Diabetes Treatments:
Diabetes Treatments:
Options for Insulin Delivery Options for Insulin Delivery
Bonnie Pepon, RN, BSN, CDE Certified Diabetes Educator Conemaugh Diabetes Institute
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
Type 1 Diabetes
Type 1 Diabetes
Type 1 Diabetes
Type 1 Diabetes
Insulin Production of Type 2
Insulin Production of Type 2
Healthy Healthy
Eating
Eating
• Sulfonylureas
• Meglitinides
• Biguanides
• Alpha Glucosidase Inhibitors
• Thiazolidinediones-TZD’s
• Incretin Mimetics
• DPP IV Inhibitors
Classes of Medications
Classes of Medications
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
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
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
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
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
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)
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
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
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
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%
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
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
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
Insulin Injection Sites
Insulin Delivery Systems
Available Now
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
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
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
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
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
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
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
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
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
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
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
Insulin Pumps
Insulin Pumps
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
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
Jet Injector
Jet Injector
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
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