INSULIN

M. Alif Rio Yudhatama

30101206675
Fk unissula
Who could benefit from insulin
therapy?
People with Type 1 diabetes are dependent on insulin
People with Type 2 diabetes
who have inadequate blood glucose control on optimised oral
hypoglycaemic agents (NICE, 2003).
with contraindications to oral hypoglycaemic agents.
who have recurrent symptoms of hyperglycaemia or unexplained
weight loss.
who are considering pregnancy.
who are pregnant.
who are post acute MI.
who have acute illness or recurrent infection.
who have foot ulceration and/or infection.
Insulin treatment attempts to mimic
the pattern of normal insulin secretion
Short-lived, rapidly
generated meal-related
70 insulin peaks

60
Insulin (U/ml)

50

40
Low, steady, basal
30
insulin profile
20

10

0
6:00 10:00 14:00 18:00 22:00 2:00 6:00
Time of day

Polonsky KS et al. J Clin Invest 1988;81:4428

Types of insulin
Animal insulin (Used since 1922)
Short acting
Intermediate acting
Mixture of short and intermediate acting (biphasic)
Human insulin (Since 1982)
Short acting
Intermediate acting
Mixture of short and intermediate acting (biphasic)
Analogue insulin (Since 1996)
Rapid acting
Long acting (basal insulin)
Mixture of rapid and intermediate acting (biphasic)
What are analogue insulins?
-chain
Analogue Gly

(or modern) s
s
insulins are -chain
Ala
Cys

formed by
Phe
Thr

s s Pro
Lys

modifying human s
s
insulin molecules
Insulin
Like soluble human
-chain lispro
insulin, analogue Gly

insulins are s
s
produced by -chain
Ala
Cys

recombinant DNA
Phe
Thr

s s Asp
Pro
Lys

technology s
s
Insulin
aspart
Hirsch IB. N Engl J Med 2005;352:17483
Human insulins
Short-acting Absorbed quickly and last for several hours
e.g., Humulin S, Insuman Rapid

Intermediate- More slowly absorbed, last for up to 24

and long- hours
acting e.g., Insulatard, Humulin I, Insuman Basal

Premixed Mixture of short- and long-acting insulin

(biphasic human insulin)
e.g.,Humulin M3, Insuman Comb

Humulin S and Humulin I are registered trademarks of Eli Lilly and Company
Insuman Rapid, Insuman Basal, and Insuman Comb are registered trademarks of Sanofi-Aventis
Insulatard and Mixtard 30 are registered trademarks of Novo Nordisk
ANALOGUE INSULINS
Rapid-acting Absorbed very rapidly, last only a few hours
Aim to control postprandial glucose

e.g., NovoRapid, Humalog, Apidra

Long-acting More slowly absorbed

Designed to provide a low level of insulin throughout
day and night
e.g., Levemir, Lantus

Premixed Mixture of rapid- and intermediate-acting insulin

e.g., NovoMix 30, Humalog Mix 25/75

Humalog is a registered trademark of Eli Lilly and Company

Lantus and Apidra are registered trademarks of Sanofi-Aventis
NovoRapid, NovoMix and Levemir are registered trademarks of Novo Nordisk
 Insulin Regimens
There are a variety of insulin regimens tailored to meet
the individual needs of people with diabetes.

The goal is to have an insulin release profile most

similar to a physiological state.

The treatment option chosen should reflect:

Type of diabetes
Persons lifestyle, age and ability to self-test blood
glucose
Presence of obesity
Choice
Types of insulin regimens
Once-daily/twice-daily intermediate- or
long-acting (basal) insulin
Once-/twice-/three-times daily premixed
insulin
Basalbolus therapy
Mealtime rapid-acting insulin
Insulin with or without oral
agents?
The majority of insulins are licensed with oral
drugs
Metformin should be continued wherever
possible
Sulphonylureas can be used with insulin
In February 2007, pioglitazone was indicated
for use with insulin in the UK
Sitagliptin is the only gliptin at present that
can be used with insulin

NICE http://www.nice.org.uk/nicemedia/pdf/NICE_full_blood_glucose.pdf
Royal College of Nursing.
http://www.rcn.org.uk/__data/assets/pdf_file/0009/78606/002254.pdf
 Once-daily basal insulin
Exact duration depends on the insulin
Insulin analogues may provide 24-hour cover
Intermediate human insulin preparations may only be active
for ~8 hours and have a more pronounced peak activity

basal human insulin

Insulin action

basal analogue
insulin

Insulin injection

Time

Schematic representation
Benefits of a once-daily
basal insulin regimen
Requires only one injection per day
May help overcome resistance to starting
insulin injections
Particularly useful when patients blood
glucose is high overnight and in the morning
Useful for patients who require someone else
(e.g., a district nurse) to administer their
insulin
May be associated with fewer side effects
than other regimens1

1. Holman RR et al. N Engl J Med 2007;357:1716-30

Royal College of Nursing.
http://www.rcn.org.uk/__data/assets/pdf_file/0009/78606/002254.pdf
 Premixed insulin
once, twice or three-times
daily
Premixed human insulin Premixed analogue insulin
Premixed Premixed
injection injection Contains:
Basal component
Short-acting component
Insulin action

Possible regimens:
Once daily with largest
daily meal (usually dinner)
Twice daily with dinner
and breakfast (figure)
Three-times daily, with
each meal

Breakfast Lunch Dinner

Schematic representation of twice-daily injections

Benefits of a premixed
insulin regimen
Targets mealtime glucose
Suited to people with fairly regular lifestyles,
who eat similar amounts at similar times
each day
Can be initiated as one injection per day to
familiarise patient with injecting*
Second or third injections of same insulin in same
device can be added if necessary to optimise
control1

1. Garber AJ et al. Diabetes Obes Metab 2006;8:5866

*although most patients are started on twice-daily premixed regimens
Basalbolus therapy
Rapid-acting human insulin Rapid-acting analogue insulin
Long-acting human insulin Long-acting analogue insulin

Rapid Rapid Rapid Long

insulin insulin insulin insulin
Insulin action

Breakfast Lunch Dinner Bedtime

Schematic representation of four injections per day

(one long acting, three rapid acting)
Benefits of a basalbolus
insulin regimen
This regimen produces an insulin profile
that is closest to natural insulin
production by the body
Offers greater flexibility over type of
food and when it can be eaten
Suited to those who are highly
motivated
Insulin practicalities
Timing
Soluble insulin: 30-45 minutes pre-meal
Short-acting insulin analogues: no more
than 15 minutes pre-meal and can be given
post-meal
Intermediate- or long-acting insulins do not
have to be given in relation to a meal
Insulin practicalities
Storage
One month in fridge or at room temperature
once the vial has been opened
Must never be frozen
Store away from source of heat
If refrigeration not available Frio bags
available
May be damaged by direct sunlight or
vigorous shaking
Injection Technique

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Injection Technique

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Injection Technique

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Injection Technique

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Injection Technique

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Injection Technique
Injection Technique

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 Sharps Disposal

Needles from syringes, pen devices and

lancets are classified as group B clinical
waste.

Sharps bins and safe clips are available on

prescription.

Disposal of sharps bin varies depending on

local policy.