INSULIN Ceri Jones Diabetes Nurse Facilitator 2013 Who

INSULIN Ceri Jones Diabetes Nurse Facilitator 2013

Who could benefit from insulin therapy? n n People with Type 1 diabetes are dependent on insulin People with Type 2 diabetes q who have inadequate blood glucose control on optimised oral hypoglycaemic agents (NICE, 2003). q with contraindications to oral hypoglycaemic agents. q who have recurrent symptoms of hyperglycaemia or unexplained weight loss. q who are considering pregnancy. q who are pregnant. q who are post acute MI. q who have acute illness or recurrent infection. q who have foot ulceration and/or infection.

Insulin treatment attempts to mimic the pattern of normal insulin secretion 70 Short-lived, rapidly generated meal-related insulin peaks Insulin (µU/ml) 60 50 40 Low, steady, basal insulin profile 30 20 10 0 6: 00 10: 00 14: 00 18: 00 22: 00 6: 00 Time of day Polonsky KS et al. J Clin Invest 1988; 81: 442– 8

Types of insulin n Animal insulin (Used since 1922) q Short acting q Intermediate acting q Mixture of short and intermediate acting (biphasic) Human insulin (Since 1982) q Short acting q Intermediate acting q Mixture of short and intermediate acting (biphasic) Analogue insulin (Since 1996) q Rapid acting q Long acting (basal insulin) q Mixture of rapid and intermediate acting (biphasic)

What are analogue insulins? n n Analogue (or modern) insulins are formed by modifying human insulin molecules Like soluble human insulin, analogue insulins are produced by recombinant DNA technology -chain s Gly -chain s Ala Cys Phe s s s Thr Lys Pro s Insulin lispro -chain s Gly -chain Phe s Ala Cys s Thr Lys Asp Pro s Insulin aspart Hirsch IB. N Engl J Med 2005; 352: 174– 83

Human insulins Short-acting n Absorbed quickly and last for several hours e. g. , Humulin S®, Insuman® Rapid Intermediateand long-acting n Premixed n More slowly absorbed, last for up to 24 hours e. g. , Insulatard®, Humulin® I, Insuman® Basal Mixture of short- and long-acting insulin (biphasic human insulin) e. g. , Humulin M 3, Insuman® Comb Humulin S and Humulin I are registered trademarks of Eli Lilly and Company Insuman Rapid, Insuman Basal, and Insuman Comb are registered trademarks of Sanofi-Aventis Insulatard and Mixtard 30 are registered trademarks of Novo Nordisk

ANALOGUE INSULINS Rapid-acting n Absorbed very rapidly, last only a few hours n Aim to control postprandial glucose e. g. , Novo. Rapid®, Humalog®, Apidra® Long-acting n More slowly absorbed Designed to provide a low level of insulin throughout day and night n e. g. , Levemir®, Lantus® Premixed n Mixture of rapid- and intermediate-acting insulin e. g. , Novo. Mix® 30, Humalog® Mix 25/75 Humalog is a registered trademark of Eli Lilly and Company Lantus and Apidra are registered trademarks of Sanofi-Aventis Novo. Rapid, Novo. Mix and Levemir are registered trademarks of Novo Nordisk

Insulin Regimens n There a variety of insulin regimens tailored to meet the individual needs of people with diabetes. n The goal is to have an insulin release profile most similar to a physiological state. n The treatment option chosen should reflect: q Type of diabetes q q q Person’s lifestyle, age and ability to self-test blood glucose Presence of obesity Choice

Types of insulin regimens n n Once-daily/twice-daily intermediate- or long-acting (basal) insulin Once-/twice-/three-times daily premixed insulin Basal–bolus therapy Mealtime rapid-acting insulin

Insulin with or without oral agents? n n n The majority of insulins are licensed with oral drugs Metformin should be continued wherever possible Sulphonylureas can be used with insulin In February 2007, pioglitazone was indicated for use with insulin in the UK Sitagliptin is the only gliptin at present that can be used with insulin NICE http: //www. nice. org. uk/nicemedia/pdf/NICE_full_blood_glucose. pdf Royal College of Nursing. http: //www. rcn. org. uk/__data/assets/pdf_file/0009/78606/002254. pdf

Once-daily basal insulin n n Exact duration depends on the insulin Insulin analogues may provide 24 -hour cover Intermediate human insulin preparations may only be active for ~8 hours and have a more pronounced peak activity basal human insulin basal analogue insulin Insulin action n Insulin injection Time Schematic representation

Benefits of a once-daily basal insulin regimen n n Requires only one injection per day May help overcome resistance to starting insulin injections Particularly useful when patient’s blood glucose is high overnight and in the morning Useful for patients who require someone else (e. g. , a district nurse) to administer their insulin May be associated with fewer side effects than other regimens 1 1. Holman RR et al. N Engl J Med 2007; 357: 1716 -30 Royal College of Nursing. http: //www. rcn. org. uk/__data/assets/pdf_file/0009/78606/002254. pdf

Premixed insulin – once, twice or three-times daily Premixed human insulin Premixed injection Insulin action Premixed injection Premixed analogue insulin Breakfast Contains: n Basal component n Short-acting component Possible regimens: n Once daily with largest daily meal (usually dinner) n Twice daily with dinner and breakfast (figure) n Three-times daily, with each meal Lunch Dinner Schematic representation of twice-daily injections

Benefits of a premixed insulin regimen n Targets mealtime glucose Suited to people with fairly regular lifestyles, who eat similar amounts at similar times each day Can be initiated as one injection per day to familiarise patient with injecting* q Second or third injections of same insulin in same device can be added if necessary to optimise control 1 1. Garber AJ et al. Diabetes Obes Metab 2006; 8: 58– 66 *although most patients are started on twice-daily premixed regimens

Basal–bolus therapy Rapid-acting human insulin Long-acting human insulin Rapid insulin Lunch Dinner Long insulin Insulin action Rapid insulin Rapid-acting analogue insulin Long-acting analogue insulin Breakfast Bedtime Schematic representation of four injections per day (one long acting, three rapid acting)

Benefits of a basal–bolus insulin regimen n This regimen produces an insulin profile that is closest to natural insulin production by the body Offers greater flexibility over type of food and when it can be eaten Suited to those who are highly motivated

Insulin practicalities Timing • • • Soluble insulin: 30 -45 minutes pre-meal Short-acting insulin analogues: no more than 15 minutes pre-meal and can be given post-meal Intermediate- or long-acting insulins do not have to be given in relation to a meal

Insulin practicalities Storage • • • One month in fridge or at room temperature once the vial has been opened Must never be frozen Store away from source of heat If refrigeration not available – Frio bags available May be damaged by direct sunlight or vigorous shaking

Injection Technique

Sharps Disposal n Needles from syringes, pen devices and lancets are classified as group B clinical waste. n Sharps bins and safe clips are available on prescription. n Disposal of sharps bin varies depending on local policy.