Insulin treatment indications n type 1 diabetes requires

Insulin treatment indications n type 1 diabetes requires lifelong insulin treatment Acute comlications ; DKA patients with type 2 : improve metabolic control -hyperglycemia- As initial therapy if presenting A 1 C≥ 9. 0% in newly diagnosed Stress –trauma-surgery infection … Renal failure – diabetic foot. . women on oral hypoglycemic drugs who wish to conceive-pregnancy n receiving high-dose steroid therapy. n Weight loss n n n

1921 Toronto – University

n The discovery of insulin in 1921. Insulin is life-saving in type 1 diabetes.

the types of insulin n Human Insulin Analogues

the types of injectable insulin n onset (the length of time before insulin reaches the bloodstream and begins to lower blood glucose), peak (the time period when the insulin is the most effective in lowering blood glucose) duration (how long insulin continues to lower blood glucose)

lispro : Humalog

Insulin Glargine: Basal Insulin Provides 24 -Hour Peakless Profile (mg/kg/min) Glucose Utilisation Rate Hourly Mean Values Insulin Glargine (n=20) 6 5 4 3 2 1 0 NPH Insulin (n=20) 0 10 20 Time After SC Injection (hours) 30 = End of observation period SC, subcutaneous. Adapted from Lantus (insulin glargine) EMEA Summary of Product Characteristics.

Pre mixed 70/30 (70% N, 30% R) Humulin 70/30 (Eli Lilly) n Mixtard 30 (Novo) (Also available as Mixtard 30 Novolet Pen) n Dongsulin 70/30 (Highnoon) n Insuget 70/30 (Getz) ================== n Analogs n n n Novomix 50 (Novo) Humolog Mix 25(Lilly) Humolog Mix 50(Lilly)

Lispro compared to regular Insulin 1 -greater blood Glucose reduction in postprandail concentration 2 - Lower AIC 3 - Fewer episodes of hypoglycemia 4 - Less weight gain.

The ideal long acting insulin n n n n 1 injection daily covers 24 hours No peaks Low incidence of hypoglycaemia Good glycaemic control Less weight gain Safe Easy handling n Injection at different sites n Injection at different times n No mixing necessary/clear solution High treatment satisfaction and acceptance

Degludec § § Insulin degludec is a modified insulin that has one single amino acid deleted in comparison to human insulin, and is conjugated to hexadecanedioic acid via gamma-L-glutamyl spacer at the amino acid lysine at position B 29. Insulin degludec (IDeg) is an ultra long acting basal insulin

Degludec n n Tresiba® is available in 2 concentrations: 200 units/m. L and 100 units/m. L Tresiba® Flex. Touch® lasts up to 8 weeks once in use

Insulin degludec and insulin degludec/ aspart. new n n Novo Nordisk’s ultra-long-acting basal insulin degludec (“Tresiba”) premixed combination of 70% degludec/30% fast -acting Novolog (Ryzodeg) flatter and stable profile, reduced risk of hypoglycemia flexible dosing

NEW PRODUCTS AND DEVICES n n n Admelog (insulin lispro injection) Approved in December 2017 Sanofi For type 2 diabetes and patients older than 3 years with type 1 diabetes

Sanofi's New Insulin Toujeo n n FDA pproved the once daily, long-acting basal insulin to treat type 1 and type 2 diabetes. Toujeo® (insulin glargine injection) 300 Units/m. L Toujeo has the same active ingredient as Lantus called insulin glargine, but at three times the concentration and with a design to release the insulin more gradually.

NEW PRODUCTS AND DEVICES n n Fiasp (insulin aspart injection) Approved September 29, 2017 Novo Nordisk

Fiasp® (insulin aspart injection) 100 U/m. L Indications and Usage n No more waiting to eat can be taken at the start of a meal, or within 20 minutes of starting n Fast onset of appearance enters the bloodstream in ~2. 5 minutes The active molecule in Fiasp® is identical to Novo. Log The Fiasp® formulation contains the addition of niacinamide (vitamin B 3) and a formulation-stabilizing amino acid (L-Arginine) n

Inhalation

n n Using inhaled insulin can mean 1 less injection per meal which is ~1, 000 less needle sticks per year Afrezza must be used with long-acting insulin in people who have type 1 diabetes.

n Afrezza cartridges comes in three doses: 4, 8 and 12 -unit cartridges.

Nasal Glucagon a single 3 -mg intranasal dose n

Goal of Insulin Therapy We are trying to duplicate how the pancreas works in releasing insulin for someone who doesn’t have diabetes

Non-diabetic Insulin and Glucose Profiles Breakfast Lunch Supper 75 Insulin (µU/m. L) 50 Insulin 25 Basal insulin 0 9. 0 Glucose 6. 0 Glucose (mmo/L) 3. 0 Basal glucose 0 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 a. m. p. m. Time of Day

Insulin Glargine: The Only Basal Insulin to Provide 24 -Hour Peakless Profile (mg/kg/min) Glucose Utilisation Rate Hourly Mean Values Insulin Glargine (n=20) 6 5 4 3 2 1 0 NPH Insulin (n=20) 0 10 20 Time After SC Injection (hours) 30 = End of observation period SC, subcutaneous. Adapted from Lantus (insulin glargine) EMEA Summary of Product Characteristics.

Common Insulin regimens

ﺻﺒﺎﺣ 30% ﻣﺴﺎ ﻇﻬﺮ 40% 30% Three mix-insulin /day

30/70 - Twice/day

Novo. Log® Mix 70/301

I N S U Two doses: The usual dosing commonly used. Initial insulin therapy L I N Three doses: J Four doses: T I O N Brittle diabetic patient. Pregnant mothers specially type 1. E C Used for active patients. Patients taking two main meals. I N Four doses: Brittle diabetic patient. Pregnant mothers specially type 1. Motivated patients. Multiple Insulin Injection Therapy

Insulin in type 2 diabetes n n n once daily NPH I injection at night only long-acting insulin analogue added to oral hypoglycaemic agents once daily Mixtard 30 Twice daily NPH I Twice daily Mixtard 30 Basal plus meal-related regimen using glargine plus aspart or lispro.

ﺻﺒﺎﺣ ﻣﺴﺎ long-acting insulin analogue added to oral hypoglycemic agents

Twice daily NPH Insulin ﺻﺒﺎﺣ 7 ﻣﺴﺎ 7

Twice daily pre mixed ﺻﺒﺎﺣ ﻟﻴﻼ

Insulin injection devices n Syringes

Novo Nordisk: Novo. Let®

Insulin Injections

i-Port Advance® Injection Port

i-Port Advance® n n small injection port worn on the body that users inject into instead of directly into the skin reduces the number of skin punctures from an average of 4 -6 per day to just one every 3 days. is suitable for adults and children. less pain, anxiety and improved quality of life

STORAGE n n n Unopened insulin should be stored in a refrigerator between 2 and 8°C (36 and 46°F); it should not be placed in a freezer. Insulin vials that are being used can be kept at room temperature for up to a month. All vials should be protected from light and excessive heat. Unused insulin should be thrown away after the expiration date. The vials should never be shaken