Insulins

Question 1

Insulin fact file

Answer 1

• polypeptide hormone that is secreted by pancreatic beta cells
• increases glucose uptake
• Role: to lower blood glucose concentration, to prevent hyperglycaemia and micro,macro and metabolic complications

Question 2

Natural insulin secretion profile

Answer 2

Basal insulin (slow and steady secretion of background insulin that controls glucose continuously released from liver) and meal time bolous insulin (secreted in response to glucose absorbed from food and drink)

Question 3

What are the 3 kinds of insulins available in the UK?

Answer 3

1) human insulin (lab made) - this is produced by recombinant DNA technology and have the same amino acid sequence as endogenous human insulin

2) Human insulin analogues (produced in the same way as human insulin but modified to be absorbed faster or longer duration)

3) Animal insulin (bovine and porcine)

Animal insulins are from animal sources - used less compared to human insulin

Question 4

Administration of insulin

Answer 4

• insulin is inactivated by GI enzymes, so its therefore given by injections (SC route is the most ideal)
• we want to inject it in the area with the most subcutaneous fat (eg. The abdomen has the fastest absorption rate) or outer thigh and buttock - which is slower compared to inner thigh and abdomen

Question 5

What is lipohyertropy

Answer 5

Injecting same small area repeatedly can lead to lipohypertropy - rotate the sites to minimise risk as much as possible.

Lipohypertropy can cause erratic absorption of insulin and contribute to poor glycemic control

Advise patients not to use the affected area for further injections until the skin has recovered properly

Check the injection sites for signs of infection,swelling, bruising and lipohypertropy before administration

Question 6

Three groups of insulinsssss

Answer 6

Insulin preps can be categorised into 3 groups based on their time-action profiles

Duration of action of each type of particular type of insulin will vary considerably from one patient to the other and so we need to assess each one -

1) Short acting insulin( soluable and rapid acting insulins)
2) intermediate acting insulins
3) long acting insulins

Question 7

Short acting - Rapid insulin
(Must inject immediately before meals)

Answer 7

• onset = 15 minutes
• duration of action = 2-5 hrs
  -Examples = LAG

Lispro (humalog)
Aspart(Novarapid and fiasp)
Glulisine(Apidra)

Question 8

Short acting soluble - Soluble IV is best insulin for diabetic emergencies (eg. Ketoacidosis and peri-operating)

Answer 8

Onset of action - 30-60 min (SC admin)
Duration of action - 9 hours
Examples - Actrapid (its a trap act rapid but its not girlll)

Humulin S
Insuman

Question 9

Intermediate - inject before meals, biphasic, mimics basal insulin, isophane(insulin+protamine)
Mix or pre mix( 1 or more daily injections)

Answer 9

Onset = 1-2 hours
Duration = 11-24hrs
Examples = Isophane/NPH - Humulin I(intermediate),Novomix, Humalogmix, Humulin M3

Question 10

Long acting - Mimics basal insulin
Determination and Lantau used in type 2 if insulin required

Answer 10

Onset - 2-4 hours
Duration - 36 hours
Examples - Determir (levemir) OD-BD
Add on to liraglutide
Glargine(Lantus, Toujeo) - OD
Delgludec(Tresiba) - OD

Question 11

Onset is what?

Answer 11

Time to inject before meals

Question 12

Basal bolus regimen

Answer 12

1) Basal-Bolus - multiple daily injections, many injections throughout the day, injections at each meal resembles natural insulin profile
Long acting/intermediate + short acting insulin

2) Basal insulin: OD or BD (LA or intermediate insulin) - given at bedtimes

3) Bolus: Taken specifically at meal time

Question 13

Advantages of basal bolus

Answer 13

1) close to natural secretion profile
2) flexible - so meals can be eaten and doses can be adjusted based on carbohydrate content or meals

Question 14

Disadvantage of multiple injections each day

Answer 14

May be tough for children for example injecting at schools suring meal times

Question 15

Who would basal bolus be best for?

Answer 15

People with busy work lives, who need to be flexible when they take their doses and how much carbs they eat

Suitable for people who follow a less regular routine

It’s 1st line recommendation for newly diagnosed type 1 diabetes patients

Can be used in type 2 patients too

TYPE 1 = is short acting at meal times and long acting (OD,BD) at bed time
TYPE 2= SA and Immediate acting

Question 16

Once daily regimens

Answer 16

• single dose of insulin each day
• For who? Type 2 diabetes + oral tablets
• Insulins? Long acting or intermediate isophane NPH
  LA- for people who experience hyperglycaemia through the day and night
  Intermediate - for people who experience hyperglycaemia at night or morning but fine in the day. THIS INSULIN is taken before bed

Question 17

Mixed Biphasic regimens

Answer 17

Works on the assumption that you are having 3 meals a day
- inject once,twice,three times a day before each meal
- people need to stick to a consistent daily routine that includes 3 meals a day
- biphasic = has 2 phases of activity = soluable/rapid acting + IM
- premixed or manually mixed with a syringe
- Can be used by type 1 and type 2 patients

Question 18

Who is mixed/biphasic recommended for mainly?

Answer 18

Type 1: people with a consistent day to day routine which includes 3 meals a day at similar times each day
(Suitable for school children because can inject before school and afterschool, no lunch time injections needed)

Type 2: people who experience a high blood glucose level after meals
- recommended for type 2 patients
- preferred for patients who do not want multiple injects a day
- not for acutely ill patients( as requirements vary) or for newly diagnosed type 1 patients

Question 19

Management of type 1 diabetes with insulin

Answer 19

Continuous subcutaneous insulin infusion(insulin pump)

• regular or continuous amount of insulin
• use rapid acting analogue or soluble insulin
• delivered by programmable/pump and insulin reservoir via cannula or subcut needle
• only for adults who’d suffer disabling hypoglycaemia or high Hb1Ac (69mmol./mol +)
• initiated by specialists

Question 21

Factors which will affect insulin requirements or can cause hypoglycaemia

Answer 21

The following will cause poor glucose control = adherence, injection issues, diet , alcohol,exercise, psychological issues, renal diseases, thyroid disorder

Question 22

Which activities require an increase?

Answer 22

Infection
Stress
Accidental or surgical trauma
Pregnancy - 2nd/3rd trimester

Question 23

Decrease in insulin requirements (because there’s an increase in the risk of hypoglycaemia)

Answer 23

• Physical activity
• vomitting
• reduced food intake
• impaired renal function
• certain endocrine disorders eg. Addisons

Question 24

Hypodermic equipment

Answer 24

• hypodermic equipment
• advise patients on safe disposal of lancets, single use syringes and needles and provide suitable disposable containers
• arrangements should be made for the suitable disposal of containers

Question 25

Sick day rules

Answer 25

Diabetics on sick days results in changes to blood sugar therefore different measures needed for management

Question 26

S - Sugar

Answer 26

- blood glucose levels can rise during illness even if the person is not eating - advise to increase blood glucose monitoring if the person has access to it - diabetes medication(sulfonylureas and insulin doses) may need to be increased temporarily during illness to manages these raised glucose levels

Question 27

I (Insulin)

Answer 27

- never stop insulin or oral diabetes medication - insulin doses may need to be increased during illness, especially if ketones are present - specific advice for people on insulin therapy

Question 28

C - Carbohydrate

Answer 28

- ensure the person maintains hydration and carbohydrate intake - if the person is not able to eat or vomitting, advise to replace meals with sugary fluids - if blood glucose levels are high,maintain fluid intake with sugar free fluids - if blood glucose levels are low, encourage regular intake of sugary fluids

Question 29

K - ketones

Answer 29

- in type 1 diabetes - advise to check for ketones every 2-4 hrs - give extra rapid acting insulin doses (in addition to regular doses)- based on total insulin dose if ketones are present - advise to drink water

Question 30

The classes of drugs that have to be stopped SADMAN

Answer 30

S- SGLT2i - if taken during an acute illness that can lead to dehydration, there is an increased risk of developing euglycaemic DKA A-ACEi - If taken during acute illness that can lead to dehydration - increased risk of developing an AKI D- Diuretic - If taken during acute illness that can lead to dehydration, increased risk of developing AKI M- Metformin - if taken and illness leading to dehydration - increased risk of lactic acidosis A-Arbs - if taken during an acute illness and dehydration - increase in AKI risk NSAIDs - AKI risk Once a person is feeling better and able to eat and drink for 24-48 hrs meds should be restarted

Question 31

Insulin prescribing and administration - how to reduce errors

Answer 31

- failure to manage insulin = death - dosing error - wrong frequency of insulin - omitted or delayed insulin

Question 32

Insulin dispensing guidance

Answer 32

- guidance has been issued by EMA on preventing medication errors with insulin - provide patients and carers with adequate info about their insulin - explain the differences in apprearance of different insulin products (most are clear but Humulin I and isophane are white and cloudy) - Training programme in place for all health care and staff expected to prescribe,prepare and administer insulin - always check the container,pen and needle size with patient

Question 33

DKA with errors

Answer 33

Reports of DKA in people with type 2 diabetes on a combination of GLP 1 agonists (byetta and victoza) and insulin who had doses of concomitant insulin rapidly reduced or discontinued

Question 34

Insulin safety information

Answer 34

- severe harm and death due to withdrawing insulin from device = insulin should not be withdrawn from insulin pen or cartridge device. Insulins syringe only calculate doses of 100 units/ml while pens can vary by multiples of 100 units per ml so fatal risk of death - overdose due to abbreviations or incorrect device MHRA advice - all types, risk of cutaneous amyloidosis at injection site - insulin can lead to amyloid protein deposits under skin - interferes with absorption and glycaemic control - presents as lumps on injection site - patients should avoid injecting at lumpy sites

Question 35

INSULIN MONITORING

Answer 35

Patients should maintain a blood glucose concentration of 4-9 for most of the time 4-7mmol/l before meals <9mmol/L after meals - all efforts should be made to prevent ir from falling below 4

Question 36

Patient and carers advice for all insulins

Answer 36

Hypoglycaemia = all patients must be carefully instructed how to avoid hypoglycaemia through appropriate adjustments of insulin type,dose and frequency together with suitable timing and quality of meals and snacks Insulin passports - passports and PILS should be offered to all patients and receiving insulin - insulin passports provide a record of patients current insulin preparations and a section for emergency information. The pils provide advice on safe use of insulin - Driving - need to avoid hypoglycaemia and should be warned about problems

Question 37

Conversion to human insulin

Answer 37

Bovine to human insulin = reduce by 10% to avoid hypoglycaemia Porcine to human = no dose change