INSULIN MANAGEMENT Kelly FOR INDIVIDUALS WITH Washburn, AGNP-C DIABETES
DISCLOSURES 2018 This speaker has no financial or other conflicts of interest to report.
OBJECTIVES Identify the commercially available insulin preparations in the United States. Review the onset, peak, and duration of the most commonly used insulin preparations. Describe the steps for insulin initiation and titration. Identify commonly overlooked areas of assessment regarding insulin management and administration. Review prescribing and safety pearls.
TYPE 2 DIABETES DX Fast asting HbA1 A1c Normal <100 mg/dL <5.7% Pre-Diabetes 100-125 mg/dL 5.7-6.4% Diabetes >/ 126 mg/dL >/ 6.5% Other Forms of Diabetes • Type 1 DM • MODY • LADA • Gestational • Etc.
YEARS OF INSULIN FDA APPROVAL 2017 2001: Admelog (insulin lispro) Novolog (insulin aspart) Fiasp (insulin aspart) Novolog 70/30 (70% insulin aspart protamine + 30% insulin aspart) 2015 Basaglar (insulin glargine) 2000: Tresiba (insulin degludec) Lantus (insulin glargine) Ryzodeg (insulin degludec/insulin aspart) Toujeo (insulin glargine) 1982-1999: Humalog 75/25 (75% insulin lispro 2014 protamine + 25% insulin lispro) Afrezza (inhaled insulin) Humalog (insulin lispro) Humalog 50/50 (50% insulin lispro 2005: protamine + 50% (insulin lispro) Levemir (insulin detemir) Novolin 70/30 (70% NPH + 30% regular) Novolin R (regular) 2004: Novolin N (NPH) Apidra (insulin glulisine) Humulin 70/30 (70% NPH + 30% regular) Humulin N (NPH) Humulin R (regular) Humulin R 500 (regular 5x concentration)
INSULIN ACTIONS RAPID ID-AC ACTING LONG-AC ACTING Afrezza Basaglar* Apidra Levemir Humalog Lantus* Novolog Tresiba Admelog Toujeo* Fiasp INS NSULIN C N COMBI BINATIONS NS Humalog Mix 75/25, 50/50 SHORT RT-AC ACTING Humulin 70/30 Humulin R Novolin 70/30 Novolin R Novolog Mix 70/30 Ryzodeg 70/30 INTER ERMED EDIATE-AC ACTING COMBIN INATIO ION P PRODUCTS W WIT ITH G GLP-1 1 ANALO LOGS Humulin N Soliqua (insulin glargine + lixisenatide) Novolin N Xultophy (insulin degludec + liraglutide)
Types of Insulin and Chart. (n.d.). Retrieved November 1, 2017, from http://www.ada-diabetes-management.com/types-of-insulin-chart/
ACTIVITY PROFILES OF DIFFERENT TYPES OF INSULIN Types of Insulin. (n.d.). Retrieved November 1, 2017, from https://dtc.ucsf.edu/types-of-diabetes/type2/treatment-of-type-2- diabetes/medications-and-therapies/type-2-insulin-rx/types-of-insulin/
https://www.uptodate.com/contents/image?imageKey=PC%2F78710&topicKey=ENDO%2F1752&source=outline_link nsulin administration locations&selectedTitle=1~150
A1C & ESTIMATED AVERAGE GLUCOSE HbA1 A1c Mean Me an P Plas asma Glu lucose ( (mg/ g/dL dL) 6% 126 7% 154 8% 183 9% 212 10% 240 11% 269 12% 298 GLYCEMIC TARGETS FRUCTOSAMINE (average of 2-3 weeks) Fast asting 80 80-130 30 2hr post <180 A1c = 0.017 x fructosamine +1.61 prandial
INSULIN INITIATION Type 2 2 DM B Basal I Insulin 0.2U/kg at bedtime Highly variable in patients with T2DM. When starting with significant hyperglycemia, consider starting with 0.5U/kg. Type 1 1 DM I Insulin Calculate TDD (0.4-1.0U/kg) Basal = 50% of TDD Bolus = 50% of TDD / 3 (for each meal) *For renal failure, decrease TDD by as much as 0.2U/kg due to decreased renal breakdown of insulin.*
INSULIN TITRATION GLARGINE TITRATION Average FBG since last dose change >/ >/ 180 80 Ad Add 8U 8U 140-180 Add 6U 120-140 Add 4U 100-120 Add 2U DETEMIR TITRATION Average FBG since last dose change Belo low t targe get Subtr tract 3U 3U At target No change Above target Add 3U
FINE-TUNING RAPID ACTING INSULIN Ad Adjusting M Meal-Time B Bol oluses F For or Break akfas ast/Lunch: <80 <80 Subtract 2 2U from mealt ltime d dose 80-130 No adjustment >130 Add 2U to mealtime dose Adjusting M Ad Meal-Ti Time B Boluses f for D Dinner: <1 <125 25 Subtr tract 2U from mealt ltime d dose 125-150 No adjustment >150 Add 2U to mealtime dose
INSULIN SENSITIVITY WITH CORRECTIONS AND INSULIN:CARB RATIOS Insulin to Car arb R Rati atio ( (I:C) 450/TDD This value means that 1U of insulin covers __g of carbs. (e.g. TDD = 35U. 450/35 = 12.86g. 1U of insulin covers 13g of carb, which is also written as 1:13. So if a pt is eating a meal with 40g of carb (40/13 = 3.08), they would administer 3U of insulin pre-meal) INSULIN S SENSITIVI VITY F Factor ( (ISF) 1700/TDD This value means that 1U of insulin will drop BG by __mg/dL of glucose. (e.g. TDD = 35U. 1700/35 = 48.57. 1U of insulin will drop BG by about 49mg/dL.) CORRECTIONS ( current BG - target BG)/ISF e.g. current BG 162, target BG 100, TDD 35U ISF = 49mg/dL 162-100 = 62/49 = 1.3 This value means that you would add 1.3U of insulin to a pre-meal bolus to correct for hyperglycemia. Can also be used for corrections between meals. Just ensure that bolus injections are separated by about 3hrs to avoid stacking.
COMMONLY OVERLOOKED AREAS OF INSULIN ADMINISTRATION Insulin storage Refrigeration vs room temp Insulin administration Location Rotation Wait 5-10seconds after depression of plunger Examine injection sites each visit Needle Reuse/Disposal Ask! Risk for bent needle and residual needle fragments leading to lipodystrophy Review sharps disposal
COMMONLY OVERLOOKED AREAS OF INSULIN MANAGEMENT: SPECIAL POPULATIONS Elde derly ly AVOID LOWS Especially avoid lows in individuals who no longer perceive mild hypoglycemia and overnight Monitor kidney functioning Consider long-term goals Rule of thumb: multiply age by 0.1 to obtain A1c goal. Consider dexterity for self-administration Mentally Ill (e.g. schizophrenia) Do not continue increasing dose if A1c does not align with insulin dosing Consider BID mixed insulin Consider visiting nursing
PRESCRIBING AND SAFETY PEARLS *Methods t s to Min inim imiz ize Pa Pain inful I l Inje jectio ions ns Inject insulin at room temp. Ensure no air bubbles in the syringe before injection. Wait until topical alcohol (if used) has evaporated completely before injection. Keep muscles in the injection area relaxed when injecting. Penetrate the skin quickly. Avoid changing direction of the needle during insertion or withdrawal. Do not reuse needles. *If injection 30U/day, 1 vial will last about 30 days. *Test strips come in bottles of 50. *Lancets come in boxes of 100. *Remember to prescribe Glucagon kits, Ketone strips, and Glucose Tabs for all individuals prescribed insulin.
REFERENCES Commissioner, O. O. (2017, October 30). Diabetes - FDA-Approved Diabetes Medicines. Retrieved November 1, 2017, from https://www.fda.gov/ForPatients/Illness/Diabetes/ucm408682.htm Diabetic Injection Sites. (n.d.). Retrieved November 1, 2017, from https://www.uptodate.com/contents/image?imageKey=PC%2F78710&topicKey=ENDO%2F175 2&source=outline_link&search=insulin administration locations&selectedTitle=1~150 Insulin Administration. (2003, January 01). Retrieved November 1, 2017, from http://care.diabetesjournals.org/content/26/suppl_1/s121 T. C., MD. (n.d.). Insulin chart. Retrieved November 1, 2017, from http://www.straighthealthcare.com/insulin-chart.html Inzucchi, S. E., MD. (2011). Diabetes Facts and Guidelines. Retrieved November 1, 2017, from https://medicine.yale.edu/intmed/drc/diabetescenter/living/50135_Yale%20National%20F_ 102165_1095_13584_v1.pdf Starting Mealtime Insulin. (n.d.). Retrieved November 1, 2017, from http://www.accurateinsulin.org/starting-mealtime-insulin/ Types of Insulin. (n.d.). Retrieved November 1, 2017, from https://dtc.ucsf.edu/types-of- diabetes/type2/treatment-of-type-2-diabetes/medications-and-therapies/type-2-insulin- rx/types-of-insulin/ Types of Insulin and Chart. (n.d.). Retrieved November 1, 2017, from http://www.ada- diabetes-management.com/types-of-insulin-chart/
Thank you for your time and dedication to your patients. Kelly Washburn, MSN, AGNP-C KellyWashburnNP@gmail.com
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