Lec 46- Diabetes 2 Flashcards
Insulin different types
-Rapid acting -Short acting -Intermediate acting -Long acting -Pre-mix
Insulin
-Decrease hepatic glucose production -Increase muscle glucose uptake -Decrease lipolysis from adipose tissue -Protein anabolism growth and differentiation -Hypoglycaemia -Weight gain
Different types of Insulins
1) Rapid acting- 10-20 minutes- lasts 3-5 hours (Aspart, lispro)- this is given just before or during a meal
2) Short acting- 15-60-4-8 hours (act rapid, humulin)
3) Intermediate-actig- 60-120 min-12-18 hrs- insulatard
4) Long acting-120-240 12-24 hr
+Prolonged soluble analogues- glargine, deter
+Very long acting soluble analogues- degludec
+Long acting bio similar- basaglar
5) Pre-mix
+Rapid-intermediate-10-20 minutes- 12-18 hrs- (Humalog)
+Short-intermediate-15-60 min-12-18hrs- Insuman comb, humbling M3
Classification of insulins by the of onset, peak and duration of action
LOOK AT BB picture
Classification of insulins according to use
- Basal-bolus regimen in type 1 diabetes
- Basal: background; use OD or BD morning and or evening;
This is intermediate or long acting insulin
- Bolus: prandial or meal time; this is before or with the main meal: Rapid or short acting insulin
- Biphasic: pre-mix; Usually BD, morning and evening; Mix or short/rapid with intermediate/ long acting
Normal day profile of plasma glucose and insulin
- Glucose never go above 10
- Insulin spikes once glucose gets above 5 mmol/L
- We try and match exogenous insulin with endogenous insulin (like with corticosteroids)
Basal-Bolus insulin regimen
- We do this by giving a basal dose (long acting) to give a steady amount over the day
- And then a bolus just before the meal so we get a peak as we are digesting food
- Pre-mix we are likely to get a steady curve as opposed to a spike pattern the patient then has to eat when the insulin is at there highest
Current insulin delivery systems
1) Pen device -Reduced injection pain and anxiety
- Durable (replace insulin cartridge)
- Disposable (no need to replace cartridge)
2) Insulin vial+syringe
3) Insulin pump (CSII) -Steady basal insulin supply with adjustments for mealtime requirements (external devices)
- Recent developments with implantable pumps (internal devices
Subcutaneous injection
-Belly, Legs, Triceps
Storage of insulin
-Before use- store in fridge
In vials- in fridge (3 months)
Out of fridge to max 25C (4-6 weeks)
-In use pens and cartridge Out of fridge at max 25C (4 weeks)
Indications for insulin in type 2 diabetes
- Type 2 diabetes- inadequate control on oral agents
- Type 2 diabetes- oral agent contraindicated
- Impaired glucose tolerance in pregnancy
- Type 2 diabetes
- Surgery
- Acute illness
Starting insulin and up-titrate the dose
- Patient history and circumstances
- Selection of regimen
- Starting dose
- Titration steps and frequency
- Glucose monitoring Starting insulin- refer to endocrinologist/ diabetologist/ GP with experience or diabetes nurse specialist
- Type 2 diabetes- basal long acting insulin
- Typical basal starting dose: 0.2 units/kg body wt (20 unit/100kg)
- Titrate based on FBG by 2 units every 2-3 days
- Typical maintenance dose: 0.3-0.4 units/kg
- Type 1 diabetes- starting dose selection variable e.g. 0.1-0.2 unit/kg -Basal 50% and Bolus 50% of total daily dose
- Carb counting for bolus insulin variable usually 1 unit per 12-15g CHO
- Glucose monitoring dependant on lifestyle e.g. meals
Insulin treatment regimen
1) Type 1 patients: Intensive basal-bolus regimens
- Multiple day time short or rapid acting bolus at meal times, plus intermediate (OD or BD) or long acting
2) Type 2 patients: usually continue metformin
- OD long acting or BD intermediate acting
- BD short-intermediate or rapid intermediate mixtures
- Multiple daytime short or rapid acting, intermediate or long acting evening
- Evening intermediate or long acting, daytime oral agents
- Various other combinations of insulins and oral agents Delivery
- Conventional injection, pen injector devices
- Pumps for CSII (Continuous subcutaneous insulin infusion)
New and future insulins in development
-Biosimilar insulins
+Biosimilar glargine (Abasglar), biosimilar lispro
- U200, U300, U500 +U200 (degludec), U200 (Humalog), U300 (glargine), U500 (Humulin)
- Very long acting insulins +In development
- Ultrafast acting- insulins +fast aspart (with nicotinamide and arginine) +Biochaperone lispro +rHuPH2- hyaluronidase + insulin analogue -Inhaled, buccal, oral administration in development +Inhaled discontinued +Oral-lyn buccal spray, patch pumps, oral insulin
NB- In pre-mix- UK quotes short acting before long acting (30:70). If its from USA its the other way around (70:30)
Glucose monitoring
- Blood plasma glucose monitors
- Pricking (lancet) device
- Continuous glucose monitoring and flash monitoring
- Always remind patient to carry +Glucose +Identification +Identification of having diabetes
- Know how to deal with a hypo- give glucose +special caution if driving, living alone, missed meals, irregular lifestyle, frail or heavy exercise
Hypoglycaemia signs and symptoms
- Hunger
- Sweating, palpitation, tremor, dizziness
- Atypical behaviour, impaired cognitive function, drowsiness, uncoordinated, speech difficulty
- Loss of concentration, confusion, headache, nausea, malaise, reduced consciousness
- Coma, seizure, brain damage death
