Insulin therapy Niloufar Ansari, Pharm. D. South Tehran Health Center, Tehran University of Medical...

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Transcript of Insulin therapy Niloufar Ansari, Pharm. D. South Tehran Health Center, Tehran University of Medical...

  • Slide 1
  • Insulin therapy Niloufar Ansari, Pharm. D. South Tehran Health Center, Tehran University of Medical Sciences
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  • The breakthrough: Toronto 1921 Banting & Best
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  • Indications for Insulin Use in Type 2 Diabetes Pregnancy (preferably prior to pregnancy) Acute illness requiring hospitalization Perioperative/intensive care unit setting Postmyocardial infarction High-dose glucocorticoid therapy Inability to tolerate or contraindication to oral antiglycemic agents Newly diagnosed type 2 diabetes with significantly elevated blood glucose levels (pts with severe symptoms or DKA) Patient no longer achieving therapeutic goals on combination antiglycemic therapy
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  • Inadequate Non pharmacological therapy Inadequate Non pharmacological therapy 1oral agent 2 oral agents 3 oral agents Add Insulin Earlier in the Algorithm Severe symptoms Severe hyperglycaemia Ketosis pregnancy Proposed Algorithm of therapy for Type 2 Diabetes
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  • Advantages of Insulin Therapy Oldest of the currently available medications, has the most clinical experience Most effective of the diabetes medications in lowering glycemia Can decrease any level of elevated HbA 1c No maximum dose of insulin beyond which a therapeutic effect will not occur Beneficial effects on triglyceride and HDL cholesterol levels Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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  • Disadvantages of Insulin Therapy Weight gain ~ 2-4 kg May adversely affect cardiovascular health Hypoglycemia However, rates of severe hypoglycemia in patients with type 2 diabetes are low Type 1 DM: 61 events per 100 patient-years Type 2 DM: 1-3 events per 100 patient-years Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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  • Types of Insulin 1. Rapid-acting 2. Short-acting 3. Intermediate-acting 4. Premixed 5. Long-acting 6. Extended long-acting (Lispro, Aspart) (Regular) (NPH) (70/30) (Lantus)
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  • Effective OnsetPeakDuration Insulin lispro
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  • Summary of available insulin preparations AgentType / Administration Glucose lowering BasalPost-meal NPHIntermediate-acting human Once or twice daily at bedtime breakfast DetemirLong-acting analogue Once or twice daily at bedtime breakfast GlargineLong-acting analogue Once daily at bedtime or before breakfast PremixedHuman or analogue mix Twice daily before breakfast and dinner RegularFast-acting human Before meals Aspart, glulisine, lispro Rapid-acting analogue Before meals Inhaled insulinRapid-acting human Before meals
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  • Insulin Pens NovoMix 30 30% insulin aspart in a soluble fraction and 70% insulin aspart crystallised with protamine NovoRapid Insulin aspart Insulatard NPH
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  • Insulin Pens
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  • Intelligent Devices Pumps Smart Phones Meters A central reporting station where data is filtered for minor versus major problems and who is to be alerted (user, guardian, MD/RN)
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  • InsulinInsulin MonitoringMonitoring HCPSelf ManagementAutomation Insulin & syringes Pumps Pens Connectivity Clinic Monitoring Home Monitors Data Management Advice/Feedback Open Loop DeliveryDelivery Closed Loop We are here!
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  • Injection Techniques
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  • Sites of injection Arms Legs Buttocks Abdomen Easy access Ample subcutaneous tissue Absorption is not affected by exercise.
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  • Side Effects 1.Hypoglycaemia - 15-15-15 rule - Dextrose 50% - Glucagon 2. Allergy: - Local allergy: redness, swelling and itching at the site of injection -General allergic reaction: sweating, vomiting, breathing difficulties, rapid heart beat, feeling dizzy 3. Lipodystrophy
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  • The ADA Treatment Algorithm for the Initiation and Adjustment of Insulin
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  • Normal physiologic patterns of glucose and insulin secretion in our body
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  • The rapid early rise of insulin secretion in response to a meal is critical, because it ensures the prompt inhibition of endogenous glucose production by the liver disposal of the mealtime carbohydrate load, thus limiting postprandial glucose excursions.
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  • Initiating and Adjusting Insulin Continue regimen; check HbA 1c every 3 months If fasting BG in target range, check BG before lunch, dinner, and bed. Depending on BG results, add second injection (can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range) Recheck pre-meal BG levels and if out of range, may need to add another injection; if HbA 1c continues to be out of range, check 2-hr postprandial levels and adjust preprandial rapid-acting insulin If HbA 1c 7%... Bedtime intermediate-acting insulin, or bedtime or morning long-acting insulin (initiate with 10 units or 0.2 units per kg) Check FG and increase dose until in target range. If HbA 1c 7%... Hypoglycemia or FG >3.89 mmol/l (70 mg/dl): Reduce bedtime dose by 4 units (or 10% if dose >60 units) Pre-lunch BG out of range: add rapid-acting insulin at breakfast Pre-dinner BG out of range: add NPH insulin at breakfast or rapid-acting insulin at lunch Pre-bed BG out of range: add rapid-acting insulin at dinner Continue regimen; check HbA 1c every 3 months Target range: 3.89-7.22 mmol/L (70-130 mg/dL) Nathan DM et al. Diabetes Care. 2006;29(8):1963-72. If HbA 1c 7%... If HbA 1c 7%...
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  • Step One Continue regimen; check HbA 1c every 3 months If fasting BG in target range, check BG before lunch, dinner, and bed. Depending on BG results, add second injection (can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range) Recheck pre-meal BG levels and if out of range, may need to add another injection; if HbA 1c continues to be out of range, check 2-hr postprandial levels and adjust preprandial rapid-acting insulin If HbA 1c 7%... Bedtime intermediate-acting insulin, or bedtime or morning long-acting insulin (initiate with 10 units or 0.2 units per kg) Check FG and increase dose until in target range. If HbA 1c 7%... Hypoglycemia or FG >3.89 mmol/l (70 mg/dl): Reduce bedtime dose by 4 units (or 10% if dose >60 units) Pre-lunch BG out of range: add rapid-acting insulin at breakfast Pre-dinner BG out of range: add NPH insulin at breakfast or rapid-acting insulin at lunch Pre-bed BG out of range: add rapid-acting insulin at dinner Continue regimen; check HbA 1c every 3 months Target range: 3.89-7.22 mmol/L (70-130 mg/dL) If HbA 1c 7%... If HbA 1c 7%... Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.
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  • Step One: Initiating Insulin Start with either Bedtime intermediate-acting insulin or Bedtime or morning long-acting insulin Insulin regimens should be designed taking lifestyle and meal schedules into account Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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  • Step One: Initiating Insulin, contd Check fasting glucose and increase dose until in target range Target range: 3.89-7.22 mmol/l (70-130 mg/dl) Typical dose increase is 2 units every 3 days, but if fasting glucose >10 mmol/l (>180 mg/dl), can increase by large increments (e.g., 4 units every 3 days) Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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  • If hypoglycemia occurs or if fasting glucose < 3.89 mmol/l (70 mg/dl) Reduce bedtime dose by 4 units or 10% if dose >60 units Step One: Initiating Insulin, contd Nathan DM et al. Diabetes Care 2006;29(8):1963-72. Reduction in overnight and fasting glucose levels achieved by adding basal insulin may be sufficient to reduce postprandial elevations in glucose during the day and facilitate the achievement of target A1C concentrations. While using basal insulin alone, never stop or reduce ongoing oral therapy
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  • If HbA 1c is
  • Continue regimen; check HbA 1c every 3 months If fasting BG in target range, check BG before lunch, dinner, and bed. Depending on BG results, add second injection (can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range) Recheck pre-meal BG levels and if out of range, may need to add another injection; if HbA 1c continues to be out of range, check 2-hr postprandial levels and adjust preprandial rapid-acting insulin If HbA 1c 7%... Bedtime intermediate-acting insulin, or bedtime or morning long-acting insulin (initiate with 10 units or 0.2 units per kg) Check FG and increase dose until in target range. If HbA 1c 7%... Hypoglycemia or FG >3.89 mmol/l (70 mg/dl): Reduce bedtime dose by 4 units (or 10% if dose >60 units) Pre-lunch BG out of range: add rapid-acting insulin at breakfast Pre-dinner BG out of range: add NPH insulin at breakfast or rapid-acting insulin at lunch Pre-bed BG out of range: add rapid-acting insulin at dinner Continue regimen; check HbA 1c every 3 months Target range: 3.89-7.22 mmol/L (70-130 mg/dL) If HbA 1c 7%... If HbA 1c 7%... Step Two Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.
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  • Step Two: Intensifying Insulin If fasting blood glucose levels are in target range but HbA 1c 7%, check blood glucose before lunch, dinner, and bed and add a second injection: If pre-lunch blood glucose is out of range, add rapid-acting insulin at breakfas