Download Type I Diabetes: Adult Case Study

Type I Diabetes: Adult
Case Study
Presented by:
Sarah Devries, Jamie Hillman, Mary
Ann Hudson, and Heather Usher
The Ohio State College of Nursing
August 2, 2010
Client Chief Complaint and Past
Medical History
45-year-old caucasian female with
chief complaints of fatigue,
weight-loss of 20 pounds in one
month, extreme thirst, and
frequent urination. Patient has
changed eyeglass prescription
twice in six months.
Patient has abandoned near-daily
aerobic exercise due to fatigue,
denies anorexia, dysuria,
abnormal stress, recreational
drug use, ETOH abuse, smoking,
prior hospitalizations,
allergies,or chronic disease.
Client Social and Family
History
Client lives with husband of 21
years and two children aged 16 and
17. Husband is employed as high
school teacher, client is 22 year
employee of a company as an
accountant. Client states family
life is busy and enjoyable. Client
denies abnormal social or familial
stressors.
Client’s mother is alive with not
significant medical history. Father
is alive and diagnosed with
hypertension managed well with ACEi.
Grandparents deceased. Only
grandparent history is that paternal
grandfather died of MI at 62.
Client Physical Exam
Ht: 5’7” Wt: 130 lbs
VS: 128/78, 72, 20
All physical
findings in head to
toe exam, including
cranial nerve exam,
are within normal
limits.
Client Diagnostic Laboratory
Results and Diagnosis
Fasting Blood
Glucose: 250
HbA1c: 9
Ketones: Negative
Diagnosis is Type I
Diabetes Mellitus
Diagnosis Criteria for Type I
Diabetes Mellitus
Diagnostic Criteria Symptoms of diabetes
(polyuria, polydipsia, unexplained weight
loss)
Plus casual plasma glucose concentration ≥200
mg/dL or Fasting plasma glucose
concentration ≥126 mg/dL or 2-hour
postchallenge glucose concentration ≥200
mg/dL during a 75-g oral glucose tolerance
test
One of the 3 criteria listed is sufficient to
establish the diagnosis of diabetes
mellitus. These assessments should be
confirmed by repeated testing on a
subsequent day in the absence of unequivocal
hyperglycemia. 1
Brief Pathophysiological Review
of Type I Diabetes Mellitus
Type 1 Diabetes Mellitus Accounts for only 5% to 10% of
all diabetes mellitus cases. Caused by an absolute
deficiency of insulin secretion due to a cellularmediated autoimmune destruction of the pancreatic βcells. Viruses associated with initiation of β-cell
destruction include congenital rubella, coxsackievirus
B, cytomegalovirus, adenovirus, and mumps. Rate of βcell destruction varies. Infants and children often
experience rapid β-cell destruction; rate of
destruction is usually slower in adults. Individuals
at increased risk can often be identified by
serological evidence of an autoimmune pathologic
process occurring in the pancreatic islet cells and by
genetic markers. 2
Treatment and Therapeutic
Objectives Guidelines Established
by American Academy of Clinical
Endocrinologists
Academy partners with American Diabetes
Association for Patient Information and
Education
Therapeutic Objectives of
Client Treatment Plan
Encourage patients to achieve glycemic
levels as near normal as possible without
inducing clinically significant
hypoglycemia (grade A AACE Guideline);
glycemic targets include:
• HbA1c ≤6.5%
• Fasting plasma glucose concentration <110
mg/dL
• 2-hour postprandial glucose concentration
<140 mg/dL 3
Therapeutic Objectives of
Client Treatment Plan
Refer patient for comprehensive, ongoing education
in diabetes self-management skills and nutrition
therapy (grade A AACE Guideline); education
should:
Be provided by a qualified health care professional
Focus on all aspects of diabetes self- management
relevant to each patient treatment plan
Promote behavioral changes to support effective and
consistent application of the prescribed diabetes
treatment plan and an overall healthy lifestyle
Be continued as an ongoing intervention to
accommodate changes in the treatment plan and
patient status
Initiate self-monitoring of blood glucose levels 4
Specific Therapeutic Objectives
for Treatment of DM I Patient
1. Obtain baseline glycemic profile
including HbA1c, fasting BG,
pre/postprandial BG for 7 days
2. After initiation of Rx therapy, monitor
and titrate patient for 2-3 months until
ideal glycemic profile is achieved
3. If glycemic goals are NOT achieved,
intiate more intense therapy and monitor
and titrate patient for another 2-3
months until ideal glycemic profile is
achieved.
Specific Therapeutic Objectives
for Treatment of DM I Patient
4.
5.
6.
7.
8.
9.
Instruct patient to always check BG before injection
of insulin or before insulin pump adjustment
Instruct patient if meeting BG target check BG
4x/day. If NOT meeting BG target, check BG
pre/postprandial, 2 hours postprandial, and 2 or 3
a.m. spot checks
Instruct patient to check BG with suspected
hypoglycemia, when at risk for hypoglycemia, or
before driving
Instruct patient to check BG more frequently during
illness or intense exercise
Instruct patient to check ketones after a BG reading
of 250 mg/dL or above.
Instruct patient to recognize the signs and symptoms
of hypoglycemia and how to treat it 5
DCCT Trial--Clinical Guidelines
Diabetes control and Complications Trial
Study with 29 medical centers and 1400 patients with Type 1
between the ages of 13 and 39 with diabetes for at least one
year. Study ran from 1983-1993
Objectives: to compare the effect of standard diabetes therapy to
intensive diabetes therapy and to determine if type of insulin
therapy had an effect on preventing complications from
diabetes.
Findings:Patients in the intensive insulin therapy group had 76%
reduced risk of retinopathy, 50% reduced risk of nephropathy,
60% reduced risk of neuropathy, 57% reduction in nonfatal
heart attacks, strokes, and heart disease, 35% reduction in
LDL, and an average HgbA1C of 7.2%
Findings were so significant, the study ended 2 years early
Recommendations:Check BG 4 times daily. Administer at least 4
injections of rapid-acting insulin daily or bolus at least 4
times with pump therapy. Adjust insulin doses for food and
exercise. Keep scheduled appointments with health care team.
Team Approach for Therapeutic
Objectives for Treatment of DM
I
Managing diabetes mellitus
requires a team approach to
patient care. However, because
diabetes is primarily a selfmanaged disease, education in
self-management skills is
essential in implementing
interventions. Initial and ongoing
self-management education must be
made available to all patients
with diabetes mellitus. Selfmanagement education improves
HbA1c levels, and increased
contact time with educators
enhances the positive effect.6
Drug Classes Used to Treat Type
I Diabetes
Drug Classes Used to Treat Type I Diabetes
Therapeutic ClassAntidiabetics
Pancreatics
Indications:
For use in patients
with diabetes mellitus
to help lower
circulating blood
glucose levels.
Efficacy
Pharmacodynamics:
Lowers circulating blood
glucose via increasing
glucose uptake into cells.
Promotes conversion of
glucose to glycogen; also
promotes conversion of
amino acids into protein
(in muscles). Increases
triglyceride formation.
Decreases release of free
fatty acids.
Safety
Side Effects:
Endocrine: hypoglycemia.
Local: lipodystrophy,
erythema, edema, pruritis.
Miscellaneous:
allergic/anaphyl-atic
reaction.
Pharmacokinetics:
Absorption: Dependent upon
type of insulin rapidly
absorbed to delayed
absorption. Systemic
absorption.
Distribution: Widely
distributed.
Metabolism: Hepatic, renal,
splenic, and muscular
metabolism.
Excretion: Hepatic, renal,
splenic, and muscular
metabolism.
Indications:
With mealtime insulin,
used to control
circulating blood
glucose in those who
cannot control their
circulating blood
glucose with insulin
alone.
Pharmacodynamics:
Synthetic analogue helps
control postprandial
hyperglycemia.
Pharmacokinetics:
Absorption: Systemic
absorption (30 to 40%)
Distribution: Bound to
Interactions:
Beta-blockers, clondine,
reserpine may mask symptoms
of hypoglycemia.
Corticosteroids, thyroid
supplements, estrogens can
increase insulin
requirements.
Alcohol, ACE inhibitors, MAO
inhibitors, oral
hypoglycemics, salicylates
may decrease insulin
requirements.
Glucosamine may worsen blood
glucose control.
Coenzyme Q-10 can cause
additional hypoglycemic
effects.
Cautions:
Stress, infection, or dietary
changes can alter
requirements of pancreatics.
Contraindicated:
Hypoglycemia.
Severe hepatic, renal, or
thyroid dysfunction.
Other endocrine dysfunction.
Duration of Action:
Dependent upon the type of
insulin used; rapid acting
to long acting.
Hormones
Suitability
Side Effects:
Endocrine: hypoglycemia.
Injection site reaction,
systemic allergic reaction.
Gastrointestinal: nausea,
vomiting, anorexia, abdominal
pain.
Central Nervous System:
dizziness, fatigue, headache.
Respiratory: cough.
Pregnancy:
Can be safely used in pregnancy.
Interactions:
Hypoglycemia when used with
other insulins.
Decreased gastric motility
with anticholinergics and
atropine.
Cautions:
Lactation.
Contraindicated:
Pancreatics--Rapid Acting
Drug Name
Insulin
Aspart
Novolog
Indications:
Controlling
hyperglycemia
in type 1 and
type 2
diabetes
mellitus.
Efficacy
Pharmacodynamics:
Decreases
circulating blood
glucose through
stimulating
glucose intake in
skeletal muscle
and fat; inhibits
hepatic glucose
production.
Pharmacokinetics:
Absorption: Rapid
acting from
subcutaneous
injection via
systemic
absorption.
Distribution:
Widely
distributed.
Metabolism:
Hepatic, renal,
splenic, and
muscular
metabolism.
Excretion:
Hepatic, renal,
splenic, and
muscular
metabolism.
Half-life: 60 to
90 minutes.
Onset: 0.17 to
0.33 hours
Peak: 1 to 3
hours.
Duration: 3 to 5
hours.
Dose
Route:
Subcutaneous
injection
-
Given
with 5 to
10
minutes
before a
meal
based on
individua
l patient
needs.
Usual
total
dose per
day is
0.5 to 1
unit/kg/d
ay.
Safety
Side Effects:
Endocrine:
hypoglycemia.
Local:
lipodystrophy,
erythema, edema,
pruritis.
Miscellaneous:
allergic/anaphyl
-atic reaction.
Drug Interactions:
Beta-blockers,
clondine,
reserpine may
mask symptoms of
hypoglycemia.
Corticosteroids,
thyroid
supplements,
estrogens can
increase insulin
requirements.
Alcohol, ACE
inhibitors, MAO
inhibitors, oral
hypoglycemics,
salicylates may
decrease insulin
requirements.
Glucosamine may
worsen blood
glucose control.
Coenzyme Q-10
can cause
additional
hypoglycemic
effects.
Suitability
Contraindications:
Hypoglycemia.
Allergy/hypersensitivity
to insulin aspart.
Cautions:
Stress and infection
(increase insulin
requirements).
Renal and hepatic
impairment (decrease
insulin requirements).
Pregnancy Category:
Category B
Pancreatics--Rapid Acting
Insulin
Lispro
Humalog
Indications:
Controlling
hyperglycemia
in type 1 and
type 2
diabetes
mellitus.
Pharmacodynamics:
Decreases
circulating blood
glucose through
stimulating
glucose intake in
skeletal muscle
and fat; inhibits
hepatic glucose
production.
Pharmacokinetics:
Absorption: Rapid
acting from
subcutaneous
injection via
systemic
absorption.
Distribution:
Widely
distributed.
Metabolism:
Hepatic, renal,
splenic, and
muscular
metabolism.
Excretion:
Hepatic, renal,
splenic, and
muscular
metabolism.
Half-life: 1
hour.
Onset: within 15
minutes.
Peak: 1 to 1.5
hours.
Duration: 6-8
hours.
Route:
Subcutaneous
injection
-
Dependent
upon
blood
glucose,
personal
response
to drug.
Usual
maintenan
ce dose
per day
is 0.5 to
1.2
unit/kg/d
ay.
Side Effects:
Endocrine:
hypoglycemia.
Local:
lipodystrophy,
erythema, edema,
pruritis.
Miscellaneous:
allergic/anaphyl
-atic reaction.
Drug Interactions:
Beta-blockers,
clondine,
reserpine may
mask symptoms of
hypoglycemia.
Corticosteroids,
thyroid
supplements,
estrogens can
increase insulin
requirements.
Alcohol, ACE
inhibitors, MAO
inhibitors, oral
hypoglycemics,
salicylates may
decrease insulin
requirements.
Glucosamine may
worsen blood
glucose control.
Coenzyme Q-10
can cause
additional
hypoglycemic
effects.
Contraindications:
Hypoglycemia.
Allergy/hypersensitivity
to insulin lispro.
Cautions:
Stress and infection
(increase insulin
requirements).
Renal and hepatic
impairment (decrease
insulin requirements).
Pregnancy Category:
Category B
Pancreatics--Rapid Acting
Insulin
Glulisine
Apidra
Indications:
Controlling
hyperglycemia
in type 1 and
type 2
diabetes
mellitus.
Pharmacodynamics:
Decreases
circulating blood
glucose through
stimulating
glucose intake in
skeletal muscle
and fat; inhibits
hepatic glucose
production.
Pharmacokinetics:
Absorption: Rapid
acting from
subcutaneous
injection via
systemic
absorption.
Distribution:
Widely
distributed.
Metabolism:
Hepatic, renal,
splenic, and
muscular
metabolism.
Excretion:
Hepatic, renal,
splenic, and
muscular
metabolism.
Half-life: 42
minutes.
Onset: within 15
minutes.
Peak: 1 hour.
Duration: 2-4
hours.
Route:
Subcutaneous
injection,
intravenous
infusion
-
-
Dependent
upon
blood
glucose,
personal
response
to drug,
exercise
level.
Administe
r 15
minutes
prior to
a meal or
within 20
minutes
after
beginning
a meal.
Can be
given
through
an
external
infusion
device.
Side Effects:
Endocrine:
hypoglycemia.
Local:
lipodystrophy,
erythema, edema,
pruritis.
Miscellaneous:
allergic/anaphyl
-atic reaction.
Drug Interactions:
Beta-blockers,
clondine,
reserpine may
mask symptoms of
hypoglycemia.
Corticosteroids,
thyroid
supplements,
estrogens can
increase insulin
requirements.
Alcohol, ACE
inhibitors, MAO
inhibitors, oral
hypoglycemics,
salicylates may
decrease insulin
requirements.
Glucosamine may
worsen blood
glucose control.
Coenzyme Q-10
can cause
additional
hypoglycemic
effects.
Contraindications:
Hypoglycemia.
Allergy/hypersensitivity
to insulin glulisine.
Cautions:
Stress and infection
(increase insulin
requirements).
Renal and hepatic
impairment (decrease
insulin requirements).
Pregnancy Category:
Category C
Pancreatics--Short Acting
Drug Name
Efficacy
Dose
Safety
Suitability
Regular
Insulin
Humulin R
Novolin R
Pharmacodynamics:
Decreases
circulating blood
glucose through
stimulating
glucose intake in
skeletal muscle
and fat; inhibits
hepatic glucose
production.
Route:
Subcutaneous
injection
Side Effects:
Endocrine:
hypoglycemia.
Local:
lipodystrophy,
erythema, edema,
pruritis.
Miscellaneous:
allergic/anaphyl
-atic reaction.
Contraindications:
Hypoglycemia.
Allergy/hypersensitivity to insulin,
preservatives, or
additives.
Indications:
Controlling
hyperglycemia
in type 1 and
type 2
diabetes
mellitus.
Pharmacokinetics:
Absorption: Rapid
acting from
subcutaneous
injection via
systemic
absorption.
Distribution:
Widely
distributed.
Metabolism:
Hepatic, renal,
splenic, and
muscular
metabolism.
Excretion:
Hepatic, renal,
splenic, and
muscular
metabolism.
Half-life: 30 to
60 minutes.
Onset: 30 to 60
minutes.
Peak: 2 to 4
hours.
Duration: 5 to 7
hours.
-
Usual
total
dose per
day is
0.5 to 1
unit/kg/d
ay in
divided
doses.
Drug Interactions:
Beta-blockers,
clondine,
reserpine may
mask symptoms of
hypoglycemia.
Corticosteroids,
thyroid
supplements,
estrogens can
increase insulin
requirements.
Alcohol, ACE
inhibitors, MAO
inhibitors, oral
hypoglycemics,
salicylates may
decrease insulin
requirements.
Glucosamine may
worsen blood
glucose control.
Coenzyme Q-10
can cause
additional
hypoglycemic
effects.
Cautions:
Stress and
infection (increase
insulin
requirements).
Renal and hepatic
impairment
(decrease insulin
requirements).
Pregnancy Category:
Category B
Cost of
Treatment
Humulin
R (100
units):
53.49vial
Pancreatics--Intermediate
Acting
Drug Name
Efficacy
Dose
Safety
Suitability
ccvbbNPH
Insulin
Humulin N
Novolin N
Pharmacodynamics:
Decreases
circulating blood
glucose through
stimulating
glucose intake in
skeletal muscle
and fat; inhibits
hepatic glucose
production.
Route:
Subcutaneous
injection
Side Effects:
Endocrine:
hypoglycemia.
Local:
lipodystrophy,
erythema, edema,
pruritis.
Miscellaneous:
allergic/anaphyl
-atic reaction.
Contraindications:
Hypoglycemia.
Allergy/hypersensitivity
to insulin,
preservatives, or
additives.
Indications:
Controlling
hyperglycemia
in type 1 and
type 2
diabetes
mellitus.
Pharmacokinetics:
Absorption: Rapid
acting from
subcutaneous
injection via
systemic
absorption.
Distribution:
Widely
distributed.
Metabolism:
Hepatic, renal,
splenic, and
muscular
metabolism.
Excretion:
Hepatic, renal,
splenic, and
muscular
metabolism.
Half-life:
Unknown.
Onset: 1 to 2
hours
Peak: 4 to 12
hours.
Duration: 18 to
24 hours.
-
Dose
dependent
upon
blood
glucose,
personal
response
to drug.
Usual
total
dose per
day is
0.5 to 1
unit/kg/d
ay total.
Drug Interactions:
Beta-blockers,
clondine,
reserpine may
mask symptoms of
hypoglycemia.
Corticosteroids,
thyroid
supplements,
estrogens can
increase insulin
requirements.
Alcohol, ACE
inhibitors, MAO
inhibitors, oral
hypoglycemics,
salicylates may
decrease insulin
requirements.
Glucosamine may
worsen blood
glucose control.
Coenzyme Q-10
can cause
additional
hypoglycemic
effects.
Cautions:
Stress and infection
(increase insulin
requirements).
Renal and hepatic
impairment (decrease
insulin requirements).
Pregnancy Category:
Category B
Cost of
Treatment
Vials:
10mL:
$42.99
.
Pens:
3mL:
$124.9
0 for
5
pens.
Pancreatics--Long Acting
Drug Name
Efficacy
Dose
Safety
Suitability
Insulin
Detemir
Levemir
Pharmacodynamics:
Decreases
circulating blood
glucose through
stimulating
glucose intake in
skeletal muscle
and fat; inhibits
hepatic glucose
production.
Route:
Subcutaneous
injection
Side Effects:
Endocrine:
hypoglycemia.
Local:
lipodystrophy,
erythema, edema,
pruritis.
Miscellaneous:
allergic/anaphyl
-atic reaction.
Contraindications:
Hypoglycemia.
Allergy/hypersensitivity
to insulin,
preservatives, or
additives.
Indications:
Controlling
hyperglycemia
in type 1 and
type 2
diabetes
mellitus.
Pharmacokinetics:
Absorption:
Delayed and
prolonged
systemically.
Distribution:
Widely
distributed.
Metabolism:
Hepatic, renal,
splenic, and
muscular
metabolism.
Excretion:
Hepatic, renal,
splenic, and
muscular
metabolism.
Half-life: Dosedependent, but
usually 5 to 7
hours.
Onset: 3 to 4
hours
Peak: 3 to 14
hours.
Duration: 6 to 24
hours.
-
0.1 to
0.2
units/kg
once
daily in
the
evening;
also, 10
units
once or
twice
daily.
Drug Interactions:
Beta-blockers,
clondine,
reserpine may
mask symptoms of
hypoglycemia.
Corticosteroids,
thyroid
supplements,
estrogens can
increase insulin
requirements.
Alcohol, ACE
inhibitors, MAO
inhibitors, oral
hypoglycemics,
salicylates may
decrease insulin
requirements.
Glucosamine may
worsen blood
glucose control.
Coenzyme Q-10
can cause
additional
hypoglycemic
effects.
Cautions:
Stress and infection
(increase insulin
requirements).
Renal and hepatic
impairment (decrease
insulin requirements).
Pregnancy Category:
Category C
Cost of
Treatment
Levemir:
$109.7910mL
vial;
$211.79pen
-
Pancreatics--Long Acting
Insulin
Glargine
Lantus
Indications:
Controlling
hyperglycemia
in type 1 and
type 2
diabetes
mellitus.
Pharmacodynamics:
Decreases
circulating blood
glucose through
stimulating
glucose intake in
skeletal muscle
and fat; inhibits
hepatic glucose
production.
Pharmacokinetics:
Absorption:
Provides slower
prolonged
absorption with a
relatively
constant
concentration
over 24 hours.
Distribution:
Widely
distributed.
Metabolism:
Partially
metabolized at
injection site to
active insulin
metabolites.
Hepatic, renal,
splenic, and
muscular
metabolism.
Excretion:
Hepatic, renal,
splenic, and
muscular
metabolism.
Half-life: 5 to 6
minutes.
Onset: 3 to 4
hours.
Peak: None.
Duration: 24
hours.
Route:
Subcutaneous
injection
-
Dependent
upon
blood
glucose,
personal
response
to drug.
Ranges
from 2 to
100
units/day
.
Conversio
n from an
intermedi
ate or
other
long
acting
insulin
means
using 80%
of total
NPH or
other
dose once
daily,
then
adjusting
based on
patient’s
needs.
Side Effects:
Endocrine:
hypoglycemia.
Local:
lipodystrophy,
erythema, edema,
pruritis.
Miscellaneous:
allergic/anaphyl
-atic reaction.
Drug Interactions:
Beta-blockers,
clondine,
reserpine may
mask symptoms of
hypoglycemia.
Corticosteroids,
thyroid
supplements,
estrogens can
increase insulin
requirements.
Alcohol, ACE
inhibitors, MAO
inhibitors, oral
hypoglycemics,
salicylates may
decrease insulin
requirements.
Glucosamine may
worsen blood
glucose control.
Coenzyme Q-10
can cause
additional
hypoglycemic
effects.
Contraindications:
Hypoglycemia.
Allergy/hypersensitivity
to insulin glargine.
Vials:
10mL:
$84.9
9.
Cautions:
Stress and infection
(increase insulin
requirements).
Renal and hepatic
impairment (decrease
insulin requirements).
Pens:
3mL:
$107.79pen
Pregnancy Category:
Category C
Pancreatics--Mixtures
Drug Name
Efficacy
Dose
Safety
Suitability
Insulin Lispro
Protamine
Suspension/Insulin
Lispro Injection
Mixture
Humalog Mix
75/25
Humalog Mix
50/50
Pharmacodynamics:
Decreases
circulating blood
glucose through
stimulating
glucose intake in
skeletal muscle
and fat; inhibits
hepatic glucose
production.
Route:
Subcutaneous
injection
Side Effects:
Endocrine:
hypoglycemia.
Local:
lipodystrophy,
erythema, edema,
pruritis.
Miscellaneous:
allergic/anaphyl
-atic reaction.
Contraindications:
Hypoglycemia.
Allergy/hypersensitivity
to insulin,
preservatives, or
additives.
Indications:
Controlling
hyperglycemia in
type 1 and type 2
diabetes mellitus.
Pharmacokinetics:
Absorption: Well
absorbed from
subcutaneous
administration
sites. Absorption
rate determined
by type of
insulin,
injection site,
volume of
injection, and
other factors.
Distribution:
Widely
distributed.
Metabolism:
Hepatic, renal,
splenic, and
muscular
metabolism.
Excretion:
Hepatic, renal,
splenic, and
muscular
metabolism.
Half-life: 5 to 6
minutes.
Onset: 15 to 30
minutes.
Peak: 2.8 hours.
Duration: 24
hours.
-
Dose
dependent
upon
blood
glucose,
personal
response
to drug.
Usual
total
dose per
day is
0.5 to 1
unit/kg/d
ay
total..
Drug Interactions:
Beta-blockers,
clondine,
reserpine may
mask symptoms of
hypoglycemia.
Corticosteroids,
thyroid
supplements,
estrogens can
increase insulin
requirements.
Alcohol, ACE
inhibitors, MAO
inhibitors, oral
hypoglycemics,
salicylates may
decrease insulin
requirements.
Glucosamine may
worsen blood
glucose control.
Coenzyme Q-10
can cause
additional
hypoglycemic
effects.
Cautions:
Stress and infection
(increase insulin
requirements).
Renal and hepatic
impairment (decrease
insulin requirements).
Pregnancy Category:
Category B
Cost of
Treatment
Vials:
10mL:
$91.25
.
Pens:
3mL:
$147.5
0 for
5
pens.
Pancreatics--Mixtures
Insulin Aspart
Protamine
Suspension/Insulin
Aspart Injection
Mixtures
NovoLog Mix
70/30
NovoLog Mix
50/50
Indications:
Controlling
hyperglycemia in
type 1 and type 2
diabetes mellitus.
Pharmacodynamics:
Decreases
circulating blood
glucose through
stimulating
glucose intake in
skeletal muscle
and fat; inhibits
hepatic glucose
production.
Pharmacokinetics:
Absorption: Well
absorbed from
subcutaneous
administration
sites. Absorption
rate determined
by type of
insulin,
injection site,
volume of
injection, and
other factors.
Distribution:
Widely
distributed.
Metabolism:
Hepatic, renal,
splenic, and
muscular
metabolism.
Excretion:
Hepatic, renal,
splenic, and
muscular
metabolism.
Half-life: 5 to 6
minutes.
Onset: 15
minutes.
Peak: 1 to 4
hours.
Duration: 18 to
24 hours.
Route:
Subcutaneous
injection
-
Dose
dependent
upon
blood
glucose,
personal
response
to drug.
Usual
total
dose per
day is
0.5 to 1
unit/kg/d
ay total.
Side Effects:
Endocrine:
hypoglycemia.
Local:
lipodystrophy,
erythema, edema,
pruritis.
Miscellaneous:
allergic/anaphyl
-atic reaction.
Drug Interactions:
Beta-blockers,
clondine,
reserpine may
mask symptoms of
hypoglycemia.
Corticosteroids,
thyroid
supplements,
estrogens can
increase insulin
requirements.
Alcohol, ACE
inhibitors, MAO
inhibitors, oral
hypoglycemics,
salicylates may
decrease insulin
requirements.
Glucosamine may
worsen blood
glucose control.
Coenzyme Q-10
can cause
additional
hypoglycemic
effects.
Contraindications:
Hypoglycemia.
Allergy/hypersensitivity
to insulin,
preservatives, or
additives.
Cautions:
Stress and infection
(increase insulin
requirements).
Renal and hepatic
impairment (decrease
insulin requirements).
Pregnancy Category:
Category C
Vials:
10mL:
$85.9
9.
NovoLog
70/30:
$110.7910mL
vial;
$218.79pen
Pancreatics--Mixtures
NPH/Regular
Insulin
Mixture
Humulin
70/30
Novolin
70/30
Indications:
Controlling
hyperglycemia
in type 1 and
type 2
diabetes
mellitus.
Pharmacodynamics:
Decreases
circulating blood
glucose through
stimulating
glucose intake in
skeletal muscle
and fat; inhibits
hepatic glucose
production.
Pharmacokinetics:
Absorption: Well
absorbed from
subcutaneous
administration
sites. Absorption
rate determined
by type of
insulin,
injection site,
volume of
injection, and
other factors.
Distribution:
Widely
distributed.
Metabolism:
Hepatic, renal,
splenic, and
muscular
metabolism.
Excretion:
Hepatic, renal,
splenic, and
muscular
metabolism.
Half-life: 5 to 6
minutes.
Onset: 30
minutes.
Peak: 4 to 8
hours.
Duration: 24
hours.
Route:
Subcutaneous
injection
-
Dose
dependent
upon
blood
glucose,
personal
response
to drug.
Usual
total
dose per
day is
0.5 to 1
unit/kg/d
ay
total..
Side Effects:
Endocrine:
hypoglycemia.
Local:
lipodystrophy,
erythema, edema,
pruritis.
Miscellaneous:
allergic/anaphyl
-atic reaction.
Drug Interactions:
Beta-blockers,
clondine,
reserpine may
mask symptoms of
hypoglycemia.
Corticosteroids,
thyroid
supplements,
estrogens can
increase insulin
requirements.
Alcohol, ACE
inhibitors, MAO
inhibitors, oral
hypoglycemics,
salicylates may
decrease insulin
requirements.
Glucosamine may
worsen blood
glucose control.
Coenzyme Q-10
can cause
additional
hypoglycemic
effects.
Contraindications:
Hypoglycemia.
Allergy/hypersensitivity
to insulin,
preservatives, or
additives.
Cautions:
Stress and infection
(increase insulin
requirements).
Renal and hepatic
impairment (decrease
insulin requirements).
Pregnancy Category:
Category C
Vials:
10mL:
$42.9
9.
Pens:
3mL:
$117.
05
for 5
pens.
Hormones
Drug Name
Efficacy
Dose
Safety
Suitability
Pramlintide
- Symlin
Pharmacodynamics:
Synthetic
analogue of
amylin, an
endogenous
pancreatic
hormone that
helps control
postprandial
hyperglycemia.
Route:
Subcutaneous
injection
Side Effects:
- Endocrine:
hypoglycemia.
- Injection site
reaction,
systemic allergic
reaction.
- Gastrointestinal:
nausea, vomiting,
anorexia,
abdominal pain.
- Central Nervous
System:
dizziness,
fatigue,
headache.
- Respiratory:
cough.
Contraindications:
- Inability to
identify
hypoglycemia.
- Hypersensitivity.
- Gastroparesis.
- Poor insulin
compliance.
- HbA1C > 9%.
Indications:
With mealtime
insulin, used
to control
circulating
blood glucose
in those who
cannot control
their
circulating
blood glucose
with insulin
alone.
Pharmacokinetics:
Absorption: 30 to
40% absorped.
Distribution: 60%
protein bound.
Metabolism:
Renally
metabolized.
Excretion:
Renally
metabolized.
Half-life: 48
minutes.
Onset: rapid.
Peak: 20 minutes.
Duration: 3
hours.
-
15 mcg
immediately
prior to
major meals
initially,
then
increased
by 15 mcg
every 3
days up to
60 mcg if
no nausea
occurs.
Drug Interactions:
- Hypoglycemia when
used with other
short-acting
insulins
(decrease premeal insulin by
50%).
- Atropine and
anticholinergics
can decrease
gastric motility.
Cautions:
- Lactation.
Pregnancy Category:
Category C
Cost of
Treatment
Pens:
- 1000
mcg/mL:
$294.49-5
mL vial
Type I DM P-Drug Tables
Insulin Lispro
(Humalog): Rapidacting
Mechanism of
Action:
1.Stimulates
peripheral glucose
uptake and storage
of glucose in the
liver
2.Inhibits hepatic
glucose production
- gluconeogenesis
3.Inhibits
lipolysis and
proteolysis
4.Regulates glucose
metabolism
Availability:
10 ml vial
3 ml vial
3 ml Penfill
cartridges x 5 for
the cartridge
device, total of
15mls
(Luxura or Memoir
pen)
3 ml prefilled pen
devices x 5, total
of 15mls
(Kwikpen)
Efficacy
Safety
Suitability
Cost
Subcutaneous
Route
Dose:
Based on
patient’s
weight,
carbohydrate
factor and
correction
factor;
generally 0.51units/kg/day
Absorption:
rapid with onset
of 5-15 minutes,
peak at 1.5
hours and
duration of 3-5
hours ;
absorption
varies with site
of injection
Bioavailability:
55-77%
Distribution:
Wide; 0.260.36L/kg
Metabolism:
Liver, Kidney,
fat; does not
interact with
CYP450
Excretion:
urine, t1/2 = 1
hour
Side effects:
Hypoglycemia,
hypokalemia,
generalized
hypersensitivity
reaction (rare),
anaphylaxis,
lipodystrophy at
injection site,
pruritis, rash,
weight gain
Contraindications:
Renal impairment,
Hepatic
impairment,
hypoglycemia.
Caution:
may need to
increase doses for
stress, pregnancy
and infection as
resistance to
insulin increases
Interactions:
Insulin may need
to be increased
with the following
meds:
corticosteroids,
isoniazid, niacin,
estrogens, oral
contraceptives,
phenothiazines,
thyroid
replacement
therapy.
Insulin may need
to be decreased
with the
following:
Anabolic steroids,
alcohol, MAOis,
most NSAIDs, oral
hypoglycemic
agents,
tetracyclines,
warfarin,
clofibrate,
phenylbutazone.
Patients may lose
ability to feel
hypoglycemia
Vial :
100units/ml;
10mls
$118
Pregnancy:
Category B
Cartridges:
1 box of 5,
300 units
per
cartridge,
$220
Type I DM P-Drug Tables
Insulin Aspart
(Novolog):
Rapid-acting
Mechanism of
Action:
1. Stimulates
peripheral
glucose
uptake and
storage of
glucose in
the liver
2. Inhibits
hepatic
glucose
production
gluconeoge
nesis
3. Inhibits
lipolysis
and
proteolysi
s
4. Regulates
glucose
metabolism
Availability:
10 ml vial
3 ml Penfill
cartridges x 5
for the
cartridge
device, total of
15mls
(Novopen 3
device)
3 ml prefilled
pen devices x 5,
total of 15mls
(Novolog
Flexpen)
Efficacy
Subcutaneous
Route
Dose:
Based on
patient’s
weight,
carbohydrate
factor and
correction
factor;
generally 0.51units/kg/day
Absorption:
rapid with onset
of 5-15 minutes,
peak at 1.5
hours and
duration of 3-5
hours ;
absorption
varies with site
of injection
Bioavailability:
55-77%
Distribution:
Wide; 0.260.36L/kg
Metabolism:
Liver, Kidney,
fat; does not
interact with
CYP450
Excretion:
urine, t1/2 = 81
minutes
Safety
Suitability
Cost
Side effects:
Hypoglycemia,
hypokalemia,
generalized
hypersensitivity
reaction (rare),
anaphylaxis,
lipodystrophy at
injection site,
pruritis, rash,
weight gain,
myalgia
Contraindications:
Renal impairment,
Hepatic
impairment,
hypoglycemia
Vial :
100units/ml;
10mls
$120
Pregnancy:
Category B
Interactions:
Insulin may need
to be increased
with the following
meds:
corticosteroids,
isoniazid, niacin,
estrogens, oral
contraceptives,
phenothiazines,
thyroid
replacement
therapy.
Caution:
may need to
increase doses for
stress, pregnancy
and infection as
resistance to
insulin increases
Insulin may need
to be decreased
with the
following:
Anabolic steroids,
alcohol, MAOis,
most NSAIDs, oral
hypoglycemic
agents,
tetracyclines,
warfarin,
clofibrate,
phenylbutazone,
ACE inhibitors.
Cartridges:
1 box of 5,
300 units
per
cartridge,
$235
Type I DM P-Drug Tables
Insulin
Glulisine
(Apidra):
Rapid-acting
Mechanism of
Action:
1. Stimulates
peripheral
glucose
uptake and
storage of
glucose in
the liver
2. Inhibits
hepatic
glucose
production
gluconeoge
nesis
3. Inhibits
lipolysis
and
proteolysi
s
4. Regulates
glucose
metabolism
Availability:
10 ml vial
3 ml Penfill
cartridges x 5
for the
cartridge
device, total of
15mls
(Opticlik pen)
3 ml prefilled
pen devices x 5,
total of 15mls
(Apidra
Solostar)
Efficacy
Subcutaneous
Route
Dose:
Based on
patient’s
weight,
carbohydrate
factor and
correction
factor;
generally 0.51units/kg/day
Absorption:
rapid with onset
of 30 minutes,
peak at 30-90
minutes and
duration of 3-5
hours ;
absorption
varies with site
of injection
Bioavailability:
55-77%
Distribution:
Wide; 0.260.36L/kg
Metabolism:
Liver, Kidney,
fat; does not
interact with
CYP450
Excretion:
urine, t1/2 = 42
minutes
Safety
Suitability
Cost
Side effects:
Hypoglycemia,
hypokalemia,
generalized
hypersensitivity
reaction (rare),
anaphylaxis,
lipodystrophy at
injection site,
pruritis, rash,
weight gain,
myalgia,
peripheral
edema,
nasopharyngitis,
respiratory
infection,
influenza,
headache (peds),
arthalgia,
hypertension
Contraindications:
Renal impairment,
Hepatic
impairment,
hypersensitivity
to metacresol,
hypoglycemia.
Vial :
100units/ml;
10mls
$105
Pregnancy:
Category C
Caution:
may need to
increase doses for
stress, pregnancy
and infection as
resistance to
insulin increases
Interactions:
Insulin may need
to be increased
with the following
meds:
corticosteroids,
isoniazid, niacin,
estrogens, oral
contraceptives,
phenothiazines,
thyroid
replacement
therapy,
sympathomimetics.
Insulin may need
to be decreased
with the
following:
Anabolic steroids,
alcohol, MAOis,
most NSAIDs, oral
hypoglycemic
agents,
tetracyclines,
warfarin,
clofibrate,
phenylbutazone,
ACE inhibitors.
Cartridges:
1 box of 5,
300 units
per
cartridge,
$203
Type I DM P-Drug Tables
Insulin Glargine
(Lantus):
Long acting
Mechanism of
Action:
1. Stimulates
peripheral
glucose
uptake and
storage of
glucose in
the liver
2. Inhibits
hepatic
glucose
production
gluconeoge
nesis
3. Inhibits
lipolysis
and
proteolysi
s
4. Regulates
glucose
metabolism
Efficacy
Subcutaneous
Route
Dose:
Use with rapid
or short-acting
insulin; QD
dosing,
generally 0.51units/kg/day;
must NOT be
mixed
Absorption:
onset of 1 hour,
no peak, and
duration of 24
hours ;
absorption
varies with site
of injection
Bioavailability:
72%
Distribution:
Availability:
10 ml vial
3 ml prefilled
pen devices x 5,
total of 15mls
(Lantus
Solostar)
Metabolism:
partial
metabolism at
carboxyl
terminus of B
chain in the SQ
depot to form
two active
metabolites – M1
and M2; does not
interact with
CYP450
Excretion: urine
Safety
Suitability
Cost
Side effects:
Hypoglycemia,
hypokalemia,
generalized
hypersensitivity
reaction (rare),
anaphylaxis,
lipodystrophy at
injection site,
pruritis, rash,
weight gain,
sodium
retention, edema
Contraindications:
Renal impairment,
Hepatic impairment
Vial :
100units/ml;
10mls
$111
Pregnancy:
Category C
Caution:
may need to
increase doses for
stress, pregnancy
and infection as
resistance to
insulin increases
Interactions:
Insulin may need
to be increased
with the following
meds:
corticosteroids,
isoniazid, niacin,
estrogens, oral
contraceptives,
phenothiazines,
thyroid
replacement
therapy,
diuretics,
sympathomimetics,
atypical
antipsychotics
Insulin may need
to be decreased
with the
following:
Anabolic steroids,
alcohol, MAOis,
most NSAIDs, oral
hypoglycemic
agents, fibrates,
tetracyclines,
warfarin,
clofibrate,
phenylbutazone,
ACE inhibitors.
Cartridges:
1 box of 5,
300 units
per
cartridge,
$202
Type I DM P-Drug Tables
Insulin Detemir
(Levemir):
Long acting
Mechanism of
Action:
1. Stimulates
peripheral
glucose
uptake and
storage of
glucose in
the liver
2. Inhibits
hepatic
glucose
production
gluconeoge
nesis
3. Inhibits
lipolysis
and
proteolysi
s
4. Regulates
glucose
metabolism
Availability:
10 ml vial
3 ml prefilled
pen devices x 5,
total of 15mls
(Levemir
flexpen)
3 ml pen
cartridges
Efficacy
Safety
Suitability
Cost
Subcutaneous
Route
Dose:
Use with rapid
or short-acting
insulin; QD or
BID dosing,
generally 0.51units/kg/day;
should NOT be
mixed with other
insulins.
Side effects:
Hypoglycemia,
hypokalemia,
generalized
hypersensitivity
reaction (rare),
anaphylaxis,
lipodystrophy at
injection site,
pruritis, rash,
weight gain,
sodium
retention, edema
Contraindications:
Renal impairment,
Hepatic impairment
Vial :
100units/ml;
10mls
$110
Absorption:
onset of 1 hour,
no peak, and
duration of 6-23
hours ;
absorption
varies with site
of injection
Bioavailability:
60%
Distribution:
98% bound to
albumin, Vd =
0.1 L/kg
Metabolism:
unknown
Excretion:
urine,
t1/2 = 5-7 hours
Pregnancy:
Category C
Caution:
may need to
increase doses for
stress, pregnancy
and infection as
resistance to
insulin increases
Interactions:
Insulin may need
to be increased
with the following
meds:
corticosteroids,
isoniazid, niacin,
estrogens, oral
contraceptives,
phenothiazines,
thyroid
replacement
therapy,
diuretics,
sympathomimetics,
atypical
antipsychotics
Insulin may need
to be decreased
with the
following:
Anabolic steroids,
alcohol, MAOis,
most NSAIDs, oral
hypoglycemic
agents, fibrates,
tetracyclines,
warfarin,
clofibrate,
phenylbutazone,
ACE inhibitors.
Cartridges:
1 box of 5,
300 units
per
cartridge,
$205
Rationale for Selecting P-drug
(Rapid-Acting Insulin)
Insulin
Lispro
(Humalog)
Insulin
Aspart
(Novolog)
Insulin
Glulisine
(Apidra)
Efficacy
+
Safety
+
Suitability
+
Cost
-
+
+
+
+/-
+
-
+
-
Rationale for Selecting P-drug
(Long-Acting Insulin)
Insuline
Glargine
(Lantus)
Insulin
Detemir
(Levemir)
Efficacy
+
Safety
+
Suitability
+
Cost
-
+
+
+/-
-
Selected p-drug combination:
insuline glargine (Lantus) +
insulin aspart (Novolog)
• Rationale for choosing combined therapy of
insulin glargine (Lantus) + insulin aspart
(Novolog)
• Recommended therapy according to American
Diabetes Association Clinical Guideline 2010:
• Recommended therapy for type 1 diabetes
consists of the following components: 1) use
of multiple dose insulin injections (3 to 4
injections per day of basal and prandial
insulin) or continuous subcutaneous insulin
infusion (CSII) therapy; 2) matching of
prandial insulin to carbohydrate intake,
premeal blood glucose, and anticipated
activity; and 3) for many patients (especially
if hypoglycemia is a problem), use of insulin
analogs.
• Less expensive than CSII therapy, despite no
difference in glycemic control (Bolli et al,
2009)
Rationale for choosing insulin
glargine
• Can be given just 1 time
daily (usually at night
before bed) – better
compliance
• Proven to provide better
glycemic control when used
with rapid-acting insulin
(like insulin aspart or
lispro) than compared to
NPH and regular insulin
therapy (Sharplin et al,
2009)
Rationale for choosing
insulin aspart
• Shown to be as
effective in
stabilizing blood
glucose rapidly as
insulin lispro
(Homko et al, 2003)
• More cost effective
than insulin lispro
Insulin
• Main Action:
• Lower blood glucose by
stimulating glucose uptake
in skeletal muscle and fat
• Also inhibit lipolysis and
proteolysis, enhances
protein synthesis
• Indication:
• Control of hyperglycemia
in patients with Type I or
Type II Diabetes Mellitus
Pharmacokinetics &
Pharmacodynamics
Insulin glargine
(Lantus)= long acting
Insulin aspart
(NovoLog)= rapid
acting
Absorption
Slow, prolonged with
constant
concentrations over 24
hrs
Distribution Identical to
endogenous insulin
Metabolism
Liver, spleen, kidney,
muscle
Route
Subcutaneous injection
Onset
3-4 hrs
Peak
Duration
None
24 hrs
Identical to
endogenous insulin
Liver, spleen, kidney,
muscle
Subcutaneous injection
0.17-0.33 hr (15-30
min)
1-3 hrs
3-5 hrs
Drug Cautions
• Contraindications:
• Hypoglycemia
• Allergy or hypersensitivity to insulin glargine
• Caution:
• Stress, infection – decrease insulin requirements
• Renal or hepatic impairment – may decrease insulin requirements
• Pediatrics – safety not established in pts < 6yrs old
• Pregnancy – may temporarily increase insulin requirements
• Adverse Reactions/Side Effects:
• Endo: Hypoglycemia
• Local: lipodystrophy, pruritus, erythema, swelling
• Misc: allergic reactions (anaphylaxis)
Drug Interactions
• Interactions
• Drug-drug:
• Beta-blockers, clonidine, reserpine – may mask signs/sx
of hypoglycemia
• Corticosteroids, thyroid supplements, estrogens,
isoniazid, niacin, phenothiazines, rifampin – may
increase insulin requirements
• Alcohol, ACE inhibitors, MAO inhibitors, salicylates –
may decrease insulin requirements
• Drug-herbal:
• Glucosamine – may worsen blood glucose control
• Fenugreek, chromium, conenzyme q10 – may give additive
hypoglycemic effects
Patient Education &
Teaching
Determining Insulin regimen
• To determine total daily dose of insulin in units =
(Multiply by 0.3 to 0.6) x (weight in kg)
Example of Beth: (0.3) x (58.967) = 17.7 ~ 17
units
• May need to increase insulin requirements later
depending on glucose control
• 40-50% of daily insulin requirements will be given
in long-acting insulin (insulin glargine)
Example of Beth: 17 units / 2 = 8.5 units
• Rest of insulin requirements to be given throughout
the day with meals and snacks as rapid-acting
insulin (insulin aspart)
Carbohydrate Coverage
•
Example: if your insulin to carbohydrate ratio is 1:10  and you eat
20 g of carbs for lunch  20 g/10 = 2 units of insulin to cover your
meal
•
Correction factor for high glucose:
[(Actual blood sugar) – (Target blood sugar)] / [Correction
Factor]
•
Total Meal Dose = (units for CHO) + (units for high glucose
correction)
Example: if Beth’s pre-lunch glucose is 220 mg/dL and her target
is 120 mg/dL with a correction factor of 50, and she plans to eat 20
g of carbs (with a insulin to carb ratio of 10)
•
High sugar correction = (220 – 120)/(50) = 2 units
•
CHO = 20/10 = 2 units
•
Total meal insulin = 2 units + 2 units = 4 units
Storage/Preparation
• Do not mix insulin glargine with
any other insulin or solution; do
not use same syringe
• May mix insulin aspart with other
types of insulin
• First draw insulin aspart into
syringe
• Store unopened vials and cartridges
in refrigerator; do not freeze
Administration
• Give insulin glargine at
approximately the same
time every day, usually
before bedtime
• Give insulin aspart
right before or right
after meals
• Importance of selection
& rotation of injection
sites (abdominal wall,
thigh, or upper arm)
• Importance of compliance
with regimen
Monitoring
• Instruction in proper testing of serum glucose
3 or more times per day (ADA Clinical Guidelines, 2010)
Before all meals
• Instruction in testing of ketones
Especially important during times of stress or illness
• Instruction in signs/sx of hypoglycemia
Nervousness, sweating, hunger, trembling, weakness,
palpitations
Carry around source of glucose at all times (candy,
glucose gel)
• Monitoring Hemoglobin A1C (goal < 7%)
2-3 times per year in patients with good glycemic
control
4 times per year in patients whose glucose needs have
changed or who show poor glycemic control
Follow/Up
• Schedule a visit to office in 2-3
days to go over blood glucose
readings, correction factors, and
carbohydrate ratios in order to
optimize insulin requirements
• Schedule appointment for 3 month
follow up visits to monitor Hgb
A1c and fasting blood glucose
until treatment is stable
• Encourage pt to maintain physical
activity routine and encourage
healthy eating
• Encourage yearly appointments with
primary care provider to monitor
cardiovascular health, esp d/t
family history
Are they both in the Ohio Board
of Nursing Formulary?
• Yes, under Section 3 – Endocrine & Metabolic
Agents – INSULIN
• Note: If giving insulin aspart as IV, must do
so with institution approved protocol
May APNs prescribe?
• Yes, with CTP
Example of Written Prescription:
•
•
Gus Hudson-Vadnais, CFNP
123 Somewhere Road, Columbus, OH 43210
•
614-123-4567 (office)
•
Date of Prescription:
Aug 2, 2010
•
Patient Name:
Beth Smith
•
Patient Weight: 130 lbs (58.967 kg)
•
Patient Address:
•
Rx:
123 Somewhere Road, Columbus, OH 43210
• Insulin glargine, 5 x 3mL cartridges for use with OptiPen One Insulin
Delivery Device
– o Give 8.5 units one time a day at bedtime
– o Administer to back of arm, thigh, or abdomen
• Insulin aspart, 5 x 3mL cartridges (100 units/mL)
– o Pt taking up to 10 units per day. Dose subject to change as ratios
change
– Take blood glucose reading prior to each meal
– o Administer insulin aspart based on appropriate carbohydrate ratio
and high blood sugar correction factor
•
Please schedule a follow-up visit to my office in 2-3 days.
Clinical Studies
Homko, C., Deluzio, A., Jimenez, C., Kolaczynski, J. W., & Boden,
G. (2003). Comparison of insulin aspart and lispro:
pharmacokinetic and metabolic effects. Diabetes Care, 26(7),
2027-31.
•
•
Objectives: To compare insulin levels and actions in patients with type 1
diabetes after subcutaneous injection of the rapid-acting insulin analogs aspart
and lispro.
Population: 7 patients with type I diabetes (2 male, 5 female)
• 5 used insulin pumps (CSII)
• 2 used MDI regimen
•
Method:
• Participants were studied at the General Clinical Research Center at
Temple University Hospital two times, 1 month apart
• Plasma glucose was normalized overnight by intravenous infusion of
insulin
• next morning, they received SQ injections of either aspart or lispro in
random order
• Over the next 4–5 h, their plasma glucose was clamped at ~5.5 mmol/l with
a variable infusion of 20% glucose.
• Study ended after 8 h
•
Results:
• Actions of both insulin lispro and aspart are the same in terms of effect
on carbohydrate and lipid metabolism
• Found them to be equally effective in treating diabetic patients
Bolli, G. B., Kerr, D., Thomas, R., Torlone, E., Sola-Gazagnes, A.,
Vitacolonna, E., Selam, J. L., & Home, P. D. (2009). Comparison of
a multiple daily insulin injection regimen (basal once-daily
glargine plus mealtime lispro) and continuous subcutaneous insulin
infusion (lispro) in type 1 diabetes: a randomized open parallel
multicenter study. Diabetes Care, 32(10), 1170-76.
•
•
Objectives: to assess the difference in glycemic control when people with type 1
diabetes using NPH insulin-based MDIs
Population:
• 58 participants ages 18–70 years from 3 European countries
– o BMI ≤ 27.0 kg/m2
– o diabetes for > 1 year
– o Hbg A1c between 6.5–9.0%
– o currently using an MDI regimen with NPH insulin
• Excluded participants with hepatic or renal impairments
•
Method:
• People with type 1 diabetes on NPH-based insulin therapy were randomized to
CSII or glargine-based MDI (both otherwise using lispro)
• Participants asked to perform 3-4 daily insulin checks (before meals and
bedtime)
•
Results:
• Both regimens showed similar results in terms of insulin dose, blood glucose
control, hypoglycemic events, treatment satisfaction
• Cost was lower for MDI regimen
Sharplin, P., Gordon, J., Peters, J. R., Tetlow, A. P., Longman,
A. J., & McEwan, P. (2009). Improved glycaemic control by
switching from insulin NPH to insulin glargine: a retrospective
observational study. Cardiovascular Diabetology, 8(3), 1-8.
•
Objectives: To assess the impact on hemoglobin A1C, weight, and insulin use of
switching from NPH (Neutral Protamine Hagedorn) to insulin glargine
•
Population: 701 total patients from a United Kingdom primary care network
• 304 (43%) with type 1 diabetes
• 397 (57%) with type 2 diabetes
•
Method:
• 24 month, nonrandomized, retrospective observational study
• Data extracted from a UK primary care database (The Health Improvement Network)
between 2002-2005
• Patients were required to have at least 12 months of data before and after
switching from NPH to glargine
• Primary analysis: the change in HbA1c after 12 months treatment with insulin
glargine
• Secondary analyses: change in weight and total daily insulin dose
•
Results: in diabetes patients treated with NPH and with evidence of suboptimal
efficacy and/or poor tolerability, switching to insulin glargine offers opportunity for
improved glycaemic control
References--Materials
American Diabetes Association (2010). Standards of medical care in diabetes. V. Diabetes
care. Diabetes Care, Suppl 1: S16-29.
Blong, Lawrence, et. al. (2007). American association of clincal endocrinologists medical
guidelines for clinical practice for the management of diabetes mellitus.Endocrine
Practice, Vol. 13 (Suppl 1: footnotes in powerpoint 1-6.
Bolli, G. B., Kerr, D., Thomas, R., Torlone, E., Sola-Gazagnes, A., Vitacolonna, E., Selam,
J. L., & Home, P. D. (2009). Comparison of a multiple daily insulin injection regimen
(basal once-daily glargine plus mealtime lispro) and continuous subcutaneous insulin
infusion (lispro) in type 1 diabetes: a randomized open parallel multicenter study.
Diabetes Care, 32(10), 1170-76.
Davis’s Drug Guide (2000-2010).
Unbound Medicine [PDA software].
Diabetes Education Online (2010). Diabetes Teaching Center at the University of San
Francisco. Retrieved July 23, 2010 from http://www.deo.ucsf.edu/type1/diabetestreatment/medications-and-therapies/type-1-insulin-rx/calculating-insuliin-dose.html.
Homko, C., Deluzio, A., Jimenez, C., Kolaczynski, J. W., & Boden, G. (2003). Comparison of
insulin aspart and lispro: pharmacokinetic and metabolic effects. Diabetes Care,
26(7), 2027-31.
Katzung, B. G, Masters, S.B., & Trevor, A. J. (2009) Basic & Clinical Pharmacology (11th
ed). New York: The McGraw-Hill. ISBN: 978-0-07-160405-5.
Sharplin, P., Gordon, J., Peters, J. R., Tetlow, A. P., Longman, A. J., & McEwan, P.
(2009). Improved glycaemic control by switching from insulin NPH to insulin glargine:
a retrospective observational study. Cardiovascular Diabetology, 8(3), 1-8.
References--Tables
Katzung, B.G., Masters, S.B., & Trevor, A.J. (2009) Basic and
Clinical Pharmacology (11th ed). New York: The McGrawHill.
Lehne, R.A., (1998). Pharmacology for nursing care (3rd ed.).
Philadelphia: W.B. Saunders Company. Deglin, J.H. &
Vallerand, A.H. (1999)
Davis's Drug Guide (6th ed). Philadelphia: F.A. Davis
Company. Epocrates Rx (2010). [database for PDA, Version
8.10]. San Mateo, CA: Epocrates, Inc. available from:
http://www.epocrates.com.