Insulina y dm
-
Upload
kamell-red -
Category
Documents
-
view
646 -
download
1
Transcript of Insulina y dm
TERAPIA DE INSULINA EN LA DIABETES MELLITUS
DR. LEOPOLDO MELÉNDEZ RIVERA
MEDICINA INTERNA
INSULINA EN EL DIABÉTICO
• DIABETES TIPO 1• DIABETES TIPO 2 REFRACTARIA A
TRATAMIENTO ORAL• DIABETES GESTACIONAL• SÍNDROMES ESPECÍFICOS
DIABETES CARE 26 S1, 2003
INSULINA EN EL DIABÉTICO
• INSULINA– ORIGEN
• BOVINA• PORCINA• HUMANA
RECOMBINANTE• ANÁLOGOS
– TIPOS• RÁPIDA• CORTA• INTERMEDIA• LARGA
DIABETES CARE 26 S1, 2003
INSULINA EN EL DIABÉTICO
NEJM 352;2:174-183, 2005
INSULINA EN EL DIABÉTICO
• MARCAS
– NPH HUMULIN N (LILLY)
– RÁPIDA
HUMULIN R (LILLY)– LISPRO
HUMALOG– GLARGINA
LANTUS– ASPARTICA
NOVORPID
DIABETES CARE 26 S1, 2003
INSULINA EN EL DIABÉTICO
• TRANSPORTE Y ALMACENAJE
– REFRIGERADA 4° A 8°– NO AGITAR– MENOS DE UN MES
• MEZCLADO– PRIMERO INSULINA
RÁPIDA Y DESPUES INTERMEDIA
– GLARGINA NO SE COMBINA
DIABETES CARE 26 S1, 2003
INSULINA EN EL DIABÉTICO
• JERINGAS
– INYECCIÓN SUBCUTÁNEA
– CAPACIDAD 0.3, 0.5, 1 Y 2 ML
– NO SE COMPARTE
– SUSTITUTOS• INYECTORES JET• BOMBAS DE INFUSIÓN
CONTÍNUA
DIABETES CARE 26 S1, 2003
INSULINA EN EL DIABÉTICO
• TÉCNICA DE INYECCIÓN
– INYECTAR VOLUMEN DE AIRE EQUIVALENTE
– CARGAR Y AGITAR GENTIL
– MEZCLAR PRIMERO INSULNA RÁPIDA
– INYECTAR A 90°– NO ASPIRAR– NO BURBUJAS
DIABETES CARE 26 S1, 2003
INSULINA EN EL DIABÉTICO
• SITIO DE INYECCIÓN
– BRAZO– GLUTEOS– ABDOMEN– ESCAPULAS– MUSLOS
DIABETES CARE 26 S1, 2003
INSULINA EN EL DIABÉTICO
• DOSIS
– INSULINA RÁPIDA 15 MIN PREPRANDIAL O AL FINAL
– INSULINA INTERMEDIA 30 MIN PREPRANDIAL– INSULINA LISPRO PREPRANDIAL INMEDIATA– INSULINA GLARGINA PREPRANDIAL INMEDIATA
DIABETES CARE 26 S1, 2003
INSULINA EN EL DIABÉTICO
• DOSIS
NEJM 352;2:174-183, 2005
INSULINA EN EL DIABÉTICO
• DOSIS
NEJM 352;2:174-183, 2005
INSULINA EN EL DIABÉTICO
• DOSIS– NPH
• COLACIÓN NOCTURNA
NEJM 352;2:174-183, 2005
INSULINA EN EL DIABÉTICO
• DOSIS. Recommended Strategies for Initiating Insulin in Type 2 Diabetes*
A1C ThresholdTherapeutic Strategy Suggested Initial Dose† Follow-up
7.0% to 10.0% despite 2 oral medications
Initiate basal insulin
10 U every day for insulin glargine Advance insulin dose weekly until FPG is within target
Continue oral medications
10 U every day or twice daily for NPH If A1C remains > 7.0% and PPG is elevated, add prandial insulin starting with largest daily meal
Monitor A1C every 3 months until < 7.0%; every 6 months thereafter
> 10.0% despite 2 oral medications
Initiate basal-prandial insulin‡
Basal, as above Optimize prandial doses for each meal
Discontinue oral secretagogues
Prandial: 5-10 U at each meal§ (Approximately 1 U for every 10-15 g of carbohydrate to start)
Advance insulin dose weekly until PPG and FPG are within target
Premixed insulin is not usually recommended, but can consider 10 U before breakfast and dinner
Monitor A1C every 3 months until < 7.0%; every 6 months thereafter
FPG = fasting plasma glucose; NPH = neutral protamine Hagedorn; PPG = postprandial glucose*Consider adding insulin in all patients who have A1C > 7.0% despite optimal doses of 2 oral agents.†Reduced doses may be prudent in chronic renal disease.‡A basal insulin can be introduced initially; however, the need to advance within 3-5 months to a basal-prandial regimen is more likely at such baseline A1C levels.§An alternative for initial dosing of prandial insulin is 5-10 U at the main meal.
Medscape General Medicine 7(4):49, 2005
INSULINA EN EL DIABÉTICO
• COMPLICACIONES
– HIPOGLICEMIA
DIABETES CARE 26 S1, 2003
INSULINA EN EL DIABÉTICO Advantages of Basal-Prandial and Premixed Insulin Regimens[42,56]
Basal-Prandial Insulin Regimens
Premixed Insulin ProductsBasal Insulin (Insulin Glargine or NPH)
Prandial Insulin (Rapid-Acting Analog or Regular Human)
Advantages
Flexibility: allows variation in timing of meals and activities
Rapid-acting analogs allow greater flexibility/allow variation in timing of meals and activities
Convenience: longer- and shorter-acting insulins combined in 1 injection (may be given twice daily)
Easy to titrate based on FPG, A1C Easy to titrate based on PPG, A1C
Glargine has no pronounced peak and is associated with a lower incidence of hypoglycemia, especially nocturnal hypoglycemia
Can mix with other insulin products to reduce number of injections
Glargine provides ~24-hour coverage with once-daily dosing
FPG = fasting plasma glucose; NPH = neutral protamine Hagedorn; PPG = postprandial glucose
Medscape General Medicine 7(4):49, 2005
INSULINA EN EL DIABÉTICO Disadvantages of Basal-Prandial and Premixed Insulin Regimens
Basal-Prandial Insulin Regimens Premixed Insulin Products
Basal Insulin (Insulin Glargine or NPH) Prandial Insulin (Rapid-Acting Analog or Regular Human)
Glargine cannot be mixed with other insulins
Greater number of daily injections
Cannot titrate basal insulin and prandial insulin individually
NPH may require 2 injections per day for 24-hour coverage
Less mealtime flexibility with regular human insulin
Increased risk for hypoglycemia
NPH is associated with variability of absorption (ie, site of injection, inter- and intrapatient)
Lunchtime prandial dose may need to be administered separately
Less mealtime flexibility
NPH has an increased risk for midmorning and/or nocturnal hypoglycemia
Difficult to administer premeal correction doses, especially with prefilled pen cartridges
FPG = fasting plasma glucose; NPH = neutral protamine Hagedorn; PPG = postprandial glucose
Medscape General Medicine 7(4):49, 2005
INSULINA EN EL DIABÉTICO
• RECHAZO
– INYECCIONES– MITOS
• CEGUERA• ALERGIAS• FASE TERMINAL• AUMENTO DE PESO• RIESGO
CARDIOVASCULAR
Medscape General Medicine 7(4):49, 2005
INSULINA EN EL DIABÉTICO
• INSULINA RÁPIDA
– EN CETOACIDOSIS • BOLO INICIAL DE 0.15 UI/KG• INFUSIÓN DE 0.1 UI/KG/HR Y DOBLAR CADA HORA
• BOLO INICIAL 0.4 UI/KG – 50% IV, 50% SC
• BOLO SC 0.1UI/KG/HR Y 10UI SC/HR
• AL ALCANZAR 250 MG/DL…
Diabetes Care 24:131-153, 2001Diabetes Care 27:S94-S102, 2004
INSULINA EN EL DIABÉTICO
• INSULINA RÁPIDA– EN CETOACIDOSIS
• AL ALCANZAR 250 MG/DL (SIN CETOSIS):
– INFUSIÓN A 0.05 UI/KG/HR– 5 UI SC/HR O 5-10 UI SC/ 2 HR
• AL ALCANZAR 200 MG/DL:
– 5 UI SC C/50 MG >150 MG/DL– 20 UI SC C/150 MG>300 MG/DL
Diabetes Care 24:131-153, 2001Diabetes Care 27:S94-S102, 2004
INSULINA EN EL DIABÉTICO
• INSULINA RÁPIDA– EN ESTADO HIPEROSMOLAR
• BOLO INICIAL 0.15 UI/KG IV• INFUSION 0.1 UI/KG/HR• DOBLAR CADA HORA HASTA BAJAR 50-70 MG/DL INICIA 1 UI/HR DOSIS-RESPUESTA INFUSIÓN 0.02 UI/KG/HR HASTA 10 – 50 UI/HR
• SIN ESTADO HIPEROSMOLAR– 5 UI SC C/50 MG >150 MG/DL– 20 UI SC C/150 MG>300 MG/DL– 0.05-0.1 UI/KG/HR AL MANTENER 250-300MG/DL
Diabetes Care 24:131-153, 2001Diabetes Care 27:553-591, 2004
INSULINA EN EL DIABÉTICO
• INSULINA RÁPIDA– DEFICIT DE AGUA
• (Na/140 – 1) X 0.6 X PESO • 150 (1.07) 60 (2.5)
• MIELINOLISIS PONTINA
Diabetes Care 24:131-153, 2001Diabetes Care 27:553-591, 2004
INSULINA EN EL DIABÉTICO
• INSULINA RÁPIDA– OSMOLARIDAD SÉRICA
•2 Na + glucosa/18 + BUN/2.8 • 150 400 60 343• 150 100 60 327• 145 100 60 316• 145 100 15 3
•Osm Ser = 280 - 310Diabetes Care 24:131-153, 2001Diabetes Care 27:553-591, 2004
INSULINA EN EL DIABÉTICO
• INSULINA RÁPIDA– EN HIPERGLICEMIA AGUDA
• 1 UI DISMINUYE 30 A 50 MG/DL DE GLUCOSA SÉRICA
– ESQUEMAS SEGÚN ESCALA DE TIRA REACTIVA
• 1 UI METABOLIZA 4 GRAMOS DE GLUCOSA EXÓGENA
– 1000 CC SOL. GLUCOSADA 5% UTILIZA 12.5 UI
GOODMAN Y GILMAN, TRATADO DE FISIOLOGÍA
INSULINA EN EL DIABÉTICO • INSULINA RÁPIDA
– EN HIPERGLICEMIA AGUDA
• ESQUEMA DE INSULINA RÁPIDA
– 200-240 MG/DL = 3UI 80-120 MG/DL– 240-360 MG/DL = 5UI 120-160 MG/DL– 360-480 MG/DL = 7UI 80-200 MG/DL
• CONDICIONANTES
– OBESIDAD– FUNCIÓN RENAL– FUNCIÓN HEPÁTICA– USO PREVIO– ESTADO CATABÓLICO
VALORACIÓN PREOPERATORIA, HALABE J.
INSULINA EN EL DIABÉTICO
• INSULINA LISPRO– EN HIPERGLICEMIA PREPRANDIALES
• 10 - 20% DE LA DOSIS TOTAL DIARIA POR CADA EVENTO
• PREVIA GLICEMIA CAPILAR UNA HORA ANTES• APLICAR 0 – 15 MINUTOS ANTES
– EN EVENTOS QUIRÚRGICOS• 10 – 20% DE LA DOSIS TOTAL CADA 4 HRS PRN• 0.02 UI/KG CADA HORA
Diabetes Care 27:553-591, 2004:
INSULINA EN EL DIABÉTICO
Medscape General Medicine 7(4):49, 2005
RESISTENCIA A LA INSULINA
www.medscape.com/viewprogram/3942, ABRIL 2005
DEFINICIÓN
• REQUERIMIENTO DIARIO >100 UI• NECESIDAD DE UN MONTO MAYOR DE INSULINA
(ENDÓGENO O EXÓGENA) PARA ALCANZAR LA RESPUESTA NORMAL
SINÓNIMOS
• SÍNDROME METABÓLICO• SÍNDROME X• SÍNDROME DISMETABÓLICO
RESISTENCIA A LA INSULINA
www.medscape.com/viewprogram/3942, ABRIL 2005
1. National Cholesterol Education Program/Adult Treatment Panel III (NCEP/ATP III) Diagnostic Criteria for the Metabolic Syndrome
Diagnosis is made when 3 or more of the following are present:
Waist circumference Men > 102 cm Women> 88 cm
Fasting triglycerides >/= 150 mg/dL
Blood pressure >/= 130/85 mmHg
HDL cholesterol </= 50 mg/dL for women; </= 40 mg/dL for men
Fasting glucose* >/= 110 mg/dL
• This was changed to 100 mg/dL following the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association (ADA) conference proceedings[
The value of 110 mg/dL does not reflect the revised ADA criteria for impaired fasting glucose.
RESISTENCIA A LA INSULINA
www.medscape.com/viewprogram/3942, ABRIL 2005
2. WHO Criteria for the Metabolic Syndrome
Insulin resistance, as identified by 1 of the following:
• Type 2 diabetes
• Impaired fasting glucose (101-125 mg/dL)
• Impaired glucose tolerance (140-199 mg/dL 2h after 75 g of glucose)
• If normal fasting glucose, glucose uptake below the lowest quartile for background population under hyperinsulinemic, euglycemic conditions
Plus 2 of the following:
• Antihypertensive medication and/or blood pressure >/= 140 mmHg systolic or >/= 90 diastolic
• Triglycerides >/= 150 mg/dL
• HDL < 35 mg/dL for men or < 39 mg/dL for women
• BMI > 30 kg/m2 and/or waist-hip ratio > 0.9 men, > 0.85 women
• Urinary albumin excretion >/= 20 mcg/min or albumin-creatinine ratio >/= 30 mg/g
RESISTENCIA A LA INSULINA
www.medscape.com/viewprogram/3942, ABRIL 2005
3. AACE Clinical Criteria for Diagnosis of the Insulin Resistance Syndrome
Risk Factor Cutoff
Overweight/obesity BMI >/= 25 kg/m2
Elevated triglycerides >/= 150 mg/dL
HDL cholesterol Men Women
< 40 mg/dL< 50 mg/dL
Blood pressure >/= 130/85 mmHg
2h post 75 g glucose challenge
> 140 mg/dL
Fasting glucose Between 110 and 126 mg/dL
Additional risk factors -Family history of type 2 diabetes-Hypertension-Coronary heart disease (CHD)-Polycystic ovary syndrome-Sedentary lifestyle-Advanced age-Ethnic groups at high risk for type 2 diabetes or CHD
RESISTENCIA A LA INSULINA
www.medscape.com/viewprogram/3942, ABRIL 2005
4. Major Cardiovascular Risk Factors
Hypertension (blood pressure > 140/90 mmHg or taking antihypertensive medication)
Cigarette smoking
Obesity
Physical inactivity
Dyslipidemia/low HDL cholesterol (< 40 mg/dL) or high triglycerides ( > 150 mg/dL)
Diabetes mellitus (coronary heart disease risk equivalent)
Microalbuminuria or glomerular filtration rate < 60 mL/min
Age ( > 55 years for men, > 65 for women)
Family history of premature coronary heart disease
RESISTENCIA A LA INSULINA
NEJM 1999; 341:248-257
CAUSAS
• MUTACIONES EN LOS TRANSPORTADORES DE GLUCOSA• ALTERACIONES EN EL GEN GLUT 4• DEFECTOS EN LA TRANSLOCACIÓN DEL GEN GLUT 4• DEFECTOS EN LAS VÍAS DE SEÑALIZACIÓN• DISMINUCIÓN DEL TRANSPORTE DE GLUCOSA POR INSULINA
RESISTENCIA A LA INSULINA
NEJM 1999; 341:248-257
CAUSAS
• FACTORES PARACRINOS• ÁCIDOS GRASOS• GLUCOTOXICIDAD• FACTOR DE NECROSIS TUMORAL
• FACTORES NO INSULÍNICOS• EJERCICIO• BRADIQUININAS• ÓXIDO NITROSO• FACTORES DE CRECIMIENTO INSULINA-LIKE• PÉPTIDO C• HORMONAS TIROIDEAS
RESISTENCIA A LA INSULINA
www.medscape.com/viewprogram/3942, ABRIL 2005
RESISTENCIA A LA INSULINA
www.medscape.com/viewprogram/3942, ABRIL 2005