Download Insulin Regimes

Insulin Regimes
Jill Little
Diabetes Specialist Nurse
Insulin Initiation
 Used to optimise glucose control
 To alleviate symptoms
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Prevent or delay complications
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Circumstances when insulin is required.
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Treatment of Type 1 diabetes.
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Treatment of Type 2 diabetes where OHA’s have failed to
control the blood sugar or the patient is intolerant of the drug.
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Gestational diabetes
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Drug induced hyperglycaemia (steroids).
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Treatment of acute diabetic emergencies- HONK (Hyperosmolar
non-ketotic hyperglycaemia, DKA (Diabetic ketoacidosis).
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Surgery
Storage of insulin
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Stored in fridge door
Stable for 28 days out of the fridge
Insulin in use should be stored at room
temperature
No direct heat
No direct sunshine
Will freeze in hold of plane
Insulin injection sites
Lipohypertrophy
What is lipohypertrophy?
This means changes, hardening of the subcutaneous fatty tissue.
What causes lipohypertrophy?
The re-use of damaged pen needles can lead to skin and tissue injuries.
This, together with frequent injections in so-called favourite sites, can
lead to lipohypertrophy.
What are the consequences of lipohypertrophy?
Injections into hardened tissue affect insulin absorption making the
insulin dose effectiveness difficult to calculate.
This can lead to unexplainable blood glucose fluctuations.
How can lipohypertrophy be avoided?
Change the injection site after every injection.
Use pen needles only 1x.
Pen needles Lothian guidance
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First line use
Omnican B Braun 4mm
Nanopass/My Life
BD Viva/Insupen
Special use BD Autoshield
cover/Novofine Autocover
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Need a portfolio of needles to
suit all types of patients
Therefore guidance only for
prescribers
Rapid Acting Analogues
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Novorapid, Humalog and Apidra
Clear insulin, bolus to cover food.
Can be given immediately before or after
food.
15 minute onset, peak 1-2 ½ hours , lasts 35 hours.
Flexible.
Insulin activity
Rapid acting insulin
0
2
4
6
8 10 12 14 16 18 20 22 24
Onset 15mins, peak 1-2hrs, lasts 3-5hrs
Short Acting Insulin
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Actrapid and Humulin S
Soluble, clear insulin.
Inject 15-30 minutes before food.
Also used in emergency and at time of
surgery.
Can give iv,im as well as sc.
SC acts within 30-60 mins, peak 2-4 hrs, last
8 hours.
iv effect lasts only 30 minutes.
Short acting insulin
Short acting / soluble
insulin
Onset 15-30mins, peak 2-4hrs, lasts 8hrs.
Intermediate Acting Insulin
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Insulatard and Humulin I .
Cloudy- needs to be resuspended.
SC onset 1-2 hrs, peak 3-12 hrs, last 16
hours.
Can be mixed with soluble.
Intermediate-acting
Insulin
Onset 1-2hrs, peak 3-12hrs, lasts 16hrs.
Long Acting Analogue Insulin
Background (basal) insulin. Smoother profile compared
with Insulatard and Humulin I. Cannot be mixed with
other insulins in same syringe. Clear insulin.
 Insulin Glargine (Lantus)
Longer duration of action, 24 hours.
Take several days to reach steady state(3-4 days).
 Detemir (Levemir)
Long acting basal analogue.
Given either once or twice daily.
Abasaglar ( insulin Glargine )
Biosimilair
Lantus- lasts up to 24hrs.
Traditional Insulin Mix.
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Humulin M3
Mixture of soluble and insoluble insulin
30%/70%.
Cloudy- needs to be resuspended.
Inject 15- 30 minutes before food
SC, onset 30-45mins, peak 8hrs, duration up
to 22hrs
Traditional insulin mix.
Onset 30-45mins, peak 8hrs, lasts up to 22hrs.
Analogue Insulin Mix.
Premixed combinations of short and
intermediate acting analogues
action
 Cloudy
(needs resuspending)
 3 different combinations
time
(25, 30, 50)
 Onset
10 - 20 minutes
 Peak
1 - 4 hours
 Duration of action up to 24 hours
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New to market – basal insulin
Longacting basal insulin
New to market
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High-strength insulin products such as insulin glargine 300 units/ml (Toujeo)
have been developed for people with large daily insulin requirements to reduce
the number and volume of injections. In 1 randomised controlled trial (RCT) in
549 people with type 1 diabetes, Toujeo had similar efficacy to insulin glargine
100 units/ml (Lantus) in terms of HbA1c reduction, but the basal insulin dose
used was higher with Toujeo than with Lantus. There was no benefit of Toujeo
over Lantus in terms of reduced hypoglycaemic events. The safety profile of
Toujeo is largely similar to that of Lantus. Toujeo is not bioequivalent to Lantus
and they are not interchangeable without dose adjustment.
New to market
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Fiasp was developed with the aim of achieving faster initial
absorption, to improve glycemic control after a meal, in people
with type 1 and type 2 diabetes
NEW TO MARKET
Insulin degludec
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Xultophy is a prefilled pen containing a fixed-ratio combination of insulin
degludec and liraglutide, licensed for the treatment of type II diabetes in
combination with oral hypoglycaemics.
Xultophy is the first product to combine a basal insulin and an incretin mimetic
to allow administration of both drugs in a single subcutaneous injection
PHARMACOLOGY
Insulin degludec is a long-acting basal insulin that is given once daily. It forms a
depot of soluble multi-hexamers following subcutaneous injection which
slowly releases insulin monomers throughout the day. Liraglutide is a glucagonlike peptide-1 (GLP-1) analogue (incretin mimetic) that improves glycaemic
control by lowering fasting and postprandial blood glucose.1
Xultophy contains a fixed-ratio combination of insulin degludec 100 units and
liraglutide 1.8mg per ml. Doses are administered by subcutaneous injection
once daily and can be adjusted in dose steps of 1 unit of insulin degludec and
0.036mg of liraglutide. The maximum daily dose of Xultophy is 50 dose steps
(50 units of insulin degludec and 1.8mg of liraglutide).1
U 500 Insulin
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Concentrated form of short acting insulin
Lilly have U500 insulin but available on name basis
only in UK. Five times concentration of U100.
Onset, peak and length of action the same as for
U100 Actrapid
Main benefit - patients on large doses of short acting
can reduce doses using U500 insulin
Improved absorption of insulin
Improved glycaemic control
Application
Twice Daily Insulin – BD 8-12 hrs apart
Once daily insulin + oral hypoglycaemics Basal Bolus Regime – CHO counting
Other Options
 CSII (Pump Therapy)
 SQ Needleless System