Diabetes Treatments: Options for Insulin Delivery. Bonnie Pepon, RN, BSN, CDE Certified Diabetes Educator Conemaugh Diabetes Institute

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1 Diabetes Treatments: Options for Insulin Delivery Bonnie Pepon, RN, BSN, CDE Certified Diabetes Educator Conemaugh Diabetes Institute

2 Diabetes 21 million people in the U.S. have diabetes $132 billion each year Type 1 diabetes no insulin production Type 2 diabetes some insulin production Gestational diabetes

3 Type 1 Diabetes

4 Type 1 Diabetes

5 Insulin Production of Type 2

8 Healthy Eating

13 Sulfonylureas Meglitinides Biguanides Alpha Glucosidase Inhibitors Thiazolidinediones-TZD s Incretin Mimetics DPP IV Inhibitors Classes of Medications

14 Sulfonylureas Most common drugs in this class: How do they work? Glipizide (Glucotrol, Glucotrol XL) Glyburide (Micronase, Diabeta, Glynase) Glimepiride (Amaryl) Stimulate the pancreas to make more insulin Work for up to 24 hours Lowers fasting and post prandial blood sugar Advantages: May decrease AIC 1.5-2% Inexpensive Side effects: Weight gain ( lbs.) Low blood sugar How to take: Take glipizide 30 min before the first meal of the day All others take with first meal of the day

make more insulin Work for up to 24 hours Lowers fasting and post prandial blood sugar Advantages: May decrease AIC 1.

15 Meglitinides Most common drugs in this class: Repaglinide(Prandin) Nateglinide (Starlix) How do they work? Stimulate the pancreas to make more insulin Work only for about 4 hours after meals Only effects post prandial sugars NOT FASTING! Advantages: May decrease A1C by 1-2% Side effects: Weight gain Low blood sugar How to take: Take up to 30 minutes before meals No meal= No pill

Stimulate the pancreas to make more insulin Work only for about 4 hours after meals Only

16 Biguanides Most common drugs in this class: How do they work? Metformin (Glucophage, Glucophage XR) Liquid Form (Riomet) Helps your body produce less glucose from the liver Helps insulin work better Reduces glucose absorption in the intestines Takes up to 2 weeks to see maximum effect Advantages: Can decrease AIC 1.5-2% Does not cause low blood sugar or weight gain May also lower triglycerides and cholesterol Side effects: Nausea and Diarrhea How to take: Take with breakfast and supper

insulin work better Reduces glucose absorption in the intestines Takes up to 2 weeks to see maximum effect Advantages: Can

17 Alpha Glucosidase Inhibitors Most common drugs in this class: How do they work? Acarbose (Precose) Miglitol (Glyset) Slows the digestion of carbs in the small intestine, thus decreasing the post prandial blood sugar spike Advantages: May decrease A1C by 0.5 to 1% Does not cause low blood sugar or weight gain Side effects: Gas and diarrhea How to take: Take with first bite of food of 3 largest meals of the day

decreasing the post prandial blood sugar spike Advantages: May decrease A1C by 0.

18 Insulin Sensitizers-TZD S Most common drugs in this class: How do they work? Rosiglitazone (Avandia) Pioglitazone (Actos) Helps insulin work better Enhances glucose uptake by the muscle tissue Reduces glucose production by the liver Takes up to 3 months to see maximum effect Advantages: May decrease A1C by 0.5-1% Does not cause low blood sugar May decrease triglycerides and increase HDL Side effects: Swelling in legs and weight gain (caution in heart failure) If on oral contraceptive, may increase risk of pregnancy Liver damage (<1% chance) Liver function is monitored every 2 months for the first year

liver Takes up to 3 months to see maximum effect Advantages: May decrease A1C by 0.

19 Combination Drugs Glucovance (glyburide/metformin) Metaglip (glipizide/metformin) Avandamet (avandia/metformin) Duetact (amaryl/actos) New Ones: Fortamet (metformin SR) Glumetza (metformin SR) Actoplus (actos/metformin) Avandryl (avandia/glimepiride)

(amaryl/actos) New Ones: Fortamet (metformin SR) Glumetza

20 Byetta (Exenatide) approved for type 2 Symlin (Pramlintide) approved for type 1 and type 2 using mealtime insulin Incretin Mimetics: : Gut Hormones

21 Januvia (Sitagliptin) Oral active, selective inhibitor for the DPP-4 enzyme A1C effect-decreased by % Can be administered with or without food Not for type 1 diabetes DPP IV Inhibitors

22 Byetta How do they work? Prevents stored sugar from entering the blood stream Stimulates insulin release Slows gastric emptying Lowers post prandial blood sugar spike Makes you feel full Reduces food intake and appetite Advantages: May decrease A1C by 1% after 6 months Promotes weight loss (5-6 lbs) Dosing: Comes in a prefilled pen that lasts one month 5 mcg twice a day for 1 month, then increase to 10mcg twice a day Give within 60 minutes of morning and evening meal Do NOT give after a meal If you miss a meal, skip the dose Side effects: Nausea (will go away with time and dose titration) Vomiting and diarrhea Low blood sugar May need to decrease dose of sulfonylurea to avoid low blood sugar

23 Symlin How do they work? Slows gastric emptying Lowers the post prandial blood sugar spike Makes you feel full Reduces food intake and appetite Slows production of glucose from liver Advantages: May lower A1C by 0.6% in Type 2 after 6 months Promotes weight loss (4 lbs) Side effects: Nausea (will decrease over time) Loss of appetite Vomiting Hypoglycemia (3 hours after dose) Decrease amount of rapid acting insulin by 50%

25 Goals of Insulin Therapy To keep the blood glucose levels as close to normal as possible Fasting mg/dl After meals mg/dl To prevent acute and long term complications To keep the HbA1c at 6.5% - 7% To feel better if you are in your goal range

26 Rapid Acting Insulin Insulin Onset of action Peaks Duration Humalog or lispro Novolog or aspart 5 to 15 minutes 30 to 60 minutes 3 to 5 hours Apidra or glulisine Short Acting Insulin Humulin R or Novolin R 30 minutes 2 to 3 hours 3 to 6 hours Clear in appearance Available in vials and pens

27 Intermediate Acting Insulin Insulin Onset of action Peaks Duration Humalin N (NPH) or Novolin N (NPH) 2 to 4 hours 4 to 12 hours 12 to 18 hours Cloudy in appearance Available in vials and pens Long Acting Insulin Levimir (detemir) 1 to 2 hours 6 to 8 hours 6 to 23 hours Lantus (glargine) 1 hour no peak 24 hours Clear in appearance Available in vials and pens Cannot be mixed in the same syringe with any other type of insulin

29 Insulin Injection Sites

30 Insulin Delivery Systems Available Now

31 Syringe/Needle/Vial Insulin comes in U 100 in the U.S. orange cover and black scale 100 units of insulin per milliliter of fluid in the vial U 500 available high insulin resistance using more than 200 units a day Outside the U.S.: U-40 red cover and red scale

32 Syringe/Needle/Vial Most common method of delivery Syringes (range of sizes) needle gauge needle length syringe capacity 3/10cc, 1/2cc, 1cc

33 Insulin Needles Syringes available 1/2 in or 12.7 mm 5/16 or 8mm Pen needles available ½in 5/16 in 3/16 in Gauges available 31, 30, 29, 28

35 Syringes Syringes are most widely available Can be adjusted to 1 or ½ units Can use most types of insulin Require good vision to measure a dose Insulin Devices

36 Pens Easy to set the correct dose by a dial Can be adjusted with ½ units or 1 unit Can use most types of insulin Very convenient and accurate for the vision impaired and those on the go Insulin Devices

37 Pumps Results in better diabetes control More flexible eating schedule Dose adjusted by 1/10 to 1/20 units Requires higher level of involvement & more advanced diabetes education and skills Insulin Devices

38 Multiple manufacturers BD, Monoject, SureComfort, Ulticare Precision Sure Dose, UltiGuard, Medicore, Aimsco Injection aides Inject-Ease by BD and Palco, Instaject (can be combined with a lancet device), NeedleAid, NovoPen 3 Penmate Insulin Syringes

39 Uses an insulin needle available in different sizes and gauges units can be counted as dialed by a click plunger is pushed in and held for several seconds before removing the needle Insulin Pens

40 Storage in refrigerator until the pen is started storage life ranges from 7 to 42 days Pre-filled pens 28 days: Humalog/Novolog/Novolin R 14 days: Novolin N 10 days: Novalin 70/30 Insulin Pens

41 Humalog Novolin R Insulin Pens: Insulin Cartridges Insulin Novolin 70/30 and Novolin N 1.5 ml 28 days 30 days 7 days 3 ml Days Novolin R/Novolog/Lantus Novolin N Novolin 70/30 Levemir 28 days 14 days 10 days 42 days

42 Insulin Humalog mix 75/25 or 50/50 Humulin mix 70/30 or 50/50 Novolog mix 70/30 Novolin mix 70/30 Pre-mixed Insulin Onset of action 30 minutes Peaks 2 to 4 hours Duration 22 to 24 hours Helpful for those with poor eyesight, dexterity problems or those who have trouble mixing from 2 different vials

46 Insulin Pumps

47 Pumps Deliver rapid acting insulin Results in better diabetes control More flexible eating schedule Dose adjusted by 1/10 to 1/20 units Requires higher level of involvement & more advanced diabetes education and skills Water proof Carb counters Risk of infection, inflamation at injection site

48 Delivers rapid acting dry powder insulin Absorbed through the lungs into the bloodstream 1mg and 3mg blister packets Cannot be used for smokers, children, pregnant women or anyone with lung problems Will be taken off the market in January 2008 Inhaled Insulin

49 Jet Injector

50 Minimize needle sticks by creating a portal to inject insulin into A small tube is inserted into the fatty tissue of the injection site It is taped in place for 2-3 days Insulin injected into the tube via pen or syringe instead of the skin Insulin Infuser

51 45 year old African-American male Diagnosed with Type 2 DM Initial glucose 280mg/dl, A1C 9.9% Started on nutrition and physical activity 3 months later still having symptoms PMH hypertension, obesity, high lipids Smoker, occasional alcohol, no drug use What therapy should be started? Case Study

52 The Pharmacist Part of the Healthcare Team

53 Questions? Please submit your questions using the chat box below.

Insulin Pens & Improving Patient Adherence

Insulin Pens & Improving Patient Adherence Bonnie Pepon, RN, BSN, CDE Certified Diabetes Educator Conemaugh Diabetes Institute Kip Benko, MD FACEP Asst Clinical Professor University of Pittsburgh School