Insulin 101

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Insulin 101

• Dana G. Carroll, PharmD, BCPS
• Clinical Associate Professor
• Harrison School of Pharmacy
• University Medical Center Department of Family
  Medicine
• University Medical Center Family Medicine
  Residency Program
• Tuesday Afternoon Seminar
• September 26, 2006

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How to contact me.

• Email dcarroll1_at_cchs.ua.edu
• Pager 464-7218
• Office 348-2891

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Non-Diabetic Glucose and Insulin Profile
GLUCOSE
INSULIN
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Humalog Novolog Apidra Insulins

• Onset 15 - 30 minutes
• Peak 1-2 hours
• Duration 4 hours
• Advantages
• Pump stable
• Freedom for meals and insulin timing
• Quick on and off set

• Disadvantages
• Cost vs regular insulin (50 per vial)

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Humulin Novolin Regular Insulin

• Onset 30 minutes to 1 hour
• Peak 2 to 4 hours
• Duration 8 hours (usually)
• Advantages
• Cost vs Humalog (1/2 price)
• IV route administration
• Pump stable

• Disadvantages
• Longer duration of action, ???increased of
  hypoglycemic rxns in brittle pts
• For maximal effect needs to be given 30 minutes
  b/f meals- offers less meal freedom

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Humulin Novolin NPH Insulin

• Onset 2-4 hours
• Peak 6 hours
• Duration 12- 18 hours
• Advantages
• Cost vs lantus ( ½ cost)

• Disadvantages
• Cannot be given IV
• Peak and trough may effect BG control
  significantly???- patient dependent factors

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Lantus Levemir Insulins

• Onset 2-4 hours
• Peak ? 8 hours vs no peak
• Duration 18 to 24 hours (dose dependent)
• Advantages
• QD dosing
• ??No peaks and troughs

• Disadvantages
• Not mix with other insulins additional
  injections
• Cost vs NPH insulin (50-70/vial)
• Injection site pain
• 24 hour duration if hypoglycemic

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Lantus and Levemir Insulins Disadvantages?

• Dosing
• Levemir Initial start PI recommends no more than
  10 units QD to BID or 0.1 to 0.2 units/kg/day OR
  same dosing as current long acting insulin
• Lantus 10-12 units QD or 80 of current long
  acting insulin dose
• Other notes
• Neither to be placed in pumps or IV
• Levemir associated with Na retention and
  increased incidence of edema

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Exubera

• Inhaled insulin- available Sept 06 in US
• Short Acting in nature
• Similar onset to Lispro
• Similar duration to Regular
• Contraindicated
• Smokers or pt quit smoking in last 6 months
• Poorly controlled lung disease (asthma and COPD)
• AEs
• Cough (worsen with cont use)
• Worsening PFTs ???
• Increased use, increased risk of Ab formation
• Hypoglycemia

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Exubera

• Dosed in mgs
• Dose as 0.05 mg/kg/ premeal dose (round to
  nearest whole dose)
• 1 mg 3 units R insulin
• 3 mg 8 units R insulin
• 6 mg 16 units R insulin
• Available as 1 mg and 3 mg blisters
• Still need long acting insulin for basal coverage
  with Exubera!

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Other insulins to consider.

• Semilente (Rapid Acting, like R)
• Lente (Intermediate Acting, like NPH)
• Ultralente and PZI (Long Acting, like lantus)
• Premixing by more than 5 minutes prior to use
  compromises efficacy of rapid acting insulin
• Combinations
• 50/50, 70/30 and 75/25
• Typically with NPH R or Humalog/Novolog

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Initial Dosing of Insulin

• Weight based
• 0.5 to 1 unit/kg/day
• 2/3 AM
• 1/3 rapid acting
• 2/3 long acting
• 1/3 PM
• 1/3 rapid acting
• 2/3 long acting

• Sliding scale transition to scheduled dosing
• Based on total daily requirements divided out
  using 2/3s 1/3s rule
• Start lower rather than higher and titrate to
  effect!!!!!!!!!!!!
• Carbohydrate counting
• 15 grams carbs 1 unit short acting insulin

Not always work for DM 2 patients! It may
actually flip to 1/3 AM and 2/3 PM based on
patient factors.
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Weight Based Dosing Example

• .7 units/kg/day x 70 kg 49 units/day (50)
• 50 units x .66 33 units AM
• 50-33 17 units PM
• 33 units x .66 22 units NPH AM
• 33-22 11 units R AM or
• 5 units Bkfast and 6 units noon
• 17 units x .66 11 units NPH PM
• 17-11 6 units R PM

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Sliding Scale Transition to Scheduled Dosing
Example

• Sliding scale total daily unit requirements
• Day 1 53 Day 2 59 Day 3 51 Day 4 49
• Avg daily requirements 53 units/day

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Sliding Scale Transition to Scheduled Dosing
Example

• 53 units per day
• 53 x .66 35 units AM
• 53-35 18 units PM
• 35 x .66 23 units NPH AM
• 35-23 12 units AM or
• 6 units bkfast noon
• 18 x .66 12units NPH PM
• 18-12 6 units R PM

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Lantus and NPH transition

• EXAMPLE
• Pt is on 70/30 50 units BID
• 5050 100 units total insulin daily
• 100 x 70 70 units NPH
• 70 x .66 46 units of lantus
• 100- 70 30 units short acting Regular or
  Humalog 10 units TID

• If on NPH and want to transition to Lantus
• NPH BID cut dose by 1/3 and that is lantus dose
• NPH QD direct conversion

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Adjusting the Insulin Doses

• BG values
• AM NOON PM HS
• 200 112 150 98
• 199 110 189 100
• 156 124 177 105
• 188 99 167 98
• 185 106 175 77
• Current regimen
• Humalog 15 units TID
• NPH 36 units AM and 45 units PM
• What doses should be adjusted?

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Mixing Insulin

• Humulin R, Novolin R, or Humalog/Novolog may
  be premixed for up to 30d prior to administration
  with NPH
• Apidra should be mixed just prior to use

• Any of the lente insulins may NOT be premixed
  more than 5 minutes before administration
• Lantus/ Levemir may not be mixed with any other
  insulins

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Injection Site Selection
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Storage and Stability

• If unpierced and stored in the refrigerator- good
  for expiration date on vial
• If pierced and stored in the refrigerator-
  expires within 2 months of being pierced
• Except for Lantus and Epidra(28 days) and
  Levemir (42 days)
• If pierced and stored at room temperature-
  expires within 1 month of being pierced
• Lantus and Levemir- preferably stored in the
  refrigerator
• Exubera and Epidra- may be stored at room temp

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How many vials does the patient need per month?

• Total daily dose of R 30 units/day
• Total daily dose of NPH 75 units/day
• 30 units/day x 30 days 900 units
• 1000 units per vial 1 vial of R per month
• 75 units/day x 30 days 2250 units
• 1000 units per vial 3 vials NPH per month

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Syringe Selection

• 3/10 size (30 unit capacity)
• 1/2 cc size (50 unit capacity)
• 1 cc size (100 unit capacity)

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Im so LOST..can you start over?
Whoopie!
QUESTIONS????????????
BREAK TIME