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Diabetes update part 2 Unlock the mysteries of insulin therapy Learn about the traditional insulins and the newer analogs so you can explain the options to your patient. BY JAMES A. FAIN, RN, BC-ADM, PHD, FAAN OF THE 17 MILLION people in the United States who have diabetes, about 4 million take insulin to control their blood glucose level and lower the risk of complications. People with Type 1 diabetes need three or more injections of exogenous insulin daily to survive because their pancreatic beta cells have been destroyed and can’t produce endogenous insulin. People with Type 2 diabetes may need insulin when oral medications and other measures don’t adequately control their blood glucose level. In this article, I’ll review the traditional insulins and discuss the newer types used to manage both types of diabetes. acting. (See Insulin Types and Characteristics to compare the differences.) Rapid-acting insulins. Insulin lispro (Humalog) and aspart (NovoLog) are rapid-acting insulin analogs that take effect 5 to 10 minutes after injection and remain effective for 3 to 5 hours. Rapid-acting insulins mimic the normal meal insulin profile more closely than short-acting insulins. Compared with the same dose of a short-acting insulin, a rapid-acting insulin achieves higher and more rapid peak serum insulin levels and has a shorter duration of action. Tell your patient to eat within 5 minutes of injecting rapidacting insulin to get the maximum benefit and to www.nursingcenter.com 3.0 ANCC/AACN CONTACT HOURS COMBINED TEST ⌹ 3.0 ANCC PHARM. Animals to analogs Insulin was introduced in the 1920s. Most formulations were made from beef or pork pancreas or a combination of both. In the 1980s, manufacturers started using genetic engineering to modify insulin’s amino acid sequence and produce analogs that mimic the action of insulin made in the human pancreas. Since then, the Food and Drug Administration (FDA) has approved various “human” insulins, which are absorbed faster and cause fewer allergic reactions. Both animal and human insulins are classified by their onset of action: rapid-, short-, intermediate-, and long- C E CONTACT HOURS COMBINED TEST Insulin types and characteristics Preparation, clarity Rapid-acting Insulin lispro (Humalog), clear Insulin aspart (NovoLog), clear Short-acting Regular (Humulin R, Novolin R), clear Regular (Iletin-pork), clear Intermediate-acting NPH (Humulin N, Novolin N), cloudy Lente (Humulin L, Novolin L), cloudy NPH (Iletin-pork), cloudy Long-acting Ultralente (Humulin U), cloudy Insulin glargine (Lantus), clear Premixed insulins, % 70/30 NPH/regular (Humulin 70/30, Novolin 70/30), cloudy 50/50 NPH/regular (Humulin 50/50), cloudy 75/25 lispro protamine/lispro (Humalog Mix 75/25), cloudy 70/30 aspart protamine/aspart (NovoLog Mix 70/30), cloudy Onset of action Peak action (hr) Duration of action (hr) 5 min 5-10 min 0.5-1.5 1-3 3-4 3-5 0.5-1 hr 0.5-2 hr 2-3 3-4 3-6 3-6 2-4 hr 3-4 hr 2-4 hr 4-10 4-12 8-14 10-16 12-18 10-16 6-10 hr 1 hr 0.5-1 hr 10-16 — Depends on insulin types in the mixture 18-20 24 10-16 Nursing2004, March 41 reduce his risk of hypoglycemia. Because of their rapid onset Key teaching points about insulin therapy of action, lispro and aspart are • Make sure your patient knows the type or types of insulin he’s taking: brand appropriate for use with an name, manufacturer, and duration of action. Emphasize that his dosages must be insulin pump, so the patient individualized and balanced with food intake and activity level. has more flexibility at meal• Teach him the proper way to draw up his prescribed insulin or to mix different times. He can wait until the types if he uses more than one. If he has trouble reading the syringe, teach him to meal reaches the table to use a magnifier or have someone else make sure the correct dose is drawn up. count carbohydrates and • Stress the importance of accuracy. Emphasize how injecting even slightly more or less than the prescribed dose can dangerously affect his blood glucose level. adjust his dose, then immedi• Teach him to always make sure he has the correct insulin before leaving the ately administer a bolus before pharmacy. Encourage him to take a used vial and compare the insulin name, eating. The short duration of strength, and directions. action of rapid-acting insulin • Explain how to safely store his insulin. Tell him to read and follow the manufacalso decreases his risk of hypoturer’s recommendations. Make sure he knows that all insulins maintain potency glycemia 3 to 4 hours after longer if refrigerated (but not frozen) before first use. Once he begins using an meals. insulin vial, he should store it at room temperature, but for no longer than 1 Short-acting insulins. month. Regular insulin and analogs • Teach him the proper insulin injection sites and technique, how to recognize and such as Humulin R and respond to hypoglycemia, and when to call his primary care provider if he develNovolin R usually reach the ops complications. • Advise him to test his blood glucose level regularly and make sure he knows bloodstream within 30 minhow to use the blood glucose meter properly. utes of injection and work for 3 to 6 hours. Teach your patient to carefully coordinate the use of a short-acting insulin with meals. Because inconsistent or variable. “Peakless” insulin its onset of action is slower Long-acting insulins. Effective for 18 to 24 hours, glargine provides than that of rapid-acting insulin glargine (Lantus) and high-dose ultralente a continuous insulin, he must inject it 30 (Humulin U) are long-acting preparations. Approved insulin level to 60 minutes before meals by the FDA in April 2000, “peakless” insulin glargine to minimize the risk of postprovides a continuous insulin level similar to the slow, similar to the prandial hyperglycemia. steady (basal) secretion of insulin from a normal panslow, steady Because of its longer duracreas. Typically, the patient administers glargine at (basal) secretion tion, short-acting insulin also bedtime, but any time is acceptable if he uses it at the of insulin from a increases the risk of hyposame time each day. glycemia 3 to 5 hours after Someone who takes multiple insulin injections may normal pancreas. meals. achieve more independence with less risk of hypoRegular insulin was once glycemia using insulin glargine. But because it has no the only insulin used for intravenous (I.V.) administra- peak action, he needs to take a bolus of short-acting tion, but now you can mix rapid-acting insulin lispro insulin before each meal to prevent postprandial with 0.9% sodium chloride or dextrose solution and hyperglycemia. Warn him not to mix insulin glargine give it I.V. in the same syringe with other insulins: It’s very acidic Intermediate-acting insulins. Insulins classified and could interfere with their action. as intermediate-acting take effect 2 to 4 hours after Premixed insulins. Premixed insulins can benefit injection and work 10 to 18 hours. They include patients who have trouble drawing two formulations NPH (Humulin N, Novolin N) and lente (Humulin into one syringe because of vision problems or diffiL, Novolin L), a high-dose formulation. The incluculty understanding the technique. First-generation sion of protamine and zinc in NPH insulin is repremixed preparations Humulin 70/30 and Novolin sponsible for prolonging its duration of action. As 70/30 contain 70% NPH and 30% regular insulin. with short-acting insulins, subcutaneous absorption Although premixed insulins closely mimic normal of intermediate- and long-acting insulins may be insulin secretion at mealtime and afterward, they 42 Nursing2004, Volume 34, Number 3 www.nursingcenter.com aren’t appropriate for most people with diabetes: Regardless of the patient’s blood glucose level, a premixed short- and intermediate-acting insulin injected before meals can promote inconsistent blood glucose levels and increase the risk of hyperglycemia. Within the past 5 years, the FDA approved two premixed insulin analogs. Humalog Mix 75/25 (75% insulin lispro protamine/25% insulin lispro) and NovoLog Mix 70/30 (70% insulin aspart protamine/ 30% insulin aspart) both have a rapid onset and intermediate duration of action and should be injected immediately before a meal. Compared with regular insulin, they result in lower postprandial blood glucose readings and decrease the risk of hypoglycemia after meals. Don’t administer these preparations I.V. or by insulin infusion pump and don’t mix them with any other insulin product. Quality of life and prevention Whether your patient takes insulin alone to manage his diabetes or uses it to supplement oral drugs, he must thoroughly understand what the various types do and how to use them properly. With safe and effective insulin therapy, he’ll enjoy a better quality of life and may avoid the debilitating long-term complications of diabetes. SELECTED REFERENCES Guthrie, R., et al.: “Glargine: A New Basal Insulin, A New Opportunity,” Diabetes Spectrum. 14(3):120-122, 2001. Kissin, A., and Katzeff, H.: “New Insulin Therapies for the Management of Diabetes Mellitus,” Practical Diabetology. 21(1):14-20, 2002. Krosnick, A.: “Five Decades of Diabetes Patient Care: The Time of My Life,” Clinical Diabetes. 20(4):173-178, October 2002. Rolla, A.: “Insulin Analog Mixes in the Management of Type 2 Diabetes Mellitus,” Practical Diabetology. 21(4):36-43, 2002. Wang, F., et al.: “Insulin Glargine: A Systematic Review of a Long-Acting Insulin Analogue,” Clinical Therapeutics. 25(6):1541-1577, June 2003. White, J., and Campbell, R.: “Pharmacologic Therapies,” in A Core Curriculum for Diabetes Educators, 5th edition, M. Franz (ed). Chicago, Ill., American Association of Diabetes Educators, 2003. James A. Fain is associate dean for academic programs at the University of Massachusetts Graduate School of Nursing in Worcester and editor of the journal The Diabetes Educator. The author has disclosed that he has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity. Online CE test offering: Access part 1, “Managing Diabetes with 'Agent Oral,’” listed separately in this issue, then take the combined CE test on oral diabetes drugs and insulin therapy at http://www.nursingcenter.com/ce/nursing. CE Test Diabetes update Instructions: • Read the articles beginning on page 36. • Take the test, recording your answers in the test answers section (Section B) of the CE enrollment form. Each question has only one correct answer. • Complete registration information (Section A) and course evaluation (Section C). • Mail completed test with registration fee to: Lippincott Williams & Wilkins, CE Dept., 16th Floor, 345 Hudson St., New York, NY 10014. • Within 3 to 4 weeks after your CE enrollment form is received, you will be notified of your test results. • If you pass, you will receive a certificate of earned contact hours and an answer key. If you fail, you have the option of taking the test again at no additional cost. • A passing score for this test is 29 correct answers. • Need CE STAT? Visit http://www.nursingcenter.com for immediate results, other CE activities, and your personalized CE planner tool. • No Internet access? Call 1-800-933-6525, ext. 331 or ext. 332, for other rush service options. • Questions? Contact Lippincott Williams & Wilkins: 212886-1331 or 212-886-1332. Registration Deadline: March 31, 2006 www.nursingcenter.com Provider Accreditation: This Continuing Nursing Education (CNE) activity for 3.0 contact hours and 3.0 pharmacology contact hours is provided by Lippincott Williams & Wilkins, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center’s Commission on Accreditation and by the American Association of Critical-Care Nurses (AACN 11696, CERP Category A). This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 3.0 contact hours and 3.0 pharmacology contact hours. LWW is also an approved provider of CNE in Alabama, Florida, and Iowa and holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classified for Texas nursing continuing education requirements as Type I. Your certificate is valid in all states. This means that your certificate of earned contact hours is valid no matter where you live. Payment and Discounts: • The registration fee for this test is $19.95. • If you take two or more tests in any nursing journal published by LWW and send in your CE enrollment forms together, you may deduct $0.75 from the price of each test. • We offer special discounts for as few as six tests and institutional bulk discounts for multiple tests. Call 1-800-933-6525, ext. 332, for more information. Nursing2004, March 43