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Diabetes Treatments: Options for Insulin Delivery. Bonnie Pepon, RN, BSN, CDE Certified Diabetes Educator Conemaugh Diabetes Institute

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Diabetes Treatments:

Diabetes Treatments:

Options for Insulin Delivery Options for Insulin Delivery

Bonnie Pepon, RN, BSN, CDE Certified Diabetes Educator Conemaugh Diabetes Institute

(2)

Diabetes Diabetes

y 21 million people in the U.S. have diabetes

y $132 billion each year

◦ Type 1 diabetes – no insulin production

◦ Type 2 diabetes – some insulin production

◦ Gestational diabetes

(3)

Type 1 Diabetes

Type 1 Diabetes

(4)

Type 1 Diabetes

Type 1 Diabetes

(5)

Insulin Production of Type 2

Insulin Production of Type 2

(6)
(7)
(8)

Healthy Healthy

Eating

Eating

(9)
(10)
(11)
(12)
(13)

• Sulfonylureas

• Meglitinides

• Biguanides

• Alpha Glucosidase Inhibitors

• Thiazolidinediones-TZD’s

• Incretin Mimetics

• DPP IV Inhibitors

Classes of Medications

Classes of Medications

(14)

Sulfonylureas

Most common drugs in this class:

Glipizide (Glucotrol, Glucotrol XL)

Glyburide (Micronase, Diabeta, Glynase)

Glimepiride (Amaryl) How do they

work?

Stimulate the pancreas to make more insulin

Work for up to 24 hours

Lowers fasting and post prandial blood sugar Advantages: May decrease AIC 1.5-2%

Inexpensive

Side effects: Weight gain (4.5-11 lbs.)

Low blood sugar

How to take: Take glipizide 30 min before the first meal of the day

All others take with first meal of the day

(15)

Meglitinides

Most common drugs in this class:

Repaglinide(Prandin)

Nateglinide (Starlix) How do they

work?

Stimulate the pancreas to make more insulin

Work only for about 4 hours after meals

Only effects post prandial sugars – NOT FASTING!

Advantages: May decrease A1C by 1-2%

Side effects: Weight gain

Low blood sugar

How to take: Take up to 30 minutes before meals

No meal= No pill

(16)

Biguanides

Most common drugs in this class:

Metformin (Glucophage, Glucophage XR)

Liquid Form (Riomet) How do they

work?

Helps your body produce less glucose from the liver

Helps insulin work better

Reduces glucose absorption in the intestines

Takes up to 2 weeks to see maximum effect Advantages: Can decrease AIC 1.5-2%

Does not cause low blood sugar or weight gain

May also lower triglycerides and cholesterol Side effects: Nausea and Diarrhea

How to take: Take with breakfast and supper

(17)

Alpha Glucosidase Inhibitors

Most common drugs in this class:

Acarbose (Precose)

Miglitol (Glyset) How do they

work?

Slows the digestion of carbs in the small intestine, thus decreasing the post prandial blood sugar spike

Advantages: May decrease A1C by 0.5 to 1%

Does not cause low blood sugar or weight gain

Side effects: Gas and diarrhea

How to take: Take with first bite of food of 3 largest meals of the day

(18)

Insulin Sensitizers-TZD’S

Most common drugs in this class:

Rosiglitazone (Avandia)

Pioglitazone (Actos) How do they

work?

Helps insulin work better

Enhances glucose uptake by the muscle tissue

Reduces glucose production by the liver

Takes up to 3 months to see maximum effect Advantages: May decrease A1C by 0.5-1%

Does not cause low blood sugar

May decrease triglycerides and increase HDL Side effects: Swelling in legs and weight gain (caution in

heart failure)

If on oral contraceptive, may increase risk of pregnancy

Liver damage (<1% chance)

Liver function is monitored every 2 months for the first year

(19)

Combination Drugs Combination Drugs

• Glucovance (glyburide/metformin)

• Metaglip (glipizide/metformin)

• Avandamet (avandia/metformin)

• Duetact (amaryl/actos) New Ones:

• Fortamet (metformin SR)

• Glumetza (metformin SR)

• Actoplus (actos/metformin)

• Avandryl (avandia/glimepiride)

(20)

Incretin

Incretin Mimetics Mimetics : Gut Hormones : Gut Hormones

Byetta (Exenatide) approved for type 2

Symlin (Pramlintide) approved for type 1

and type 2 using mealtime insulin

(21)

DPP IV Inhibitors DPP IV Inhibitors

Januvia (Sitagliptin)

y Oral active, selective inhibitor for the DPP-4 enzyme

y A1C effect-decreased by 0.65-0.8%

y Can be administered with or without food

y Not for type 1 diabetes

(22)

Byetta

How do they work?

Prevents stored sugar from entering the blood stream

Stimulates insulin release

Slows gastric emptying

Lowers post prandial blood sugar spike

Makes you feel full

Reduces food intake and appetite

Advantages: May decrease A1C by 1% after 6 months

Promotes weight loss (5-6 lbs)

Dosing: Comes in a prefilled pen that lasts one month

5 mcg twice a day for 1 month, then increase to 10mcg twice a day

Give within 60 minutes of morning and evening meal

Do NOT give after a meal

If you miss a meal, skip the dose

Side effects: Nausea (will go away with time and dose titration)

Vomiting and diarrhea

Low blood sugar

May need to decrease dose of sulfonylurea to avoid low blood sugar

(23)

Symlin

How do they work?

Slows gastric emptying

Lowers the post prandial blood sugar spike

Makes you feel full

Reduces food intake and appetite

Slows production of glucose from liver Advantages: May lower A1C by 0.6% in Type 2 after 6

months

Promotes weight loss (4 lbs)

Side effects: Nausea (will decrease over time)

Loss of appetite

Vomiting

Hypoglycemia (3 hours after dose)

Decrease amount of rapid acting insulin by 50%

(24)
(25)

Goals of Insulin Therapy

y

To keep the blood glucose levels as close to normal as possible

◦ Fasting 70-100 mg/dl

◦ After meals 100-140 mg/dl

y

To prevent acute and long term complications

y

To keep the HbA1c at 6.5% - 7%

y

To feel better if you are in your goal range

(26)

Rapid Acting Insulin

Insulin Onset of

action Peaks Duration

Humalog or lispro

5 to 15

minutes 30 to 60

minutes 3 to 5 hours Novolog

or aspart

Apidra

or glulisine

Short Acting Insulin

Humulin R or Novolin R

minutes30 2 to 3

hours 3 to 6 hours

„Clear in appearance

„Available in vials and pens

(27)

Intermediate Acting Insulin

Insulin Onset of

action Peaks Duration

Humalin N (NPH) or Novolin N (NPH)

2 to 4

hours 4 to 12

hours 12 to 18 hours

„Cloudy in appearance

„Available in vials and pens

Long Acting Insulin

Levimir

(detemir) 1 to 2

hours 6 to 8

hours 6 to 23 hours Lantus

(glargine) 1 hour no peak 24 hours

„Clear in appearance

„Available in vials and pens

„Cannot be mixed in the same syringe with any other type of insulin

(28)
(29)

Insulin Injection Sites

(30)

Insulin Delivery Systems

Available Now

(31)

Syringe/Needle/Vial Syringe/Needle/Vial

y Insulin comes in U–100 in the U.S. ◦ orange cover and black scale

◦ 100 units of insulin per milliliter of fluid in the vial

y U–500 available

◦ high insulin resistance using more than 200 units a day

y Outside the U.S.: U-40

◦ red cover and red scale

(32)

Syringe/Needle/Vial Syringe/Needle/Vial

„

Most common method of delivery

„

Syringes (range of sizes)

„

needle gauge

„

needle length

„

syringe capacity

„

3/10cc, 1/2cc, 1cc

(33)

Insulin Needles Insulin Needles

„

Syringes available

„

1/2 in or 12.7 mm

„

5/16 or 8mm

„

Pen needles available

„

½ in

„

5/16 in

„

3/16 in

„

Gauges available

„

31, 30, 29, 28

(34)
(35)

Syringes

◦ Syringes are most widely available

◦ Can be adjusted to 1 or ½ units

◦ Can use most types of insulin

◦ Require good vision to measure a dose

Insulin Devices

Insulin Devices

(36)

Pens

◦ Easy to set the correct dose by a dial

◦ Can be adjusted with ½ units or 1 unit

◦ Can use most types of insulin

◦ Very convenient and accurate for the vision impaired and those on the go

Insulin Devices

Insulin Devices

(37)

Pumps

◦ Results in better diabetes control

◦ More flexible eating schedule

◦ Dose adjusted by 1/10 to 1/20 units

◦ Requires higher level of involvement & more advanced diabetes education and skills

Insulin Devices

Insulin Devices

(38)

y Multiple manufacturers

◦ BD, Monoject, SureComfort, Ulticare Precision Sure Dose, UltiGuard, Medicore, Aimsco

y Injection aides

◦ Inject-Ease by BD and Palco, Instaject (can be combined with a lancet device),

NeedleAid, NovoPen 3 Penmate

Insulin Syringes

Insulin Syringes

(39)

y Uses an insulin needle

◦ available in different sizes and gauges

◦ units can be counted as dialed by a click

◦ plunger is pushed in and held for several seconds before removing the needle

Insulin Pens

Insulin Pens

(40)

y Storage in refrigerator until the pen is started

◦ storage life ranges from 7 to 42 days

y Pre-filled pens

◦ 28 days: Humalog/Novolog/Novolin R

◦ 14 days: Novolin N

◦ 10 days: Novalin 70/30

Insulin Pens

Insulin Pens

(41)

Insulin Pens:

Insulin Cartridges

1.5 ml

Insulin Days

Humalog 28 days

Novolin R 30 days

Novolin 70/30 and

Novolin N 7 days

3 ml

Novolin

R/Novolog/Lantus 28 days

Novolin N 14 days

Novolin 70/30 10 days

Levemir 42 days

(42)

Pre-mixed Insulin

Insulin Onset of

action Peaks Duration

Humalog mix 75/25 or 50/50

30

minutes 2 to 4

hours 22 to 24 hours Humulin mix

70/30 or 50/50

Novolog mix 70/30

Novolin mix 70/30

„Helpful for those with poor eyesight, dexterity problems or those who have trouble mixing from 2 different vials

(43)
(44)
(45)
(46)

Insulin Pumps

Insulin Pumps

(47)

Pumps

◦ Deliver rapid acting insulin

◦ Results in better diabetes control

◦ More flexible eating schedule

◦ Dose adjusted by 1/10 to 1/20 units

◦ Requires higher level of involvement & more advanced diabetes education and skills

◦ Water proof

◦ Carb counters

◦ Risk of infection, inflamation at injection site

(48)

y Delivers rapid acting dry powder insulin

y Absorbed through the lungs into the bloodstream

◦ 1mg and 3mg blister packets

◦ Cannot be used for smokers, children, pregnant women or anyone with lung problems

Will be taken off the market in January 2008

Inhaled Insulin

Inhaled Insulin

(49)

Jet Injector

Jet Injector

(50)

y Minimize needle sticks by creating a portal to inject insulin into

y A small tube is inserted into the fatty tissue of the injection site

y It is taped in place for 2-3 days

y Insulin injected into the tube via pen or syringe instead of the skin

Insulin Infuser

Insulin Infuser

(51)

y

45 year old African-American male

y

Diagnosed with Type 2 DM

y

Initial glucose 280mg/dl, A1C–9.9%

◦ Started on nutrition and physical activity

◦ 3 months later still having symptoms

◦ PMH –hypertension, obesity, high lipids

◦ Smoker, occasional alcohol, no drug use

What therapy should be started?

Case Study

Case Study

(52)

The Pharmacist The Pharmacist

Part of the Healthcare Team

Part of the Healthcare Team

(53)

Questions?

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