WHICH PATIENTS NEED INSULINCo Insulin should be given to all
patients with type 1 diabetesns Insulin Therapy FOR TYPE 2 DIABETES
Consider initiating combination insulin injectable therapy when
blood glucose is>300350 mg/dL and/or A1C is >1012%. ider
initiating combination insulin injectable therapy when blood
glucose is>300350 mg/dL and/or A1C is >1012%.
Slide 3
Slide 4
INSULIN PREPARATIONS
Slide 5
Human versus analogs The time to peak and the duration of
action of human insulin preparations (NPH [Neutral Protamine
Hagedorn] and regular insulin do not replicate endogenous basal and
postprandial insulin secretion. Thus, insulin analogs (lispro,
aspart, glulisine, glargine, detemir, degludec) were
developed.
Slide 6
The very rapid-acting insulin analogs have both faster and
shorter duration of action than regular insulin for pre- meal
coverage The long-acting analogs have a longer and flatter profile
than NPH for basal coverage.
Slide 7
To produce an insulin preparation with a faster onset and
shorter duration of action than regular insulin, modifications were
made in the insulin molecule to prevent it from forming hexamers or
polymers that slow absorption and delay action.
Slide 8
As an example, insulin aspart is identical to human regular
insulin except for a substitution of aspartic acid for proline at
position B28. This substitution results in a reduction in hexamer
formation and consequently more rapid absorption faster onset of
action, and shorter duration of action
Slide 9
Insulin glargin is identical to human insulin except for a
substitution of glycine for asparagine in position A21 and by the
addition of two arginine molecules in the B-chain of the insulin
molecule. These modifications result in a change in the pH such
that, after subcutaneous administration, glargine precipitates in
the tissue forming hexamers, which delays absorption and prolongs
duration of action.
Slide 10
Glargine has no appreciable peak and a duration of action that
usually lasts 24 hours. Glargine cannot be mixed with rapid-acting
insulins as the kinetics of both the glargine and rapid-acting
insulin will be altered.
Slide 11
Insulin therapy in type 2 diabetes mellitus
Slide 12
combination oral agent and insulin therapy Basal insulin o NPH
insulin has been used commonly at bedtime o Insulin glargine (once
daily) o detemir (once or twice daily)
Slide 13
The long-acting insulins, glargine and detemir, may have some
modest clinical advantages over NPH less symptomatic and nocturnal
hypoglycemia in type 2 diabetes with the important disadvantage of
higher cost.
Slide 14
Insulin dose If a bedtime dose of NPH, detemir, or glargine
insulin is being added to oral hypoglycemic drug therapy, we
recommend starting at 10 units or 0.2 units per kg
Slide 15
Fasting blood glucose (FBG) should be measured every day. An
increase of 2 to 4 units in the bedtime insulin dose should be made
periodically (approximately every three days) if the mean FBG is
above 130 mg/dL during this time.
Slide 16
If fasting glucose levels are very elevated (>250 mg/dL ) or
if a patient is known to be very insulin resistant, initial doses
can be higher and titration more aggressive.
Slide 17
Optimal timing of insulin dose NPH insulin may be most
effective if given at bedtime In contrast, a morning rather than a
bedtime dose of insulin glargine may provide better glycemic
control in patients with type 2 diabetes who are also treated with
an oral agent. Ann Intern Med 2003
Slide 18
If basal insulin has been titrated to an acceptable fasting
blood glucose level, but A1C remains above target, consider
advancing to combination injectable therapy to cover postprandial
glucose excursions. Options include adding a GLP-1 receptor agonist
mealtime insulin
Slide 19
A less studied alternative,transitioning from basal insulin
totwice-daily premixed (or biphasic) insulin analog (70/30 aspart
mix, 75/25 or 50/50 lispro mix), could also be considered. Regular
human insulin and human NPH-Regular premixed formulations (70/30)
are less costly alternatives to rapid- acting insulin analogs and
premixed insulin analogs, respectively, but their pharmacodynamic
profiles make them suboptimal for the coverage of postprandial
glucose excursions
conventional insulin therapy Before the conclusion of the DCCT
in 1993, the most commonly used insulin regimens (ie, "conventional
insulin therapy") consisted of twice-daily injections of
short-acting (regular) and intermediate-acting insulin.
Slide 25
This regimen was not physiologic and is no longer recommended
unless the patient cannot or will not comply with an intensive
insulin regimen.
Slide 26
Multiple daily insulin inject Basal insulin NPH Insulin
glargine Insulin detemir In type 1 diabetes, insulin glargine may
have a slight glycemic advantage and detemir less risk of severe
hypoglycemia compared with NPH.
Slide 27
In patients with type 1 diabetes (but not type 2), glycemic
control is similar if once-daily glargine is given before
breakfast, before dinner, or at bedtime but there is less nocturnal
hypoglycemia with breakfast administration.
Advantages of rapid-acting insulin It decreases the
postprandial rise in blood glucose concentration. It is more
convenient because it can be injected 10 to 15 minutes prior to or
up to immediately after meals The action of insulin lispro is not
blunted by mixing with NPH insulin just before injection, as is the
action of regular insulin N Engl J Med 2005
Slide 30
Multiple daily insulin inject
Slide 31
Choosing basal/bolus insulin The choice of basal and bolus
insulin for a multiple daily injection regimen depends upon patient
preference, lifestyle, and cost concerns
Slide 32
Insulin dose Most newly diagnosed patients with type 1 diabetes
can be started on a total daily dose of 0.2 to 0.4 units of insulin
per kg per day. approximately one-half of the total dose should be
given as a basal insulin
Slide 33
the NPH is usually given as approximately two-thirds of the
dose in the morning and one-third at bedtime. The remainder of the
total daily dose (TDD) is given as short or rapid-acting insulin,
divided before meals.