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Diabetes

Management with insulins
by

Persephone Mosier

on 14 August 2014

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Transcript of Diabetes

1) http://www.robinsonlibrary.com/science/physiology/biochemistry/insulin.htm
2) http://www.typefreediabetes.com/Articles.asp?ID=150
3) http://www.advantajet.com/body_sup_ins.htm
4) http://www.consumermedsafety.org/medication-safety-articles/item/581-an-accidental-over-dial-leads-to-an-overdose
5)http://www.vetrxdirect.com/product/view/novolin-n
6) http://www.1800petmeds.com/Humulin+N+Insulin-prod10693.html
7) http://www.mexrx.net/product_info.php/products_id/1497/osCsid/decba7e62b0a7bb1d5d78290c69f63e3
8) http://www.diabetesmine.com/2014/02/ask-dmine-lantus-drips-mimicking-an-insulin-pump.html
9) https://www.accu-chek.com/us/glucose-meters/aviva.html
10) http://www.prodigymeter.com/?page_id=935
11) http://thisiscaleb.com/2010/12/15/apidra®-v-140-sanofi-aventis/
12) http://medconnections.com/drugs/humalog.html
13) http://odsmedical.com/novolog-insulin-aspart-prescription-drug-novolog-information-rx-novolog/
14) http://www.forbes.com/sites/henrymiller/2012/10/29/when-genetic-engineering-came-of-age/


Diabetes
Intermediate Acting Insulin
NPH Insulin (Novolin® N, Humulin® N)
Short Acting Insulin
Type 1 vs Type 2
Insulin:Carbohydrate Ratio
Rapid Acting Insulin
Type 1-
Autoimmune disease
Beta cell destruction in the pancreas
Typical young onset
Type 2-
Insulin resistance
Progressive disease
Not necessarily insulin dependent
Typically older onset

1.American Diabetes Association Clinical Practice Recommendations 2013. Diabetes Care 2013;36 (supp1):s11-66.
2.American Diabetes Association Diagnosis and Classification of Diabetes Mellitus 2010. Diabetes Care 2009;33(supp1):s62-69
American Diabetes Association Clinical Practice Recommendations 2014. Diabetes Care 2014;37 (supp1):s14-80. Table 2
Inpatient Vs Outpatient Glucose Goals
Inpatient:
Outpatient
Critically ill patients- 140-180mg/dL
Non-critically ill patients-
<140mg/dL with
postprandial BG <180mg/dL
American Diabetes Association Clinical Practice Recommendations 2014. Diabetes Care 2014;37 (supp1):s14-80.
Fasting- 70-130mg/dL

Postprandial- <180mg/dL

Bedtime- 100-140mg/dL
A1C Goals
ADA- <7%
or
<6% *
AACE-≤6.5%*
or
>6.5%
* For patients not experiencing hypoglycemic events or pregnant women
1.American Diabetes Association Clinical Practice Recommendations 2013. Diabetes Care 2013;36 (supp1):s11-66.
3.A1C High and Low. Digital image.
University of Kansas Medical Center.
The University of Kansas Medical Center. Web. 1 July 2014.
Insulin Glulisine (Apidra)*
Subcutaneous
Onset: 0.2-0.5 hours
Peak Effect: 1.6-2.8 hours
Duration of Effect: 3-4 hours
Insulin Glulisine. Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Updated May 16, 2014. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/320048. Accessed 1 July 2014

Common Adverse Effects
Hypoglycemia
Weight Gain
Injection Site Reaction
Drug Interactions
Beta Blockers
Dextrose (IV fluids)

Key Counseling Points
Consequences of hypoglycemia
Double check product
Rotation of injection site
Throw away vial after 28 days at room temperature.
Not on EH formulary
Insulin Lispro (Humalog)
100units/mL (3mL)
Subcutaneous
Onset: 0.25-0.5 hours
Peak Effect: 0.5-2.5 hours
Duration of Effect: ≤5 hours
Insulin Lispro. Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Updated May 16, 2014. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/320046. Accessed 1 July 2014

Insulin Aspart (NovoLog)*
Subcutaneous
Onset: 0.2-0.3 hours
Peak Effect: 1-3 hours
Duration of Effect: 3-5 hours
Not on EH Formulary
Insulin Aspart. Lexi-Drugs Online. Hudson, OH: Lexi-Comp. Inc. Updated May 16 2014. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/320061. Accessed 1 July 2014

Insulin Regular (Humulin R)
100 units/1mL (10mL)
Subcutaneous
Onset: 0.5 hours
Peak Effect: 2.5-5 hours
Duration of effect 4-12 hours *
may increase with dose
Insulin Regular. Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Updated June 30, 2014. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/320101. Accessed 1 July 2014

Insulin's Mechanism of Action
Binds to membrane-bound receptors
Stimulates hepatic glycogen synthesis
Increases protein synthesis
Stimulates circulating lipoproteins to provide free fatty acids
Facilitates triglyceride synthesis and storage
Directly inhibits the hydrolysis of triglycerides
Promotes intracellular movement of potassium
Insulin Glulisine. Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Updated May 16, 2014. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/320048. Accessed 1 July 2014
Insulin Glulisine. Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Updated May 16, 2014. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/320048. Accessed 1 July 2014
Insulin Glulisine. Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Updated May 16, 2014. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/320048. Accessed 1 July 2014
Insulin Glulisine. Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. Updated May 16, 2014. http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/320048. Accessed 1 July 2014
Long Acting Insulin
Insulin Glargine (Lantus®, Lantus Solostar®)
Insulin Detemir (Levemir®, Levemir FlexPen®)
Eskenazi Health
Glucometer Education


Alternative Meters
Eskenazi Health
July 16th 2014

Basal/Bolus Regimens
NPH Insulin
(Novolin® N, Humulin® N)
100 units/mL
10 mL vial
Only use if suspension appears cloudy or milky
Do not use if lumps and/or solid particles have formed
Criteria for Diagnosis
Insulin Glargine (Lantus®)
(Lantus Solostar®)
100 units/mL
10 mL vial
3 mL pens x5 per box
Clear solution for injection
Intermediate Acting and
Long Acting Insulin Pharmacokinetics
Starting Insulin Dosages
Type 1 Diabetes Mellitus (T1DM)
1) 0.5 to 0.6 units/kg initially
50% of total daily dose for basal insulin
50% of total daily dose for meal coverage
Starting Insulin Dosages Type 2 Diabetes Mellitus (T2DM)
NPH or long-acting insulin at bedtime; initially in combination with oral agents
Insulin Sensitivity Factor/Correction Factor
When to use
Elevated pre-prandial blood glucose levels
How to use
In addition to amount of short-acting insulin required from insulin:carb ratio
2) 1 unit for every 15 grams of carbohydrates
1:15 carb ratio
3) Two daily injections of mixed insulin
2/3 of daily dose in AM
2/3 dose = NPH
1/3 dose = short-acting
1/3 of daily dose in PM
2/3 dose = NPH
2/3 dose = short-acting
Exceptions to typical insulin dosing for T1DM
Honeymoon phase
Reduce insulin dose for a short period
0.1 to 0.4 units/kg
Acute illness or ketosis
Higher doses can be used
Decrease in insulin sensitivity
Many methods for initial basal insulin dosing:
0.15 - 0.2 units/kg/day
Simply 10 - 15 units at bedtime initially
FBG ÷ 18
Weight (kg) ÷ 10
Many methods for initial bolus insulin dosing:
0.1 units/kg/meal
5-10 units/meal
1-2 units of insulin for every 15 grams of carbohydrates
Adjustments to T2DM insulin dosing
Initial basal insulin regimen:
Increase by 1-2 units for every 20 mg/dL of fasting blood glucose >100 mg/dL
Increase by 2-4 units for every 50 mg/dL of fasting blood glucose >150 mg/dL
Doses of >1 unit/kg often seen as patients progress through late stage of disease
A1C and Blood Glucose Targeting
Diary Log
How to calculate personal insulin:carbhydrate ratio
Keep a diet log for 3 days
Establish carbohydrate intake for each meal
Divide # of carbohydrates for a meal by amount of bolus insulin
Check blood glucose pre- and 3 hours post- meal
Adjust ratio accordingly
Rule of 500
T2DM Treatment Algorithm
Average 1 unit insulin: 15 grams of carbohydrate (1 serving)
Adjustments to insulin:carbohydrate
May have more than one insulin:carb
Breakfast
Lunch
Dinner
Ratio may change with
Body weight
Physical activity
Hormonal changes
T1DM or T2DM in pregnancy
1:5 ratio is not unusual in 3rd trimester
NPH Insulin
Inject SubQ
NOT recommended for IV or IM administration
NOT recommended for external SubQ insulin infusion pump
NOT to be injected cold
Mixing Insulin
In same syringe
Pharmacists and/or pharmacy students counsel every meter, every time!
Documentation
Insulin NPH. Lexi-Drugs. Lexi-Comp Online. Lexi-Comp, Inc. Hudson, OH. Available at: http://online.lexi.com. Accessed July 3, 2014.
Dipiro, J & et al. Diabetes Mellitus. In: Pharmacotherapy: A Pathophysiologic Approach. 8th ed.

Dipiro, J & et al. Diabetes Mellitus. In: Pharmacotherapy: A Pathophysiologic Approach. 8th ed.

Accu-Chek®. ACCU-CHECK Aviva Plus system. Available at: https://www.accu-chek.com/us/glucose-meters/aviva.html Accessed July 7, 2014.
Dipiro, J & et al. Diabetes Mellitus. In: Pharmacotherapy: A Pathophysiologic Approach. 8th ed.

Dipiro, J & et al. Diabetes Mellitus. In: Pharmacotherapy: A Pathophysiologic Approach. 8th ed.

American Diabetes Association Standards in Medical Care in Diabetes 2014. Diabetes Care 2014;37 (supp1):s14-80.
Dipiro, J & et al. Diabetes Mellitus. In: Pharmacotherapy: A Pathophysiologic Approach. 8th ed.

Dipiro, J & et al. Diabetes Mellitus. In: Pharmacotherapy: A Pathophysiologic Approach. 8th ed.

Dipiro, J & et al. Diabetes Mellitus. In: Pharmacotherapy: A Pathophysiologic Approach. 8th ed.

Dipiro, J & et al. Diabetes Mellitus. In: Pharmacotherapy: A Pathophysiologic Approach. 8th ed.

Dipiro, J & et al. Diabetes Mellitus. In: Pharmacotherapy: A Pathophysiologic Approach. 8th ed.

Dipiro, J & et al. Diabetes Mellitus. In: Pharmacotherapy: A Pathophysiologic Approach. 8th ed.

Dipiro, J & et al. Diabetes Mellitus. In: Pharmacotherapy: A Pathophysiologic Approach. 8th ed.

Dipiro, J & et al. Diabetes Mellitus. In: Pharmacotherapy: A Pathophysiologic Approach. 8th ed.

American Diabetes Association Standards in Medical Care in Diabetes 2014. Diabetes Care 2014;37 (supp1):s14-80.
American Diabetes Association Standards in Medical Care in Diabetes 2014. Diabetes Care 2014;37 (supp1):s14-80.
American Diabetes Association Standards in Medical Care in Diabetes 2014. Diabetes Care 2014;37 (supp1):s14-80.
American Diabetes Association Standards in Medical Care in Diabetes 2014. Diabetes Care 2014;37 (supp1):s14-80.
American Diabetes Association Standards in Medical Care in Diabetes 2014. Diabetes Care 2014;37 (supp1):s14-80.
American Diabetes Association Standards in Medical Care in Diabetes 2014. Diabetes Care 2014;37 (supp1):s14-80.
American Diabetes Association Standards in Medical Care in Diabetes 2014. Diabetes Care 2014;37 (supp1):s14-80.
Bhargava A, Johnson JF, Weir JP. Case Series: Premixed insulin dosing in actual practice: two-thirds in AM, one-third in PM, or half and half?. Clinical Diabetes 2009; 27: 91-95

Dosing:
-Conventional approach is to have two-thirds of the total daily dose (TDD) in the morning before breakfast and one-third in the evening before dinner
-Some evidence to support TDD split evenly between morning and evening






Advantages
-Carrying convenience
-Less administration embarrassment
-Less at risk for administration errors compared with mixing separate vials of insulin
-Potential for better regimen adherence

Disadvantages
-Harder to achieve complete glycemic control


Premixed Insulin
-Bhargava A, Johnson JF, Weir JP. Case Series: Premixed insulin dosing in actual practice: two-thirds in AM, one-third in PM, or half and half?. Clinical Diabetes 2009; 27: 91-95
-Johnson, JF. Healio Endocrinology. Premixed analog insulin: What is the tradeoff between convenience and achievement of target HbA1c?. Available at: http://www.healio.com/endocrinology/diabetes/news/print/endocrine-today/%7B3c766344-cebc-40f8-ad24-3512e0176a3e%7D/premixed-analog-insulin-what-is-the-tradeoff-between-convenience-and-achievement-of-target-hba1c. Accessed July 8, 2014.
-Insulin Aspart Protamine and Insulin Aspart. Monograph. Lexicomp Online. Lexicomp, Inc. Hudson, OH. Available at: http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/320043. Accessed July 8, 2014.
Eskenazi Insulin Mixing Policy
-Insulin glargine should not be mixed
-Mixed NPH and short-acting insulin should be used immediately or stored
-Rapid-acting insulin's onset is not blunted when mixed with short-acting and intermediate-acting insulins
-Slight decrease in the absorption rate when rapid-acting and NPH are mixed
-Can mix short-acting and intermediate-acting insulins

Insulin Mixing Guidelines
Insulin Asdministration. American Diabetes Association 2002; 25: 5112-5115

Eli Lilly. Humulin R U-500 (CONCENTRATED). Available at: http://www.humulinhcp.com/pages/index.aspx?WT.srch=1&WT.mc_id=4994-44814-678. Accessed July 8, 2014.


U-500 insulin
Advantages
-Treatment of insulin-resistant patients
-Decreased volume for injection
-Increased absorption compared to U-100
-Relatively cheaper

Disadvantages
-Delayed onset and peak
-Dosing errors
-Hypoglycemia
-Hyperglycemia, Diabetic Ketoacidosis, and Hyperosmolar Non-Ketotic Syndrome

-Eli Lilly. Humulin R U-500 (CONCENTRATED). Available at: http://www.humulinhcp.com/pages/index.aspx?WT.srch=1&WT.mc_id=4994-44814-678. Accessed July 8, 2014.
-DiPiro JT, Talbert RL, Yee GC, et al. Endocrinologic Disorders. In: Pharmacotherapy: A Pathophysiologic Approach. 9th ed. Posey M, eds. McGraw-Hill Publishing Company; 2014.
-Segal AR, Brunner JE, Burch FT, et al. Use of concentrated insulin human regular (U-500) for patients with diabetes. Am J Health Syst-Pharm 2010;67:1526-1536.


-Currently no syringe available to dose U-500 insulin
-Subcutaneous injection in the abdominal wall, the thigh, the gluteal region or in the upper arm.
-Rotate the injection site within one area
-Lightly grasp a fold of skin and inject at a 90° angle
-Embed the needle within the skin for 5 seconds after depression of the plunger
-Do not mix U-500 with other insulins

Administration
-Eskenazi Health. Standardization of ordering and dispensing of concentrated Humulin U-500 insulin, 950-191. Available at: https://eskenazihealth.policystat.com/policy/657068/latest/. Accessed July 8, 2014.
-Eli Lilly. Humulin R U-500 (CONCENTRATED). Available at: http://www.humulinhcp.com/pages/index.aspx?WT.srch=1&WT.mc_id=4994-44814-678. Accessed July 8, 2014.


-
Inpatient
: Verification that dose in volume and units match and drug was ordered by Endocrinology
Outpatient
: Initial orders have drug and dose checked

-
Inpatient
: Drawn up in a TB syringe in the pharmacy
Outpatient
: Patients need an active order of TB syringes

- The label for all doses will contain "CONCENTRATED insulin product" and will list the dose in both volume and units
Eskenazi Health. Standardization of ordering and dispensing of concentrated Humulin U-500 insulin, 950-191. Available at: https://eskenazihealth.policystat.com/policy/657068/latest/. Accessed July 8, 2014.

Dispensing
- Ordered using the term "concentrated U-500 insulin"
- Require the dose to be in both the volume and the number of units
- All initial inpatient orders require an endocrinology consult, outpatient do not.

Eskenazi Health. Standardization of ordering and dispensing of concentrated Humulin U-500 insulin, 950-191. Available at: https://eskenazihealth.policystat.com/policy/657068/latest/. Accessed July 8, 2014.


Ordering
PD is a 67 yowf, and former host of a food network show, that comes to the outpatient pharmacy at Eskenazi Health for the first time. Her physician put her on Humulin R U-500 to help decrease her daily volume of injected insulin. If she is to receive 300 units twice daily, how should the provider have written the order? Assuming she has no additional prescriptions on file, what else, if anything, should the physician write for? Would this prescription(s) need an endocrinology consult?

Question
Necessary components of the U-500 order:
-“concentrated U-500 insulin”
-Dose in volume
-Dose in units

Answer:
“concentrated U-500 insulin: inject 0.3 mL (150 units) subQ two times per day”

Additional Components:
-PD would need an order for TB syringes
-No endocrinology consult is needed in the outpatient setting

Answer
Insulin Devices
-Insulin Administration. American Diabetes Association 2002; 25: 5112-5115
-Wonderly, K. Healthline. Insulin jet injectors. Available at: http://www.healthline.com/health/type-2-diabetes/insulin-jet-injectors#2. Accessed July 8, 2014.
-The institute for family health. Insulin pen instructions. Available at: http://www.institute2000.org/wp-content/uploads/2012/05/How-to-use-your-insulin-pen.pdf. Accessed July 8, 2014.


Syringe and Vial
(1)
(4)
Insulin Pen
Jet Injector
(3)
(2)
Any questions on
Diabetus?
Persephone Kriner-Sotos, Outpatient Pharmacy Intern
Ashley Brost, Inpatient Pharmacy Intern
Zack McCormack, Inpatient Pharmacy Intern

Bhargava A, Johnson JF, Weir JP. Case Series: Premixed insulin dosing in actual practice: two-thirds in AM, one-third in PM, or half and half?. Clinical Diabetes 2009; 27: 91-95

Insulin Administration. American Diabetes Association 2002; 25: 5112-5115
Dosing Conversions
Dosing
Segal AR, Brunner JE, Burch FT, et al. Use of concentrated insulin human regular (U-500) for patients with diabetes. Am J Health Syst-Pharm 2010;67:1526-1536.

Question & Answer
Picture References
(1)
Mixing Insulin
(5)
(6)
(7)
(8)
(9)
Insulin NPH. Lexi-Drugs. Lexi-Comp Online. Lexi-Comp, Inc. Hudson, OH. Available at: http://online.lexi.com. Accessed July 3, 2014.
Insulin glargine. Lexi-Drugs. Lexi-Comp Online. Lexi-Comp, Inc. Hudson, OH. Available at: http://online.lexi.com. Accessed July 3, 2014.
Insulin glargine. Eskenazi Health. Lexi-Comp Online. Lexi-Comp, Inc. Hudson, OH. Available at: http://online.lexi.com. Accessed July 3, 2014.
Diabetes ICD-9 Code. Centers for Medicare and Medicaid Services. Available at: http://www.cms.gov/medicare-coverage-database/staticpages/icd-9-code-lookup.aspx Accessed July 15, 2014.
Prodigy Voice® Talking Glucose Meter
Available at Eskenazi Health
Prodigy Voice Taking Glucose Meter. Prodigy Voice. Available at: http://www.prodigyvoice.com/ Accessed July 15, 2014.
(10)
Rule of 1800
American Diabetes Association Clinical Practice Recommendations 2014. Diabetes Care 2014;37 (supp1):s14-80.
Garber, Alan J., et al. "American Association of Clinical Endocrinologists' comprehensive diabetes management algorithm 2013 consensus statement." Endocrine practice 19 (2013): 1-48.
What does 15 grams of carbohydrates look like?
Example
1800 ÷ 90 total daily insulin dose = 20

1 unit will decrease blood glucose 20 mg/dL
2 units will decrease blood glucose ~40-50 mg/dL

Scale
150-200 mg/dL:2 units
201-250 mg/dL:4 units
251-300 mg/dL:6 units
301-350 mg/dL:8 units
>350 mg/dL:10 units

Written as
2:50 >150
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