insulin use

8/17/2019 Insulin Use

1/51

INSULIN THERAPYIN DIABETES MELLITUS

Dra. WIDYATI, Apt, MClinPharm


2/51

PENGGUNAAN INSULIN

• Inslin th!rap" #an $! s!% t&&'!r#&m! (l#&s! t&)i#it"

• Us! in a#t! an% #hr&ni# #ar!


3/51

Glucose toxicity

• C&ntri$t! t& %!'!l&pm!nt &* inslinr!sistan#! an% impair!% inslin s!#r!ti&n

• In t"p! + #hr&ni# !l!'ati&n in plasma(l#&s! #&n#!ntrati&n l!a%s t& pr&(r!ssi'!impairm!nt in inslin s!#r!ti&n as !ll asa((ra'ati&n &* inslin r!sistan#! %! t&downregulation &* th! (l#&s!-transp&rts"st!m.

• Ths, impairm!nts in inslin s!#r!t&r"r!sp&ns! an% inslin a#ti&n ar! th! r!slt&* %"nami# pr!ss!s.

• Inslin th!rap" #an $! s!% t& &'!r#&m!(l#&s! t&)i#it"


4/51

GAL &* Ph"si&l&(i#al /Basal-B&ls0Inslin Th!rap"

Parameter Adults(mg/dL)

School Age(6–12 years)(mg/dL)

Adolescentsand Young Adults (13–29years)(mg/dL)

Pregnancy(mg/dL)

1astin( plasma(l#&s!

234563 734583 734563 93473

+ hrp&stpran%ialplasma (l#&s!

:583 N&t r&tin!l"r!#&mm!n%!%

N&t r&tin!l"r!#&mm!n%!%

;5+3

+4< am plasma(l#&s!

=23 5334583 7345>3 =93

H$A5#$ :2.3?# :8.3? :2.>?% >49?

Urin! @!t&n!s! A$s!nt t& rar! A$s!nt t& rar! A$s!nt t& rar! Rar!


5/51

INSULIN USE IN ACUTE CASE

• t& r!%#! th! s"mpt&ms an% a%'!rs! !!#ts &*(l#&t&)i#it"

• Inslin th!rap" #an $! start!% at a %&s! &* 3.>U@(+< hr.

• Pati!nts h& ha'! m&r! si(ni#ant inslin%!#i!n#" n!!% a mi) &* rapi%-a#tin( inslin an%int!rm!%iat! inslin $!*&r! $r!a@*ast, rapi%-a#tin(inslin $!*&r! spp!r, an% int!rm!%iat! inslin at$!%tim! t& #&ntr&l th!ir *astin( (l#&s! l!'!l.

•$!s! pati!nts #an r!ir! 533 U &r m&r! %ail"• Wh!n (l#&s! #&ntr&l impr&'!s ith t!mp&rar"inslin s!, an &ral m!%i#ati&n #an $! intr&%#!%(ra%all" hil! $l&&% (l#&s! l!'!ls ar!m&nit&r!% an% th! am&nt &* inslin is sl&l"r!%#!%.


6/51

ACUTE CASES

o D!#&mp!nsati&n %! t& anint!r#rr!nt !'!nt /!(, in*!#ti&n,a#t! inr", str!ss0

o S!'!r! h"p!r(l"#!mia ith@!t&n!mia &r @!t&nriao A#t! !'!ntsF A#t! C&r&nar"

S"n%r&m! /ACS0, Str&@!

o Up#&min( sr(!r"o All!r(" &r &th!r s!ri&s r!a#ti&n t&

&ral a(!nts


7/51

INSULIN USE IN CHRNIC

CARE


8/51

INSULIN USE IN DM TYPE +

• In%i#ati&nF h!n (l#&s! #&ntr&l #an n& l&n(!r $!maintain!% ith &ral #&m$inati&n

• Inslin th!rap" &'!r#&m! inslin r!sistan#! an% pr&'i%!a%!at! inslin !'!n in th! pr!s!n#! &* isl!t $!ta-#!ll%"s*n#ti&n

• In%i#ati&ns *&r inslin th!rap" &* t"p! + %ia$!t!s Fo H"p!r(l"#!mia %!spit! ma)imm %&s!s &* &ral a(!ntso A#t! Cas!so Un#&ntr&ll!% !i(ht l&sso Pr!(nan#"o R!nal %is!as!

o A pr!*!r!n#! *&r inslin th!rap" $" th! pati!nt &r ph"si#ian.

8


9/51

&m$inasi AD-Inslin

• S!t!lah @&m$inasi AD (a(al m!n(&ntr&l(la

Kombinasi ↓FPG(mg/dl)

↓HbA1c (%)

SU+ insulin 60-0 0!"-1#

$&'omin+in

s

60-0 1!-*!"

Acabos+ins 0-16 0!-0!"

Glim,iid+ins

110 *!*

Pio li&aon+i ."- 0 -1 07


10/51

Gradual insulin initiation

• 1&r a pati!nt h& ta@!s ma)imal %&s!s &* &ral anti%ia$!ti#m!%i#ati&ns in #&m$inati&n, inslin th!rap" #an $! initiat!% m&r!(ra%all"

• Th! *&ll&in( inslin &pti&ns ar! a'aila$l!Fo NPH inslin, l!nt!, &r ltral!nt! at $!%tim!o Hman anal&(! inslin 2363 &r 2>+> mi)tr!s $!*&r! spp!r &r

$!*&r! $r!a@*ast, &r $&tho Basal inslin (lar(in! /Lants0 at $!%tim!, $!*&r! spp!r, &r in th!m&rnin(

• Pati!nts &*t!n ha'! hi(h *astin( (l#&s! l!'!ls, an% th!r!*&r!,$asal inslin &r inslin at $!%tim! is a (&&% #h&i#!.

• Inslin sppr!ss!s th! in#r!as!% h!pati# (l#&s! pr&%#ti&n an%

l&!rs *astin( (l#&s! #&n#!ntrati&ns.• I* int!rm!%iat! inslin is #h&s!n, th! am&nt #an $! #al#lat!% $"%i'i%in( a pati!nts $&%" !i(ht in @il&(rams $" *&r an% sin(that nm$!r t& %!t!rmin! th! startin( %&s! /r!sltin( in &n! *&rth&* th! r!(lar %&s!0 &r $" (rin( th! %&s! a##&r%in( t& a rati& &*3.> U@( an% sin( +>? t& 63? &* that am&nt as th! initial %&s!.

• I* $asal inslin (lar(in! is $!in( s!%, n& sp!#ial #al#lati&ns ar!n!#!ssar". A startin( %&s! &* 53 U is pr!s#ri$!%, an% th! %&s! is53


11/51

Comparing insulin treatmentoptions in type 2

• NPH insulin compared with insulin glargine similarpercentage of reduction in HbA1c of 7% or less. However,those who received glargine eperienced less h!pogl!cemiaoverall "##% versus $7% and less nocturnal h!pogl!cemia.

• &nsulin 7'(#' and glimepiride with a combination of insulin7'(#' and placebo. At $) wee*s, reduction in HbA1c "from+.+% to 7.%, but the group receiving glimepiride re-uired#% less insulin to achieve this goal.

• /he new insulin analogues offer more ph!siologic insulinprofiles.0hen insulin lispro was added to sulfon!lurea therap!and compared with NPH and oral medication, patients in thelispro group had lower postprandial glucose levels, decrease inHbA1c levels that was statisticall! significant, despite higherfasting glucose levels with the lispro therap!

55


12/51

PEMILIHAN INSULIN

T e/! rat"on o# Act"on $rand %ame &an #act rer


13/51

Tye/!urat"on o# Act"on $rand %ame &anu#acturer Rapid ActingInslin lispr& Hmal&( Lill"Inslin aspartInslin (llisin!

N&'&L&(Api%ra

N&'& N&r%is@San&-A'!ntis

Short ActingR!(lar Hmlin R Lill" N&'&lin R N&'& N&r%is@Intermediate ActingNPH /is&phan! inslinssp!nsi&n0

Hmlin N Lill"

N&'&lin N N&'& N&r%is@Long ActingInslin (lar(in! Lants San&-A'!ntisInslin %!t!mir L!'!mir N&'& N&r%is@Combination InsulinsNPHr!(lar mi)tr!/23?63?0

Hmlin 2363 Lill"

N&'&lin 2363 N&'& N&r%is@NPHr!(lar mi)tr!/>3?>3?0

Hmlin >3>3 Lill"

Inslin aspartpr&tamin!inslin aspartmi)tr! /23?63?0

N&'&l&( Mi) 2363 N&'& N&r%is@

Inslin NPLinslin lispr& Hmal&( Mi) 2>+> Lill"


14/51

'nsul"n nset (hr) Pea (hr)!urat"on(hr) Aearance

Rapi% a#tin(/inslin lispr&,

aspart an%(llisin!0

>4+> min 63473 min :> Cl!ar

R!(lar 3.>45 +46 >48 Cl!ar

NPH +4< .24+6.+ Cl!ar$

a Th! &ns!t, p!a@, an% %rati&n &* inslin a#ti'it" ma" 'ar" #&nsi%!ra$l"

*r&m tim!s list!% in this ta$l!. S!! t!)t an% Ta$l! >3-5+.$Sh&l% n&t $! mi)!% ith &th!r inslins &r a%minist!r!% IK. S&m!pati!nts r!ir! ti#!-%ail" %&sin(.


15/51

1a#t&rs Alt!rin( Inslin a$s&rpti&n

Factor CommentsRoute of administration ns!t &* a#ti&n m&r! rapi% an%

%rati&n &* a#ti&n sh&rt!r *&rIK=IM=SC562

Intraplm&nar" inslin has m&r! rapi%&ns!t an% sh&rt!r %rati&n than SCinslin, r!s!m$lin( IKpharma#&@in!ti#s2+

Factors altering clearance R!nal *n#ti&n R!nal *ailr! l&!rs inslin #l!aran#!

ma" pr&l&n( an% int!nsi*" a#ti&n &*!)&(!n&s an% !n%&(!n&s inslin

Inslin anti$&%i!s I(G anti$&%i!s $in% inslin as it isa$s&r$!% an% r!l!as! it sl&l", th!r!$"%!la"in( an%&r pr&l&n(in( its!!#t667

Th"r&i% *n#ti&n H"p!rth"r&i%ism in#r!as!s #l!aran#!,$t als& in#r!as!s inslin a#ti&n,ma@in( #&ntr&l %i#lt pati!ntssta$ili! as th!" $!#&m! !th"r&i%

Factors altering SC absorption 1a#t&rs that rais! SC $l&&% J& O

* li


16/51

T"p!s &* Inslin

Insulin Glulisine (Apidra, Sanofi-Aventis)

• Is a rapid-acting insulin analog that differs from human insulin by substitution

of lysine for asparagine at position B3 and glutamic acid for lysine at positionB3!

• "urrently not #$A approved for use in pediatric patients!

• It is pregnancy category "!

• %o&ers postprandial glucose e'cursions similar to insulin lispro and insulin

aspart!

Short-Acting Insulin

• nset of action of 3 to * minutes, a pea+ effect at to hours, and a duration

of action of to . hours! /se of regular insulin in patients &ith type 0 diabetes

is much less common &ith the advent of the rapid-acting insulins!

• 1reviously, an inhaled human insulin po&der (2'ubera, 1fier, 4e& 5or+, 45)

&as available! In ctober ., 1fier announced that it &ould no longer ma+e

this insulin o&ing to its infre6uent use! In 7arch 8, %illy announced that it

&as cancelling the trials of its inhaled insulin!


17/51

T"p!s &* Inslin /CNTINUE0

Int!rm!%iat!-A#tin( Inslin !.(. NPH

ns!t &* a#ti&n is appr&). + h&rs /ran(!, 5460, p!a@ !!#ts #r atappr&). 9 t& 5< h&rs

DA &* NPH is appr&) 59 t& +< h&rs.

Pr!mi) Inslin

Pr!mi)!% NPH an% r!(lar inslin in a )!% rati& &* 23F63 ar! a'aila$l!

*r&m Lill" as Hmlin 2363 an% N&'& N&r%is@ as N&'&lin 2363. Lill"als& ma@!s a pr!mi)!% *&rmlati&n in a >3F>3 rati& /Hmlin >3>30.

A%%iti&nal pr!mi)!% *&rmlati&ns ar! a'aila$l! h!r!in $&th inslinlispr& an% inslin aspart ha'! $!!n #&-#r"stalli!% ith pr&tamin! t&#r!at! an int!rm!%iat!-a#tin( inslin similar t& NPH. Hmal&( Mi) 2>+>

an% Hmal&( Mi) >3>3 /Lill"0 ar! pr&%#ts ith lispr& pr&tamin! an%inslin lispr& in a )!% rati& &* 2>F+> an% >3F>3, r!sp!#ti'!l".

Th!s! pr!mi)!% inslins ar! a'aila$l! *&r pati!nts h& ha'! %i#lt"m!asrin( an% mi)in( inslins an% ar! %&s!% ti#! %ail".

Th!s! inslins ar! #&mpati$l! h!n mi)!% t&(!th!r an% r!tain th!irin%i'i%al pharma#&%"nami# pr&l!s


18/51

T"p!s &* Inslin /CNTINUE0

LNG ACTING INSULIN

Inslin Glar(in! /Lants, San&-A'!ntis0

• n#! a %a" SC a%ministrati&n *&r th! tr!atm!nt &* a%lt an% p!%iatri#

pati!nts /a(! 90 ith t"p! 5 %ia$!t!s &r a%lt pati!nts ith t"p! +%ia$!t!s h& r!ir! $asal /l&n(-a#tin(0 inslin *&r th! #&ntr&l &*h"p!r(l"#!mia.

• A%minist!r!% an"tim! %rin( th! %a", $t it is imp&rtant t& ta@! it at th!sam! tim! !a#h %a" $t #&mm&nl", $!*!&r! $!%

• Is an inslin anal&( in hi#h aspara(in! in p&siti&n A+5 is s$stitt!%ith (l"#in! an% t& ar(inin!s ar! a%%!% t& th! C-t!rmins &* th! -#hain

Inslin D!t!mir /L!'!mir, N&'& N&r%is@0,

• Appr&'!% in Qn! +33> an% &ins inslin (lar(in! as th! s!#&n% $asalinslin

• It is pr!(nan#" #at!(&r" C.

• Unli@! &th!r inslin anal&(s, in hi#h th! amin& a#i% s!!n#! ism&%i!%, *&r inslin %!t!mir, a *att" a#i% m&i!t" is a%%!% t& th! lastamin& a#i% &n th! !n% &* th! -#hain.

• M&r! sl&l" a$s&r$!% in th! SC tiss! $!#as! th! *att" a#i% m&i!t"$in%s t& al$min, #r!atin a l&n -a#tin inslin.


19/51

T!)as Dia$!t!s C&n#il

Gi%!lin!


20/51

Tar(!ts

• A5# ; 9,> ?

• 1PGSMBG ; 553m(%l

• + hr PPGSMBG ;5


21/51

Tr!atm!nt Nai'!

• S"mpt&mati#

• 1PG +93 m(%l

• A5# 53?, @!t&a#i%&sis, r!#!nt rapi%!i(ht l&ss

• PilihanF

• 5. n#!-%ail" Inslin• +. Mlti-%&s! inslin

• 6. Int!nsi'! inslin mana(!m!nt


22/51

ral A(!nt 1ailr!

• 2,3 ?= A5# : 8,>?

• PilihanF

• 5. n#!-%ail" Inslin• +. Mlti-%&s! inslin

• 6. Int!nsi'! inslin mana(!m!nt


23/51

ral A(!nt 1ailr!

• A5# = 8,>?

• PilihanF

• 5. Mlti-%&s! inslin• +. Int!nsi'! inslin mana(!m!nt

• 6. n#! 4%ail" inslin


24/51

n#!-Dail" Inslin

• At $!%tim! F NPH &r L&n(-a#tin( inslin• B !*&r! spp!rF sh&rt-a#tin( inslin &r

pr!mi) 2363

• D&sis aal F 3,5-3,+> U@( &r 9-53 U nt@manla @rs

• Nai@@an %&sis s!tiap +-6 hari.

• Titrati&n s#h!%l!F =583m(%l 4 9 nit

• 5


25/51

Mlti 4D&s! Inslin

• + ) snti@ F NPH Sh&rt a#tin(inslin

• r pr!mi) 2363

• 6 ) snti@ /i* ntrnalh"p&(l"#!mia0F Sh&rt a#tin( inslin$!*&r! $r!a@*ast an% $!*&r! spp!rsli%in( s#al! NPH $!*&r! $r!a@*astan% $!%tim! &r L&n( a#tin( inslin

• Startin( %&s!F 3,6-3,> nit@(


26/51

Int!nsi'! InslinMana(!m!nt

• 5F5 $asalF$&ls

• Basal FNPH $!*&r! $r!a@*ast, $!*&r!spp!r &r $!%tim! ) + &r L&n( a#tin(Inslin

• B&lsF Sh&rt a#tin( inslin at !a#hm!al

• Startin( %&s!F 3,6-3,> U@(


27/51

M!t&%! P!m$!rian Inslin


28/51


29/51


30/51

ASUS DM TYPE 5

• A.H., Wanita 58th , >3@(, 593#m MRS%( @!lhan p&l"%ipsia, ntria /9)s!malam0, *ati(!, p!nrnan BB 9@(

%alam + $lan. Hasil p!ri@sa La$ GDP573m(%l %an GDA +>3m(%l. H$A5#,

5


31/51

Basal-B&ls /Ph"si&l&(i#al0 Inslin Th!rap"

• A ph"si&l&(i#al inslin r!(im!n is %!si(n!% t& mimi#n&rmal inslin s!#r!ti&n as #l&s!l" as p&ssi$l!

• B!t!!n m!als an% thr&(h&t th! ni(ht, th! pan#r!ass!#r!t!s small am&nts &* inslin that ar! s#i!nt t&

sppr!ss lip&l"sis an% h!pati# (l#&s! &tpt /$asalinslin0.

• T& m!th&%s ha'! $!!n s!% t& a#hi!'! a similarpatt!rn &* inslin r!l!as!F /a0 inslin pmp th!rap"/pr!'i&sl" r!*!rr!% t& as V#&ntin&s s$#tan!&s

in*si&n &* inslin0 an% /$0 $asal-$&ls inslin r!(im!ns#&nsistin( &* &n#! t& ti#! %ail" %&s!s &* $asal inslin#&pl!% ith pr!-m!al %&s!s &* rapi% &r sh&rt-a#tin(inslin

Inslin Pmp Th!rap"


32/51

Inslin Pmp Th!rap"

• Th! s! &* an inslin pmp is #rr!ntl" th! m&st pr!#is! a" t& mimi#n&rmal inslin s!#r!ti&n.

• C&nsists &* a $att!r"-&p!rat!% pmp an% a #&mpt!r that #an pr&(ram

th! pmp t& %!li'!r pr!%!t!rmin!% am&nts &* r!(lar inslin, inslinlispr&, inslin aspart, &r inslin (llisin! *r&m a r!s!r'&ir t& as$#tan!&sl" ins!rt!% #ath!t!r &r n!!%l! /!.(., MiniM!% Para%i(m 2++,N&rthri%(!, CA Animas +3+30.87,73 Th!s! s"st!ms ar! p&rta$l! an%%!si(n!% t& %!li'!r 'ari&s $asal am&nts &* inslin &'!r +< h&rs as !llas m!al-r!lat!% $&ls!s. A $&ls &* r!(lar inslin #an $! r!l!as!% $" th!

pati!nt 63 mint!s $!*&r! *&&% in(!sti&n.• M&st pati!nts sin( an inslin pmp, h&!'!r, pr!*!r t& s! th! rapi%-

a#tin( inslin anal&(s in th!ir pmp. 1&r m!al #&'!ra(!, th! rapi%-a#tin(inslin #an $! (i'!n 3 t& 5> mint!s $!*&r! !atin(. Th! %!li'!r" &* th!$&ls #an $! a%st!% %!p!n%in( &n th! t"p! &* *&&% !at!n /!.(., pi!#! &*#a@! '!rss sli#! &* pia0.

• Th! pr!*!rr!% m!al plannin( appr&a#h *&r pati!nts sin( an inslin pmpis #ar$&h"%rat! #&ntin(.

• Th! Vinslin t& #ar$&h"%rat! rati& &r h& m#h #ar$&h"%rat! is #&'!r!%$" 5 nit &* inslin mst $! %!t!rmin!%. n! m!th&% is t& s! th! V>33Rl!. Th! nm$!r >33 /&r 3 *&r r!(lar inslin0 is %i'i%!% $" th! t&tal

%ail" %&s! &* inslin th! pati!nt is sin( t& %!t!rmin! th! inslin t&#ar$&h %rat! rati& s!! !sti&n 56 . Inslin m s ar! #a a$l! &*

Mltipl! Dail" In!#ti&ns


33/51

Mltipl! Dail" In!#ti&ns

*o+ can "nsul"n "n,ect"ons -e adm"n"stered to A.*. "n a +ay that m"m"cs the hys"olog"calrelease o# "nsul"n #rom the ancreas

• En%rin&l&(ists ha'! %!'!l&p!% a 'ari!t" &* inslin r!(im!ns that ar! int!n%!% t& mimi# th! r!l!as!&* inslin *r&m th! pan#r!as. A t&tal %ail" %&s! &* inslin is !stimat!% !mpiri#all" /!.(., 3.>

nit@(%a"0 &r a##&r%in( t& (i%!lin!s list!% in Ta$l! >3-55. Th! t&tal %ail" %&s! &* inslin th!n is splitint& s!'!ral %&s!s. In (!n!ral, th! $asal %&s! #&mpris!s appr&)imat!l" >3? &* th! t&tal %ail" %&s!.

• A r!(im!n m#h l!ss #&mm&nl" s!% in pati!nts ith t"p! 5 %ia$!t!s in'&l'!s in!#tin( a mi)tr! &*int!rm!%iat!-a#tin( an% r!(lar &r rapi%-a#tin( inslin ti#! %ail", $!*&r! $r!a@*ast an% $!*&r! %inn!r/1i(. >3-


34/51

Inslin Th!rap"

• Ph"si&l&(i# inslin r!pla#!m!ntF t&r!pli#at! n&rmal inslin s!#r!ti&n,#&mpris!F

Basal InslinF inslin a'aila$l!&'!rni(ht an% $!t!!n m!als t&sppr!ss h!pati# (l#&s! pr&%#ti&n

M!al-r!lat!% inslin/BLUS0F (i'!n !a#h m!al t& pr&m&t! (l#&s!tiliati&n a*t!r !atin(

6<


35/51

M!al-R!lat!% InslinR!pla#!m!nt

R!(lar InslinF• Ma" n!!% sna#@s t& pr!'!nt p&stpran%ial

h"p&(l"#!mia• L&n(!r DA as %&s! in#r!as!

• Sl&s #&rr!#ti&n &* h"p!r(l"#!mia• Cati&n p&stpran%ial !)!r#is!• C&ntri$t!s t& $asal inslin h!n tim! $!t!!n

m!al is l&n( Inslin Lispr&

• P&stpran%ial (l#&s! l!'!l impr&'!%• C&nsist!n#" &* a#ti&n as %&s! in#r!as!s• L!ss n!!% *&r sna#@s• L!ss h"p&(l"#!mia• G&&% *&r !)!r#is!= +h&rs a*t!r a m!al

6>


36/51

Basal Inslin R!pla#!m!nt

• Int!rm!%iat! a#tin( InslinsF NPH,L!nt!

• Ris@ &* h"p&(l"#!mia at tim! &* p!a@a#ti&n

• N&t tr! $asal inslin

• D&!s n&t pr&'i%! ar&n% th! #l@a#ti&n

• M&rnin( s! as pran%ial inslin *&rln#h #an $! a pr&$l!m

• Can $! i'!n $!%tim! &nl &r ti#!69


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Basal Inslin R!pla#!m!nt

• L&n( A#tin( InslinsF Glar(in!

• P!a@l!ss inslin Jat, sm&&tha#ti&n

• M&r! pr!%i#ta$l! a$s&rpti&n

• Can $! (i'!n &n#! at $!%tim! &rti#!

62


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Basal-B&ls /Ph"si&l&(i#al0 Inslin Th!rap"

&asal'&olus ($hysiological) Insulin "herapy* Indications andi


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$recautions$atient Selection Criteria

T"p! 5, &th!ris! h!alth" pati!nts /=2 "!ars &* a(!0 h& ar! hi(hl" m&ti'at!%an% #&mpliant in%i'i%als. Mst $! illin( t& t!st $l&&% (l#&s! #&n#!ntrati&nsmltipl! tim!s %ail" an% in!#t < %&s!s &* inslin %ail", &n a'!ra(!W&m!n ith %ia$!t!s h& plan t& #&n#!i'!

Pr!(nant pati!nts ith %ia$!t!s /pr!-!)istin(0

Pati!nts p&&rl" #&ntr&ll!% &n #&n'!nti&nal th!rap" /in#l%!s t"p! + pati!nts0

T!#hni#al a$ilit" t& t!st $l&&% (l#&s! #&n#!ntrati&ns

Int!ll!#tal a$ilit" t& int!rpr!t $l&&% (l#&s! #&n#!ntrati&ns an% a%st inslin

%&s!s appr&priat!l"A##!ss t& train!% an% s@ill!% m!%i#al sta t& %ir!#t tr!atm!nt pr&(ram an%pr&'i%! #l&s! sp!r'isi&nA+oid or Use Cautiously in $atients ,ho Are $redisposed to Se+ere-ypoglycemic Reactions or in ,hom Such Reactions Could be .atalPati!nts ith #&nt!r-r!(lat&r" ins#i!n#"

β-A%r!n!r(i# $l@!r th!rap"At&n&mi# ins#i!n#"A%r!nal &r pititar" ins#i!n#"Pati!nts ith #&r&nar" &r #!r!$ral 'as#lar %is!as!/NoteF C&nt!r-r!(lat&r" h&rm&n!s r!l!as!% in r!sp&ns! t& h"p&(l"#!miama" ha'! a%'!rs! !!#ts in th!s! in%i'i%als0

Unr!lia$l!, n&n#&mpliant in%i'i%als, in#l%in( th&s! h& a$s! al#&h&l &r%r s an% th&s! ith s #hiatri# %is&r%!rs


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PENETAPAN DSIS

INSULIN


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Estimatin( T&tal Dail" Inslin R!ir!m!nt

Tye 1 d"a-etes

Initial %&s! 3.643.> nit@(

H&n!"m&&n phas! 3.+43.> nit@(

With @!t&sis, %rin( illn!ss, %rin((r&th

5.345.> nits@(

Type diabetes

With inslin r!sistan#! 3.245.> nits@(

Estimating &asal Insulin Re/uirements

Basal r!ir!m!nts 'ar" thr&(h&t th! %a",appr&)imat!l" >3? &* t&tal%ail" inslin n!!%s. Th! $asal r!ir!m!nt als& is inJ!n#!% $" th!pr!s!n#! &* !n%&(!n&s inslin, th! %!(r!! &* inslin r!sistan#!, an% $&%"!i(ht.


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ESTIMATING INSULIN DSE/CNT0

• Estimating $remeal Insulin Re/uirements

• Th! V>33 rl! !stimat!s th! nm$!r &* (rams &*#ar$&h"%rat! that ill $! #&'!r!% $" 5 nit &* rapi%-a#tin(inslin. Th! rl! is m&%i!% t& th! V3 rl! i* sin(r!(lar inslin.>33t&tal %ail" %&s! &* inslin /TDD0 X nm$!r &* (rams#&'!r!%!"ampleF 1&r a pati!nt sin( >3 U%a", >33>3 X 53. Th!r!*&r!, 53 ( #ar$&h"%rat! &l% $! #&'!r!% $" 5 nit &*inslin lispr&, (llisin!, &r aspart. This !ati&n &r@s '!r"

!ll *&r t"p! 5 pati!nts in !stimatin( th!ir pr!m!al inslinr!ir!m!nts. B!#as! pati!nts ith t"p! + %ia$!t!s ha'!inslin r!sistan#!, th! rl! ma" n%!r!stimat! th!ir inslinr!ir!m!nts.


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ESTIMATING INSULIN DSE/CNT0

• etermining the 0Correction .actor1

• 1&r !)ampl!, i* th! pr!m!al &r $!%tim! $l&&% (l#&s! tar(!t is 5


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Gi%!lin!s *&r D&sin( Inslin• &asic Insulin ose

• A%st th! $asi# inslin %&s! /i.!., th! %&s! that th! pati!nt ill$! instr#t!% t& ta@! %ail"0. This assm!s that %i!t an% ph"si#ala#ti'it" ar! sta$l!. S!t a r!as&na$l! (&al initiall". This ma" m!anth! pp!r limits &* th! a##!pta$l! #&n#!ntrati&ns ma" $! hi(hinitiall" /!.(., :+33 m(%L0.

• M&'! t&ar% a m&r! i%!al (&al sl&l".

• nl" a%st inslin %&s!s i* a pattern &* r!sp&ns! is &$s!r'!%n%!r sta$l! %i!t an% !)!r#is! #ir#mstan#!s. That is, th! sam!r!sp&ns! t& inslin is &$s!r'!% *&r 6 %a"s.

• Unl!ss all l!'!ls ar! =+33 m(%L, tr" t& a%st &n! #&mp&n!nt &*inslin th!rap" at a tim!. Start ith th! inslin #&mp&n!nt

a!#tin( th! *astin( $l&&% (l#&s! #&n#!ntrati&n.• A%st th! $asi# inslin %&s! $" 54+ nits at a tim!. Th! am&nt

pr!s#ri$!% is $as!% &n th! in%i'i%al pati!nts r!sp&ns! t& inslin. This #an $! %!t!rmin!% $" l&&@in( at th! pati!nts t&tal %ail"%&s! sin( th! V>33 rl! /s!! th! *&ll&in(, an% Ta$l! >3-550.


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Gi%!lin!s *&r D&sin( Inslin/CNT0

• Supplementary Insulin oses

• n#! th! $asi# %&s! &* inslin has $!!n !sta$lish!%, sppl!m!ntal%&s!s &* rapi%- &r sh&rt-a#tin( inslin #an $! pr!s#ri$!% t& #&rr!#t

preprandial h"p!r(l"#!mia. 1&r !)ampl!, i* th! (&al is 5


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Gi%!lin!s *&r D&sin( Inslin /CNT0

• Anticipatory Insulin oses Th!$asi# inslin %&s! is in#r!as!% &r%!#r!as!% $as!% &n th! anti#ipat!%

!!#ts &* %i!t &r ph"si#al a#ti'it".In#r!as! lispr&aspart(llisin! &rr!(lar inslin $" 5 nit *&r !a#h

a%%iti&nal 5> ( &* #ar$&h"%rat!in(!st!% /!.(., h&li%a" m!al0 &r%!#r!as! th! sal %&s! $" 54+ nits

i* th! m!al is small!r than sal-


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ass 5

• Tn HM >8th 593#m 8>@(, MRS @ar!naa@an m!nalani &ps @atara@. Pa%asaat MRS hasil p!m!ri@saan (la

pasa +59m(%l, GD +amPP+6


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ass +

• Tn Y, 6m(%l +PP 65>m(%l. Pasi!n m!n(a@ m!mili@iria"at DM s%ah lima tahnan

%!n(an &$at Gli$!n@lami%! 5-5-3%an m!t*&rmin 6)>33m(.

• Ba(aimana Pharm #ar! nt@ @ass

iniZ


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ass 6

• Tn >7th, 52+#m 2>@(, MRS %!n(an@!lhan @!n#in( ti%a@ lan#ar, %is!rtairasa panas %an n"!ri pa%a saat

@!n#in(. Pasi!n m!n(a@ m!mili@iDM s%ah 8tahn %an masih minmGli@lai%! 5-5-3 %an M!t*&rmin 6 )

8>3m(. Hasil la$F 1PG +9>m(%l +QPP598m(%l L!@&sit /N0,L!@&sria/0. Hasil &$s!r'asi TTK

TD 5


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ass <

• Tn N


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ass >

• Tn P 9+th, 595#m, >7@( MRS%!n(an %ia(n&sa str&@! in*ar@ %ih!misph!r! @anan "an( las. Hasil

La$ GDP 5>

insulin use

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