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Pharmacy Practice II > Diabetes: Insulin Therapy > Flashcards

Diabetes: Insulin Therapy Flashcards

1
Q

Pharmacologic Therapy: Treatment Options

A

• Type 1 diabetes

  • Insulin
  • Symlin (pramlintide): Rx only
• Type 2 diabetes
- Oral agents: Rx only
• Sulfonylureas
• Non-Sulfonylurea Secretagogues
• Biguanide
• Thiazolidinediones
• Alpha-glucosidase inhibitors
• DPP-4 Inhibitors
• SGLT-2 Inhibitors
  • Injectables: Insulin, Pramlintide (Rx only), Exenatide, dulaglutine, semaglutide (Rx only)
  • Inhaled: Insulin
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2
Q

Actions of Insulin

A

STOP: gluconeogenesis, glucogenolysis, lipolysis, ketogenesis, proteolysis

GO: glucose uptake in muscle/ad tissue, glycolysis, glycogen synthesis, protein synthesis, uptake of ions

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3
Q

Insulin Appearance

A

• Rapid-Acting: Clear / Colorless
- Lispro, Aspart, Glulisine

• Short-Acting: Clear / Colorless
- Regular

• Long-Acting: Clear / Colorless
- Glargine, Detemir, Degludec

• Intermediate-Acting: Cloudy / White
- NPH

• Combinations: Cloudy / White
- Regular, Novolog, Humalog

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4
Q

Rapid-Acting Insulin: Ex, DF, Pros, Cons

A

• Examples

  • Insulin lispro (Humalog®, Admelog®)
  • Insulin aspart (Novolog®, Fiasp®)
  • Insulin glulisine (Apidra®)
  • Rx ONLY, vials and pens
  • Produced through recombinant DNA technology
  • Typical dosing frequency: BID-QID, 15 minutes before a meal

• Pros

  • Closely mimics endogenous postprandial insulin
  • Works very fast
  • More flexibility with mealtimes
  • Improves postprandial hyperglycemia
  • Usually less hypoglycemia than regular insulin

• Cons

  • Caution with CHO intake (if < than expected = hypoglycemia)
  • Cost, insurance coverage, MDI
  • RX only
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5
Q

Short-Acting Insulin: Ex, DF, Pros, Cons

A

• Example

  • Regular insulin (Humulin® R or Novolin® R)
  • Clear & colorless

• Typical dosing frequency
- BID-QID, 30 minutes before meal

• Pros

  • Relatively inexpensive
  • Available OTC
  • May be given IV as well

• Cons

  • Takes longer to work & may cause delayed hypoglycemia
  • Less flexibility with mealtimes
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6
Q

Intermediate-Acting Insulin: Ex, DF, Pros, Cons

A

• Examples
- NPH (Humulin® N, Novolin® N) (Protamine suspension slows dissolution & absorption from the injection site) (Insulin of choice for mixing)

  • Typical dosing frequency: Daily (at bedtime) or BID
  • Pros
  • Provides basal insulin coverage
  • Relatively inexpensive
  • Available OTC

• Cons

  • Protamine & zinc may cause immunologic reactions such as urticaria at the injection site
  • Action may be unpredictable leading to hypoglycemia
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7
Q

Insulin Glargine (Lantus®, Basaglar®): Type, DF, Pros, Cons

A

Long acting insulin
• Insulin analog, 28 days stable at RT

• Typical dosing frequency:

  • Insulin glargine: QD
  • Must only inject in subcutaneous tissue (not IM or IV)

• Pros

  • Glargine provides more predictable, steady, long acting, “peakless” basal insulin for about 24 hours.
  • Decrease nocturnal hypoglycemia and less weight gain compared with NPH

• Cons

  • Cost
  • Injection site stinging, cannot be mixed
  • pH=4 for stability
  • RX Only
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8
Q

Insulin glargine-yfgn (Semglee®)

A

Long-acting insulin

  • New interchangeable biosimilar
  • Think generic (but not really)
  • Biosimilar to Lantus only
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9
Q

What Is an Interchangeable Biosimilar Product?

A

An interchangeable product is a biosimilar that may be substituted for a reference product without the intervention of the prescribing healthcare provider, depending on state pharmacy laws.

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10
Q

Insulin Glargine: Mechanism of Action

A
  • Injection of an acidic solution (pH 4.0)
  • Precipitation of glargine in subcutaneous tissue (pH 7.4)
  • Slow dissolution of free glargine hexamers from precipitated glargine (stabilized aggregates)
  • Protracted action
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11
Q

Insulin Detemir (Levemir®): Type, DF, Pros, Cons

A

Long-acting insulin

• Insulin analog, 42 days stable at RT
• Typical dosing frequency:
- Insulin detemir: QD-BID
- Must only inject in subcutaneous tissue (not IM or IV)

• Pros

  • Detemir provides more predictable, steady, long acting, “peakless” basal insulin for about 24 hours at higher doses
  • Does not cause stinging (neutral pH)
  • Decrease nocturnal hypoglycemia and less weight gain compared with NPH

• Cons

  • Cost
  • RX Only
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12
Q

Insulin Degludec (Tresiba®): Type, DF, Pros, Cons

A 
Long-acting insulin
• Ultra-long-acting insulin
• Available as U-100 and U-200
• Insulin analog, 8 weeks stable at RT
• Typical dosing frequency: Once Daily

• Pros

  • Predictable, steady, long acting, “peakless” basal insulin for 42 hours.
  • Does not cause stinging (neutral pH)

• Cons

  • Cost
  • RX Only
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13
Q

Concentrated Insulins

A
  • Humalog® (lispro) U-200
  • Tresiba® (degludec) U-200
  • Toujeo® (glargine) U-300
  • Available in insulin pens
  • Similar PK to U-100

• Regular U-500
- Vial and pen

  • Pros: Less volume for injection
  • Cons: Cost
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14
Q

Inhaled Insulin

A

• Examples

  • Insulin (Afrezza®) inhalation powder
  • Produced through recombinant DNA technology
  • Typical dosing frequency: BID-QID, 5 minutes before or during a meal
  • Pros
  • Closely mimics endogenous postprandial insulin
  • Works very fast (peak in 15 minutes)
  • More flexibility with mealtimes
  • Improves postprandial hyperglycemia
  • Less hypoglycemia than rapid insulin
  • Less weight gain

• Cons

  • Multiple inhalations for large doses
  • Cost, insurance coverage
  • RX only
  • Lung disease
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15
Q

Afrezza Inhaled Insulin

A

• Afrezza is available as cartridges with
- 4 units of insulin
- 8 units of insulin
• Must use with an inhalation device called a Dreamboat
• The cartridges and inhaler should be kept at room temperature for 10 minutes prior to use
- Storage in refrigerator is recommended

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16
Q

Valeritas V-Go® (basal + bolus)

A
  • 24-hour disposable wearable delivery device
  • Holds 56, 66, or 76 units*
  • 2.4”x1.3”x0.5”
  • Offers 3 continuous preset basal rates totaling 20, 30, & 40 u/day and on-demand bolus dosing in 2 unit increments (up to 36 u/day)
17
Q

Insulin Mixtures

A

Novolin R, Humulin R 70/30 or 50/50

  • 70% NPH (50%)
  • 30% Regular (50%)

Humalog R Mix 75/25

  • 75% insulin lispro protamine
  • 25% insulin lispro

Novolog R Mix 70/30

  • 70% insulin aspart protamine
  • 30% insulin aspart

Ryzodeg R 70/30

  • 70% insulin degludec
  • 30% insulin aspart
18
Q

Initiating Insulin Therapy in Type 1 Diabetes

A 
• Initially start total daily insulin at approximately 0.2-0.5 units/kg/day
• Divide 1⁄2 daily dose as basal and 1⁄2 daily dose as bolus
• Basal
- NPH
- Insulin glargine or insulin detemir 
• Bolus
- Regular insulin
- Rapid acting analogs
• Doses vary up to 1 Unit/kg/day
19
Q

Initiating Insulin Therapy in Type 2 Diabetes

A 
• Add single dose of basal insulin
- Glargine, detemir, or NPH
- Usually administered at bedtime
• Use conservative starting dose
• 10 units (empiric)
• 0.1 to 0.2 units/kg
• 0.3 to 0.4 units/kg if severe hyperglycemia
• Usually in combination with oral agent(s) plus lifestyle changes
20
Q

Converting Insulins

A

• 1:1 ratio for the following insulins

  • Glargine, detemir, and degludec
  • Regular, lispro, aspart, and glulisine
  • U-100, U-200, and U-300
21
Q

Converting from NPH

A

• If a patient is already on NPH and you want to switch to a long acting analog:

  • Add up the total daily dose of NPH
  • Decrease dose by 20%
  • This is your daily dose of long acting insulin
22
Q

Intensive Insulin Regimens

A

• Goal = mimic insulin secretion of the functioning pancreas
- Basal insulin with or without insulin bolus to accommodate meals
• Individualized dosing plans
• Increased SMBG is a must
• Risks
- weight gain & hypoglycemia
• Benefits
- improved glycemic control
- delays worsening or progression of diabetes complications

23
Q

Insulin Preparations

A
  • U-100 = 100 units per 1 mL
  • U-200 = 200 units per 1 mL
  • U-300 = 300 units per 1 mL
  • U-500 = 500 units per 1 mL
  • 1 vial = 10 mL
  • # units per vial: _____
  • 1 pen = 3 mL
  • # units per pen: _____
  • Caution for travelers: Not always available worldwide
  • All have pH of 7.4 except insulin glargine has pH of 4
24
Q

Peak and Duration of Insulins

A
  • Lispro/Aspart/Glulisine:
    Peak 30min-2hr, Duration 3-5 hr
  • Regular:
    Peak 2-4hr, Duration 4-8 hr
  • NPH:
    Peak 4-10hr, Duration 10-18
  • Detemir: 6-24 hr
  • Degludec: 42 hr
  • Glargine: 20-26
25
Q

Degludec: MOA

A
  • Insulin injected
  • Phenol from the vehicle diffuses quickly and degludec links up via single side chain contacts
  • Long multi-hexamer chains assemble

Pharmacy Practice II (25 decks)

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