Diabetes Treatments: Diabetes Treatments: Options for Insulin Options for Insulin

DeliveryDelivery

Bonnie Pepon, RN, BSN, CDECertified Diabetes Educator

Conemaugh Diabetes Institute

DiabetesDiabetes

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

Type 1 DiabetesType 1 Diabetes

Type 1 DiabetesType 1 Diabetes

Insulin Production of Type 2 Insulin Production of Type 2

Healthy Healthy EatingEating

Classes of MedicationsClasses of Medications

• Sulfonylureas

• Meglitinides

• Biguanides

• Alpha Glucosidase Inhibitors

• Thiazolidinediones-TZD’s

• Incretin Mimetics

• DPP IV Inhibitors

SulfonylureasMost common drugs in this class:

• Glipizide (Glucotrol, Glucotrol XL)• Glyburide (Micronase, Diabeta,

Glynase)• Glimepiride (Amaryl)

How do they work?

• 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 (4.5-11 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

MeglitinidesMost 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

BiguanidesMost common drugs in this class:

• Metformin (Glucophage, Glucophage XR)• Liquid Form (Riomet)

How do they work?

• 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

Alpha Glucosidase InhibitorsMost common drugs in this class:

• Acarbose (Precose)• Miglitol (Glyset)

How do they work?

• 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

Insulin Sensitizers-TZD’SMost common drugs in this class:

• Rosiglitazone (Avandia)• Pioglitazone (Actos)

How do they work?

• 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

Combination DrugsCombination 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)

Incretin Mimetics: Gut HormonesIncretin Mimetics: Gut Hormones

◦Byetta (Exenatide) approved for type 2

◦Symlin (Pramlintide) approved for type 1 and type 2 using mealtime insulin

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

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%

DPP IV InhibitorsDPP IV Inhibitors

Januvia (Sitagliptin)

Oral active, selective inhibitor for the DPP-4 enzyme

A1C effect-decreased by 0.65-0.8%

Can be administered with or without food

Not for type 1 diabetes

Rapid Acting InsulinInsulin Onset of

actionPeaks Duration

Humalog or lispro

5 to 15 minutes

30 to 60 minutes

3 to 5 hours

Novolog or aspart

Apidra or glulisine

Short Acting InsulinHumulin R or Novolin R

30 minutes

2 to 3 hours

3 to 6 hours

Clear in appearanceAvailable in vials and pens

Intermediate Acting InsulinInsulin Onset of

actionPeaks Duration

Humalin N (NPH) or Novolin N (NPH)

2 to 4 hours

4 to 12 hours

12 to 18 hours

Cloudy in appearanceAvailable in vials and pens

Long Acting InsulinLevimir (detemir)

1 to 2 hours

6 to 8 hours

6 to 23 hours

Lantus (glargine)

1 hour no peak 24 hours

Clear in appearanceAvailable in vials and pensCannot be mixed in the same syringe with any other type of insulin

Insulin Injection Sites

Insulin Delivery SystemsAvailable Now

Syringe/Needle/VialSyringe/Needle/VialInsulin 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

Syringe/Needle/VialSyringe/Needle/Vial

Most common method of delivery

Syringes (range of sizes) needle gauge needle length syringe capacity

3/10cc, 1/2cc, 1cc

Insulin NeedlesInsulin Needles Syringes available

1/2 in or 12.7 mm 5/16 or 8mm

Pen needles available ½ in 5/16 in 3/16 in

Gauges available 31, 30, 29, 28

Insulin DevicesInsulin Devices

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 DevicesInsulin Devices

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 DevicesInsulin Devices

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 SyringesInsulin Syringes

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 PensInsulin Pens

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 PensInsulin Pens

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: Insulin Cartridges

1.5 mlInsulin Days

Humalog 28 days

Novolin R 30 days

Novolin 70/30 and Novolin N

7 days

3 mlNovolin R/Novolog/Lantus

28 days

Novolin N 14 days

Novolin 70/30 10 days

Levemir 42 days

Pre-mixed InsulinInsulin Onset of

actionPeaks Duration

Humalog mix 75/25 or 50/50

30 minutes

2 to 4 hours

22 to 24 hours

Humulin mix 70/30 or 50/50

Novolog mix 70/30

Novolin mix 70/30

Helpful for those with poor eyesight, dexterity problems or those who have trouble mixing from 2 different vials

Insulin PumpsInsulin Pumps

Inhaled InsulinInhaled Insulin

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

Jet InjectorJet Injector

Insulin InfuserInsulin Infuser

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 daysInsulin injected into the tube via pen or

syringe instead of the skin

Insulin Delivery SystemsInsulin Delivery SystemsIn the FutureIn the Future

Oral insulinTransdermal insulinBuccal insulinArtificial pancreasImplantable insulin pump

Case StudyCase Study

45 year old African-American maleDiagnosed 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?

The PharmacistThe PharmacistPart of the Healthcare TeamPart of the Healthcare Team