1、Slides current until 2008Pharmacological managementInsulinSection 3|Part 2 of 3Curriculum Module III-3|InsulinInsulin managementCurriculum Module III-3 Slide 2 of 41Insulin A hormone secreted by the beta cells Secreted in response to glucose or other stimuli,such as amino acids Normal response chara
2、cterized by low basal levels of insulin,with surges of insulin triggered by a rise in blood glucoseInsulin6002040BreakfastLunchSupperInsulin managementCurriculum Module III-3 Slide 3 of 41Insulin actionIncreases glucose uptake,particularly in muscle,liver and adipose tissueSuppresses glucose output
3、from the liverIncreases formation of fatInhibits breakdown of fatsPromotes amino-acid uptake and prevents protein breakdownInsulin managementCurriculum Module III-3 Slide 4 of 41Indications for insulin therapy Type 1 diabetes Women with diabetes who become pregnant or are breastfeeding Transiently i
4、n type 2 diabetes in special situations In type 2 diabetes,inadequately controlled on glucose-lowering medicines(secondary failure)Insulin managementCurriculum Module III-3 Slide 5 of 41Insulin therapy Insulin therapy aims to replicate the normal physiological insulin response Insulin regimens shoul
5、d be individualized type of diabetes willingness to inject lifestyle blood glucose monitoring age dexterity glycaemic targetsInsulin managementCurriculum Module III-3 Slide 6 of 41Insulin types and actionOnset(hrs)Peak(hrs)Duration(hrs)Rapidlispro aspart-23-4Shortsolubleregular-12-4 6-8IntermediateN
6、PHlente1-21-36-12 6-12 18-24 18-24Long actingultralente glarginedetemir4-63-41-28-20 3-243-8 24 or more24 or more 12-24(dose-dependent)Insulin managementCurriculum Module III-3 Slide 7 of 41International labelingwww.idf.orgInsulin managementCurriculum Module III-3 Slide 8 of 41Variability in insulin
7、 absorptionInsulin managementCurriculum Module III-3 Slide 9 of 41Factors affecting absorption Lipohypertrophy Dose of injection Site and depth of injection Exercise Ambient and body temperature Insulin type Incomplete re-suspensionInsulin managementCurriculum Module III-3 Slide 10 of 41 What is the
8、 most common insulin regimen used in your country?How well do you think it works?How do people accept insulin?ACTIVITYInsulin managementCurriculum Module III-3 Slide 11 of 41Insulin regimens:once a day insulinSoluble insulinIntermediate-acting insulinInsulin6002040BreakfastLunchSupperEndogenous insu
9、linInsulin managementCurriculum Module III-3 Slide 12 of 41Twice a day insulinSoluble insulinIntermediate-acting insulinInsulin6002040Endogenous insulinBreakfastLunchSupperInsulin managementCurriculum Module III-3 Slide 13 of 41Three times a day insulinSoluble insulinIntermediate-acting insulinInsul
10、in6002040Endogenous insulinBreakfastLunchSupperInsulin managementCurriculum Module III-3 Slide 14 of 41Rapid-acting insulin analogueIntermediate-acting insulinBasal-bolus regimenInsulin6002040Endogenous insulinBreakfastLunchSupperInsulin managementCurriculum Module III-3 Slide 15 of 41Long-acting in
11、sulin analogueLong-acting insulin analoguesRapid-acting insulin analogueInsulin6002040Endogenous insulinBreakfastLunchSupperInsulin managementCurriculum Module III-3 Slide 16 of 41Commencing insulin therapy Insulin should never be used as a threat Fear of injecting is common;needle phobia is rare He
12、althcare professionals attitude is key to acceptance People should be praised and encouraged to promote a positive attitude Blood test is more painful than insulin injection Forget the oranges;just do it!Insulin managementCurriculum Module III-3 Slide 17 of 41Commencing insulin therapy Starting dose
13、 will depend on many factors age weight type and duration of diabetes glycaemic targets In type 2 diabetes,consider continuing maximum tolerated oral glucose-lowering medicines 10 units of intermediate-acting insulin once a dayInsulin managementCurriculum Module III-3 Slide 18 of 41Injecting insulin
14、 Should be given into subcutaneous tissue Skin of a very thin person may have to be gently pinched Insulin at room temperature less painful Needle can be inserted at 45-90 45 for very thin people 90 for overweight people or when using short needle Swabbing with alcohol is not necessaryInsulin manage
15、mentCurriculum Module III-3 Slide 19 of 41Insulin devicesSyringe and needle Usually disposable,intended for one injection only May need to use doses divisible by 5 or 10 if visually impairedPens Easy to use Loading pen may be difficult for elderly Disposable pensInsulin managementCurriculum Module I
16、II-3 Slide 20 of 41Insulin devicesPumps Insulin delivered every few minutes over 24 hours Require large commitmentInhaled insulin For bolus doses only Large device Unknown long-term effects on lungsInsulin managementCurriculum Module III-3 Slide 21 of 41HbA1CPre-meal2 hours post-mealTarget for most
17、people with diabetes7%4-7mmol/L*90-130mg/dl*15-10mmol/L*180mg/dl*1IDF Global guideline for Type 2 diabetes*26.5%6.0mmol/L110mg/dl8.0mmol/L145mg/dlAdjusting insulin what are the targets?*CDA 2003,*1ADA 2004,*2 IDF 2005 Treatment targets should be individualized,especially for very young and very old
18、Absence of hypoglycaemiaInsulin managementCurriculum Module III-3 Slide 22 of 41Starting insulin in type 2 diabetesFINFAT:start small dose intermediate-acting insulin at night Aim for target fasting levels first Adjust by 2-4 units or 10%Second injection only added once fasting targets reached Insul
19、in managementCurriculum Module III-3 Slide 23 of 41Adjusting insulinPattern management Watch levels for 2-3 days Address hypoglycaemia first Aim for target fasting levels next Adjust by 2-4 units or 10%Wait 2-3 daysInsulin managementCurriculum Module III-3 Slide 24 of 41Adjusting insulin Flexible do
20、se guideline Eating more Exercising more Insulin to carbohydrate ratio Evaluate with next blood glucose Tailored to individual needsInsulin managementCurriculum Module III-3 Slide 25 of 41Which insulin to adjust when?Blood glucoseInsulin to be changedFastingBedtime or supper intermediate-or long-act
21、ingPost-breakfastMorning short-or rapid-acting insulin Pre-lunchMorning intermediate-acting insulinPost-lunchMorning intermediate-acting insulin or lunchtime short-or rapid-acting insulin Pre-supper(dinner)Morning intermediate-acting insulinPost-supper(dinner)Supper-time short-or rapid-acting insuli
22、nDuring the nightSupper-time or bedtime intermediate-actingInsulin managementCurriculum Module III-3 Slide 26 of 41Insulin practicalitiesTiming Soluble insulin:30-45 minutes pre-meal Short-acting insulin analogues:no more than 15 minutes pre-meal and can be given post-meal Intermediate-or long-actin
23、g insulins do not have to be given in relation to a mealInsulin managementCurriculum Module III-3 Slide 27 of 41Storage One month in fridge or at room temperature once the vial has been opened Must never be frozen Store away from source of heat If refrigeration not available store in clay pot or hol
24、e in ground May be damaged by direct sunlight or vigorous shakingInsulin practicalitiesInsulin managementCurriculum Module III-3 Slide 28 of 41 Insulin strength may differ(U40,U100,U500)Ensure that the syringe matches the strength!Long-acting insulin analogues are clear in appearance Identify and di
25、fferentiate insulin typePrecautionsInsulin managementCurriculum Module III-3 Slide 29 of 41Mixing insulins NPH and soluble insulins can be mixed without changing properties Check with the manufacturer before mixing any other insulins Pre-drawn syringes can be kept in fridge(2-80 C or 36-460 F)for on
26、e monthInsulin managementCurriculum Module III-3 Slide 30 of 41Side effects Hypoglycaemia Weight gain Lipohypertrophy Lipoatrophy Insulin oedema Allergic reactionInsulin managementCurriculum Module IV-1Slide 31 of 41ACTIVITYInsulin:NPH 25 units,Reg.10 units before breakfast NPH 15 units,Reg.10 units
27、 before supperPre-breakfastmmol/L(mg/dl)Pre-lunchPre-supper2 hours post-supperDay 110.4(187)6.5(117)7.0(126)9.2(165)Day 29.6(172)5.4(97)6.8(122)10.2(183)Day 311.0(198)6.2(112)6.5(117)8.8(158)Example 1Insulin managementCurriculum Module IV-1Slide 32 of 41ACTIVITYExample 2Insulin:rapid-acting before e
28、ach meal and NPH at bedtimePre-breakfast mmol/L(mg/dl)Pre-lunchPre-supper2 hours post-supperDay 17.0(126)6.5(117)15.1(272)10.3(185)Day 26.7(120)5.4(97)14.6(263)12.2(219)Day 36.5(117)6.2(112)12.5(225)11.8(212)Insulin managementCurriculum Module III-3 Slide 33 of 41What would you advise if.The insulin
29、 had been taken and the restaurant meal was late Regular insulin should be taken before a meal but the pre-meal blood glucose is 3.5 mmol/L(63mg/dl)A tennis match is scheduled an hour after lunch A person wakes up nauseated and does not want to eat Blood glucose levels do not coincide with how a per
30、son feelsACTIVITYInsulin managementCurriculum Module III-3 Slide 34 of 41Summary All people with type 1 diabetes must be treated with insulin The majority of people with type 2 diabetes will need insulin within 5 to 10 years of diagnosis Insulin therapy should not be used as a threat Insulin regimen
31、s should be individualized Insulin should be adjusted to achieve blood glucose as close to target range as possible Insulin managementCurriculum Module III-3 Slide 35 of 41Review question One advantage that rapid-acting insulin has over regular insulin is that it:Must be given immediately after the
32、mealDoes not have to be kept in the fridgeDoes not need a basal insulin to be given as wellHas a short and predictable action timeInsulin managementCurriculum Module III-3 Slide 36 of 41Review question2.Which of the following does not affect the absorption of insulin?The temperature of the insulin T
33、he temperature of the area to be injected The amount of insulin to be injected The type of injection device,i.e.pen or syringeInsulin managementCurriculum Module III-3 Slide 37 of 41Review question3.Jonathan says his doctor has suggested he take insulin four times a day.He asks if this is not going
34、to be too much insulin.What is your best response?It is not possible to take too much insulin,you just have to eat more The action of insulin taken four times a day is closest to the action of endogenous insulinTaking insulin four times a day will be very difficult,and the results will not be much b
35、etterYour doctor feels that taking insulin four times a day will make you pay more attention to your diabetesInsulin managementCurriculum Module III-3 Slide 38 of 41Review question4.Suleen has been on insulin twice a day a mixture of intermediate and soluble in the morning,and again before dinner.He
36、r records show that her fasting levels are 10-12mmol/L(180-216mg/dl),but the rest of the day,her levels are less than 8.5mmol/L(153mg/dl).What change(s)would you suggest to her insulin regimen to improve her levels?Suggest she eats less at dinner and more at lunch Suggest she increases her soluble b
37、efore dinner Suggest she increases her intermediate before dinner Suggest she moves her intermediate to bedtime and decrease her soluble in the morning Insulin managementCurriculum Module III-3 Slide 39 of 41Review question5.The goal of bedtime insulin in the person with type 2 diabetes who is on or
38、al blood glucose-lowering medicines is to:Provide insulin to cover the bedtime snack Reduce the fasting glucose level Reduce the number of oral blood glucose-lowering medicines Prevent hypoglycaemia during the nightInsulin managementCurriculum Module III-3 Slide 40 of 41AnswersddbdbInsulin managemen
39、tCurriculum Module III-3 Slide 41 of 41ReferencesKlingensmith GJ,Ed.Intensive Diabetes Management,3rd ed.Virginia:American Diabetes Association,2003.Colwell JA.Hot Topics Diabetes.Philadelphia:Hanley&Belfus,2003.American Diabetes Association.Insulin Administration.Diabetes Care 2004;27(Suppl 1):S106
40、-109.Davidson MB.Diabetes Mellitus Diagnosis and Treatment.4th ed.Philadelphia:W.B.Saunders Company,1998.Ilkova H,Glaser B,Tunckale A,Bagriacik N,Cerasi E.Induction of long-term glycemic control in newly diagnosed type 2 diabetic patients by transient intensive insulin treatment.Diabetes Care 1997;2
41、0:1353-6.Nathan DM.Initial management of glycemia in Type 2 diabetes mellitus.N Engl J Med 2002;347:1342-9.Canadian Diabetes Association Clinical Practice Guidelines Expert Committee.Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Cana
42、da.Canadian Journal of Diabetes 2003;27(suppl 2).Olsson P-O,Hans A,Henning VS.Miscibility of human semisynthetic regular and lente insulin and human biosynthetic,regular and NPH insulin.Diabetes Care 1987;10:473-7.IDF Clinical Guidelines Task Force.Global Guidelines for Type 2 diabetes.Brussels:International Diabetes Federation,2005.
