of Cambridge identified the amino acid sequence in insulin & said that insulin is a protein consisting of two chains & it has a half life of 4-5 min in blood. Fredric sanger later got a nobel prize for his workinn the year 1958. So, yet another nobel prize in the history of insulin
The insulin extracted by Banting & Best was in small quantity, what was required is manufacturing insulin on a large scale so that many patients could reap the benefits of this wonder drug. It was in 1923 that Novo started manufacturing insulin in Denmark after obtaining permission From Banting & Best. At around the same time Eli LILLY started manufacturing insulin in the US.
Since then Most developments in insulin therapy have originated from the laboratories of Novo-Nordisk’ and this includes
NPH insulin
highly purified insulin
monocomponent insulin
semisynthetic insulin
biosynthetic human insulin
Insulin analogues like Insulin aspart, Premixed analogue & Insulin detemir
Currently Novo Nordisk manufactures human insulin from yeast using rDNA technology.
Eli Lilly on the other hand uses E.coli, a gram negative bacterium to produce human insulin by rDNA technology
Here we give the action profiles of NN brands including the newer introductions, NovoRapid & NovoMix 30
Note the difference in onset, peak & duration of action of NovoRapid & Actrapid & similarly NovoMix 30 & Mixtard 30
Here we give the action profiles of NN brands including the newer introductions, NovoRapid & NovoMix 30
Note the difference in onset, peak & duration of action of NovoRapid & Actrapid & similarly NovoMix 30 & Mixtard 30
Here we give the action profiles of NN brands including the newer introductions, NovoRapid & NovoMix 30
Note the difference in onset, peak & duration of action of NovoRapid & Actrapid & similarly NovoMix 30 & Mixtard 30
In this regimen which is fairly commonly used two injections of a patient -mixed intermediate + soluble insulin are given per day
These two injections are given before breakfast & before bedtime.
The proportion/dosage of insulins can be titrated based on BG profiles.
This regimen has its own drawbacks which include
Mixing insulins is tedious and problematic for the patient
Inaccuracy of dose is common
Errors in dose could lead to problems. HENCE THIS REGIMEN IS NOT PREFERRED AS IT IS MORE PROBLEMATIC FOR THE PATIENT
In this regimen which is fairly commonly used two injections of a patient -mixed intermediate + soluble insulin are given per day
These two injections are given before breakfast & before bedtime.
The proportion/dosage of insulins can be titrated based on BG profiles.
This regimen has its own drawbacks which include
Mixing insulins is tedious and problematic for the patient
Inaccuracy of dose is common
Errors in dose could lead to problems. HENCE THIS REGIMEN IS NOT PREFERRED AS IT IS MORE PROBLEMATIC FOR THE PATIENT
In this regimen which is fairly commonly used two injections of a patient -mixed intermediate + soluble insulin are given per day
These two injections are given before breakfast & before bedtime.
The proportion/dosage of insulins can be titrated based on BG profiles.
This regimen has its own drawbacks which include
Mixing insulins is tedious and problematic for the patient
Inaccuracy of dose is common
Errors in dose could lead to problems. HENCE THIS REGIMEN IS NOT PREFERRED AS IT IS MORE PROBLEMATIC FOR THE PATIENT
In this regimen which is fairly commonly used two injections of a patient -mixed intermediate + soluble insulin are given per day
These two injections are given before breakfast & before bedtime.
The proportion/dosage of insulins can be titrated based on BG profiles.
This regimen has its own drawbacks which include
Mixing insulins is tedious and problematic for the patient
Inaccuracy of dose is common
Errors in dose could lead to problems. HENCE THIS REGIMEN IS NOT PREFERRED AS IT IS MORE PROBLEMATIC FOR THE PATIENT
Insulin being polypeptide hormone is destroyed in the stomach when given orally, and therefore needs to be given parenterally by subcutaneous injection (all insulins) or by intravenous infusion ( neurtral soluble regular rapid acting insulin).
Insulin administration may be done on a regular basis or intermittent basis.
Regular insulin administration is required in all patients with type 1 diabetes, and in those type 2 diabetes patients who have a primary or secondary failure of response to OHA therapy.
Insulin is required intermittently in patients with type 2 diabetes whenever :
1. they are scheduled to undergo major surgery
2. during pregnancy, labor and delivery
3. during myocardial infarction
4. during the treatment of acute and chronic infections such as pneumonia and tuberculosis respectively
5. During acute metabolic crises like hyperosmolar coma, lactic acidosis or diabetic ketoacidosis
6. During gestational diabetes mellitus if diet and exercise do not provide adequate control
In all intermittent use categories Human Insulin is the drug of first choice.
We now have evidence for action of insulin beyond glycemic control. These actions beyond glycemic control are shown in the right panels here.
As mentioned earlier insulin is inject able & has to be given subcutaneously. The common sites for administration of insulin are abdomen, buttocks, upper arm, Thigh- front & outer side. The patient is always advised to rotate the site of injection around a selected area. the absorption of insulin depends on several factors & one of them is the site of injection, as shown in the slide.. buttock slow absorption, abdomen faster absorption.
There are 5 side effects of insulin & they include hypo, allergic reactions, insulin lipoatrophy & lipohypertrophy, insulin edema & weight gain
There are many barriers to insulin therapy & these are more in the minds of doctors, which is why, we say that early insulin therapy in particular and insulin therapy in type 2 diabetes is caught in a jigsaw puzzle of perceptions. There is a gap between the perception of patients and their treating physicians
If we bridge this gap in the perceptions, we can help insulin therapy in type 2 diabetes get out of this jigsaw and we could do this with a large study called ICEON done in 2002 in India.
Well, the reasons why doctors are not prescribing insulin are 3 – fear of hypoglycemia, compliance and fear of injection.
DIPPAP 2 , a large physician survey conducted by NN in 1998 showed that 53% of doctors fear hypoglycemia. The survey showed that 35% of patients put on insulin are non-compliant for reasons shown.
A ORG-MARG survey showed that 34% of diabetics are afraid of injection.
Here are the storage guidelines as per our package inserts ….
Another question is….
There is nothing dangerous about contamination
Dont share FlexPens with other users
What do experts say … Dr. Gill G.V says that
Storage of patient supplies of insulin in warm climates is not an important practical issue, & should not interfere with supplies of vital insulin to pts. in developing countries.
Our preparations are robust & can be stored up to one month at room temperature