INSULIN

THERAPY
Olagunju Timilehin

OUTLINE

Introduction

Types

of insulin Indications for insulin therapy Principles of insulin therapy Complications Monitoring glycaemic control

INTODUCTION
The

beta islet cells of the pancreas produce insulin Insulin is an anabolic hormone that functions primarily in facilitating glucose uptake by cells It has effects on the: liver, skeletal muscles and fat cells

METABOLIC ACTIONS OF INSULIN

Increase (anabolic) Decrease

Carbohydrate metabolism gluconeogenesis Glucose transport Glycogenesis glycolysis glycogenolysis

METABOLIC ACTION OF INSULIN

Insulin increase(anabolic) Lipid metabolism Insulin decrease

Triglyceride synthesis
Fatty acid synthesis Protein metabolism Protein synthesis

lipolysis
ketogenesis

Protein degradation

INDICATIONS FOR INSULIN THERAPY

Type

1 diabetes mellitus Pregnant or breastfeeding diabetic women Special conditions in type 2 DM (transient use): surgery, infection, stressful conditions) Inadequate control in type 2 DM on oral antidiabetic drugs Diabetic emergencies: DKA, HONK

TYPES OF INSULIN
Based

on the source:Porcine (pigs),bovine (sheep), recombinant DNA insulin (humans) Based on the duration of action:rapid acting, short acting, intermediate acting, long acting. Based on route of administration: injectable or inhaled.

Type Rapid: lispro

Onsethrs <1/4 -1 1 -2 1-3

Peak-hrs Durationhrs - 21/2 2-4 6 - 12 6 - 12 8 - 20 31/2 41/2 6-8 18 - 24 18 24 24 or more

aspart
Short:soluble regular
Intermediate:NP H

lente Long-acting: ultralente glargine

4-6

3-4

3 - 24

>24 or more

EXAMPLES OF INJECTABLE INSULIN

Rapid acting insulin: lispro and aspart, very fast onset of action, more rapidly removed from circulation. Short-acting insulin: regular/soluble, suitable for multiple dose regimen, for intravenous infusion in labour and during diabetic emergencies. disadv: enters circ too slowly and effect persists long after meal, predisposing to hypoglycaemia.

 Intermediate

acting insulin: NPH(neutral protamine hagedorn) and lente. Protamine/zinc is added to human/aml insulin to aid formation of insulin crystals which dissolve slowly. They are premixed with soluble insulin to form stable mixtures 30%soluble+70%NPH

 Long-acting

insulin: ultralente, glargine, determir. Insulin glargine: decreased solubility at physiologic pH which prolongs its action.

MODES OF ADMINISTRATION
Syringes: plastic, pen Infusion pumps (CSII) continous subcutaneous insulin injection. Adv: basal overnight infusion can be programmed to fit each patients need Disadv: nuisance of being attached to a pump, skin infection, risk of ketoacidosis if insulin flow is broken. Inhalation: only short acting insulin can be given via this route. only 10% of administered insulin reaches the circulation.

PRINCIPLES OF INSULIN THERAPY

Normal: there is a baseline insulin secretion and insulin secretion due to a raised plasma glucose level Insulin therapy is aimed at mimicking this. Total dose of insulin require per day: 0.5 1.0/kg/day Common regimen used: twice daily injection of an intermediate and shortacting insulin before breakfast and after dinner.

 2/3 AM:

2/3 of intermediate acting

insulin
1/3 of short acting insulin 1/3AM: 2/3 of intermediate acting insulin 1/3 of short acting insulin

PRINCIPLES OF INSULIN THERAPY

Insulin

injection: Use a sharp needle Inject subcutaneously Children and young adults- 31G, 6mm Older adults- 30G, 8mm Insert needle to its full length Sites: abdomen> arm> thigh Change site of insulin regularly

COMPLICATIONS

Hypoglycaemia: commonest Symptoms develop - <3mmol/L Prominent autonomic symptoms Severe hypoglycaemia-neurologic symptom Nocturnal hypoglycaemia At injection site: painful, erythematous lesion (intradermal injection), scarring, lipoatrophy, lipohypertrophy, allergic skin reaction, injection abscess Insulin resistance