dm fundamentals –class 3 insulin and pattern management

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DM Fundamentals – Class 3Insulin and Pattern Management

Beverly Thomassian, RN, MPH, BC‐ADM, CDEPresident, Diabetes Education Services

2017

Insulin – Ultimate Hormone Replacement Therapy – Class 3

Incorporating National Guidelines into practice

Using basal/bolus insulin therapy to improve glucose control from hospital to home

Glucose patterns and adjustment strategies

Insulin – the Ultimate Hormone Replacement Therapy

Objectives: •Discuss the actions of different insulins•Describe using pattern management as an insulin adjustment tool.


Poll question 1. A patient tells you she doesn't want to start on insulin. What is your best response?a. The needles are so small, you won't feel a thing.

b. You might die if you don't take insulin.

c. Tell me why.

d. There is a doctors' order to start insulin.

Psychological Insulin Resistance (PIR)

50% of providers in study threatened pts “with the needle”.

Less than 50% of providers realized insulins’ positive effect on type 2 dm

Most pts don’t believe that insulin would “better help them manage their diabetes”.

Solutions: Find the root of PIR and address it, use more insulin pens

Diabetes Attitudes, Wishes, Needs Study ‐ Rubin

Needle Size often a BarrierSize DoesMatter

Use more short needles – 4 mm

Effective for pts with BMI of 24‐ 49

Keeps it subq

If pt thin, inject at angle

To avoid leakage, count to 10 before withdrawing needle

½ the patients who could benefit from insulin are not using it due to needle phobias


Poll question 2. What best describes the role of bolus insulins?

a. cover carbs at meals and hyperglycemia

b. helps to lower fasting blood glucose

c. keeps overnight blood sugars under control

d. should be used during hypoglycemic episodes

Insulin(µU/mL)

Glucose(mg/dL)

Physiologic Insulin Secretion: 24‐Hour Profile

150

100

50

07 8 9 10 11 12 1 2 3 4 5 6 7 8 9

A.M. P.M.

Basal Glucose

Time of Day

50

25

0 Basal Insulin

Breakfast Lunch Dinner

Bolus Insulin

Mealtime Glucose

Insulin Action Teams Bolus: lowers after meal glucose levels Rapid Acting Aspart, Lispro, Glulisine, Afrezza

Short Acting Regular

Basal: controls glucose between meals, hs Intermediate NPH

Long Acting Detemir (Levemir) Glargine (Lantus, Basaglar) Degludec (Tresiba)


Bolus Insulins(½ of total daily dose ÷ meals)

Name Onset Peak Action

Lispro (Humalog) 15‐30 min 1‐1.5 hrs

Aspart (NovoLog)

Glulisine (Apidra)

Afrezza (Inhaled)

Regular 30 mins 2‐4 hrs

Poll question

3. Which insulins are cheapest?a. Lantus, Levemir

b. Novolog, Humalog

c. Reg, NPH

d. Insulin pens

Cost Per Vial in Northern CA


Afrezza – Inhaled Insulin –Approved 2014 – Type 1 or 2

Only studied in adults over 18Not indicated for pregnancy, while breastfeeding

Steps, Cost, Terms Afrezza is regular human insulin in powder form using Technospheretechnology.

Pricing –similar pricing as pens ~ $300 a month

Referred to as TI in papers –“Technosphere Insulin”

Afrezza Dosing and Considerations Bolus regular insulin – inhaled before meals

Dosing: 4, 8 and 12 unit cartridges Convert with 1:1 ratio to existing insulin dose

Lung function test before start (FEV1) Not for pts w/ chronic lung issues

Asthma, COPD, history of lung cancer, smokers

Can cause acute bronchospasm – Black box warning

Side effects: Hypoglycemia, sore throat, cough

Less hypoglycemia than injected insulin


Afrezza Inhaler

Replace inhaler every 15 days –Do not wash

Bolus Insulin Summary

Regular, Novolog, Humalog, Apidra, Afrezza

Starts working fast (15‐30 mins)

Gets out fast (3‐6 hours)

Post meal BG reflects effectiveness

Should comprise about ½ total daily dose

Covers food or hyperglycemia.

1 unit Covers ≈ 10 ‐15 gms of carb

Lowers BG ≈ 30 – 50 points

Bolus Insulin Timing How is the effectiveness of bolus insulin determined? 2 hour post meal (if you can get it)

Before next meal blood glucose

Glucose goals (ADA) – may be modified by provider/pt 1‐2 hours post meal <180

Before next meal – 80 ‐ 130


Bolus – Insulin Sliding ScaleStarts at 150, 2 units for every 50 mg/dl >150

Basal Insulins(½ of total daily dose)

Intermediate Acting Peak Action Duration NPH 4‐12 hrs 12‐24

Long Acting Peak Action Duration Detemir (Levemir) No Peak 20 hrs Glargine (Lantus) 24 hrs Glargine (Basaglar) 24 hrs Degludec (Tresiba) 42 hrs

Fasting BG reflects efficacy of basal

Degludec and Basaglar Degludec (Tresiba) An ultra long acting insulin ‐ lasts

up to 42 hours

Takes 3‐4 days to reach steady state

Available in u‐100 and u‐200 pens

Seems to cause less hypo

Adjust dose every 3‐4 days

Wait at least 8 hours between doses

Good at room temp for 8 wks

Ryzodeg 70/30 mixture of insulin degludec and aspart


Basal Insulin Summary

NPH, Levemir, Glargine, Degludec

Covers in between meals, through night

Starts working slow (4 hours)

Stays in long (12‐24 hours) NPH 12 hrs

Levemir, Glargine 20‐24 hrs

Degludec – up to 42 hrs

Fasting blood glucose reflects effectiveness

Pattern Management

Poll Question 4. When looking at glucose patterns, which problem do you fix first?

a. hyperglycemia

b. hypoglycemia

c. non‐compliance

d. legible writing


Pattern Management Safety 1st!! ‐ Evaluate 3 day patterns

Hypo: eval 1st and fix: If possible, decrease medication dose

Timing of meals, exercise, medications

Hyperglycemia: evaluate 2nd Identify patterns

Before increase insulin, make sure not missing something (carbs, exercise, omission)

Type 2 – Amaryl 4mg AM, 10u Lantus pm

Case Study 70 yr old, avid walker

BMI 24, Weighs 60kg, creat 1.5

A1c – 9.8%, BG 250 – 300s during day

Insulin – 30 units Lantus (solostar pen)

Oral Meds: glipizide 20mg What medication changes?

What insulin changes?

Pt can’t afford insulin pen – what other option


Basal + 20 mg GlipizideType 2, 60kg – A1c 9.8%

Basal insulin key points – Type 2? ADA Standards of Care 2017 Start basal insulin at 10 units or 0.1 to 0.2 units/kg day

Keep metformin and sometimes one other oral agent

Consider NPH insulin at HS if cost is a factor

When is it too much basal insulin? If basal insulin is >0.5 units/kg day, advance to combination injectable therapy Add bolus, switch premixed 70/30 or to Basal + GLP‐RA

Maintain metformin therapy and stop other oral meds to decrease complexity.


Combo Sub‐Q Insulin

Case Study 70 yr old, avid walker

BMI 24, Weighs 60kg, creat 1.5

A1c – 9.8%, BG 300s for past weeks

30 units Lantus Pen (60kg x .5 = 30units max dose)

Oral Meds: glipizide 20mg What medication changes? Stop glipizide

What insulin changes? Try adding 1 bolus injection at largest meal, or switch to 70/30. 2/3s am, 1/3 pre dinner = 20units 70/30 am, 10 units 70/30 pre dinner

Pt can’t afford insulin pen – use vial and syringes


20u 70/30 am, 10u 70/30 pmPatterns? Changes needed?

Basal Bolus – What Adjustments? Pt weighs 80kg

Poll Question

5. Which of the following are suggested insulin teaching keys? (multiple)

a. Test, inject, eat – TIE

b. abdomen is preferred injection site

c. use a sharps container to dispose of needles/lancets

d. always have treatment for hypo available


Intensive Diabetes Therapy

Insulin Dosing Strategy

50/50 Rule

0.5‐1.0 units/kg day

Basal = 50% of total Glargine QD

NPH or Detemir BID

Bolus = 50% of total

usually divided into 3 meals

Example

Wt 50kg x 0.5 = 25 units of insulin/day

Basal dose: 13 units

Glargine 13 units QD

Degludec 13 units QD

NPH/Detemir 6u BID

Bolus dose: 12 units

4 units NovoLog, ApidraHumalog, Regular each meal

Intensive Diabetes TherapyInsulin Dosing Strategy

50/50 Rule


Basal = 50% of total Glargine QD

NPH or Detemir BID

Bolus = 50% of totalusually divided into 3 meals

Example – You Try Wt 60 kg x 0.5 = ___ units of insulin/day

Basal dose: ____ unitsGlargine ____ QDDeguldec ____ QDNPH/Detemir __ BID

Bolus dose: ____ units___units NovoLog, ApidraHumalog, Reg each meal

Intensive Diabetes TherapyInsulin Dosing Strategy

50/50 Rule


Basal = 50% of total

Glargine QD

NPH or Detemir BID

Bolus = 50% of total

usually divided into 3 meals

Example – You Try Wt 60kg x 0.5 = 30 units of insulin/day

Basal dose: 15 unitsGlargine 15 QD orDegludec 15 QDNPH/Detemir 7u BID

Bolus dose: 15 units 5 NovoLog, Apidra, Humalog, Reg each meal


Basal Bolus – Using 50/50 Rule ‐ Ptweighs 80kg

Insulin Dosing Type 1 & 2

U-500 Insulin: When More With Less Yields Success: Diabetes Spectrum March 20, 2009 vol. 22 no. 2 116-122

More than 200 units a day?


Quick Question 6: What best describes U‐500 Regular Insulin?

a. Regular insulin delivered in 5xs the volume of U‐100

b. High potency inhaled insulin

c. Regular insulin that is 5xs the concentration of U‐100

d. Insulin that is given 5 times a day

Humulin Regular U‐500

Consider U‐500 High Potency Insulin

5 x’s the concentration of u100

500 units per mL vs 100 units per mL 20 mL a vial. 500 units per mL= 10,000 units/vial

Costs ~ $400 $1,200 per vial

Less volume


Dedicated U‐500 Insulin Syringe Manufactured by BD – Nov 2016

5 unit increments

No conversion required

If 85 units of U‐500 R Insulin is ordered…

Humulin R U‐500 Updated Package Insert

Patients using the U‐500 vial must be prescribed the U‐500 insulin syringe

Administer U‐500 two to three times daily 30 minutes before a meal

Don’t mix U‐500 with other insulins

Do not perform dose conversion when using U‐500 KwikPen or U‐500 Insulin syringe.

Do not transfer U‐500 from the KwikPen into any syringe.

All Concentrated InsulinsNo calculation required

All concentrated insulin pens and the U‐500 syringe automatically deliver the correct dose in less volume.

Pen comes in 5 unit increments

No conversion, calculations or adjustments required.For example, if order reads:“85 units Regular U-500 Insulin”Pull plunger to 85 units U-500 Insulin on the U-500 Syringe.Dial 85 units on the U-500 Pen


Dosing Strategies u‐500 Dosing – take total daily needs and split into 2‐3 doses

2 doses: 60% am / 40% pm or

3 doses: 40/30/30 or 40/40/20

No basal insulin needed, because U‐500 has bolus and basal action

Needs careful monitoring/ education

Example ‐ Pt on 240 units of insulin a day 140 units am / 100 units pm (2 doses)

100 / 70 / 70 or 100 / 100/ 40

Lispro (Humalog) U‐200 Kwik Pen 2 xs the concentration of U‐100

200 units per mL Humalog U‐200 Kwik Pen

Comes in 3mL pen/ 600 units (2 pack)

Once opened, keep at room temp. Toss after 28 days.

Not approved for use in insulin pump


Humalog 200 units/mL KwikPen

Toujeo U‐300 Solostar Pen

For example, if order reads:“30 units Toujeo U-300 Solostar Pen”

Dial the pen to 30 units.

Glargine (Toujeo) Solostar Pen U‐300 Glargine 300 units / mL Need 10‐14% higher dose than previous U‐100 dose

Start with 1:1 conversion and adjust based on FBG

Less nocturnal and hypoglycemia.

Similar weight gain to U‐100

Extend release of U‐300 results in smoother, stable more prolonged profile

More injection site reactions with U‐300

Max 80 units injection

Comes in 1.5mL pen/450 units (3 or 5 pack)

Once opened, keep at room temp. Toss after 42 days.


Degludec (Tresiba) FlexTouch U‐200 Pen

Concentration – 200 Units/mL

Max 160 units injection

Comes in 3mL pen/600 units (3 pack)

Dose increments – 2 units

Once opened, keep at room temp. Good for 8 weeks

For example, if order reads:“160 unitsTresiba U-200 FlexTouch Pen”

Dial the pen to 160 units.

Concentrated Insulin

Pros Cons

As pts are getting heavier, more insulin is needed

More insulin in less volume

Patients need less insulin ‐

Risk of incorrect administration

Cost

Making sure orders are written correctly

Quick Question 7: Which of the following is true about all concentrated insulins?

a. Need to convert to get correct dose

b. Delivers the same amount of insulin in more volume.

c. Delivers the correct dose in less volume

d. No calculation or conversion required

e. C & D


Key Teaching Points Never withdraw concentrated insulin from a pen into a syringe

All concentrated insulin pens and the U‐500 insulin syringe automatically deliver the correct dose in less volume.

No conversion, calculation or adjustment required.

When writing Rx include type of insulin, concentration, delivery device and dose.

Bolus insulin with meals

Basal 1‐2xs daily

Abdomen preferred injection site

Stay 1” away from previous site

Don’t re‐use ultra fine syringes

Keep unopened insulin in refrigerator

Toss opened insulin vial after 28 days

Proper disposal

Review patients ability to withdraw and inject.

Side effects include hypoglycemia/wt gain

Insulin pens – Prime needle to assure

accurate insulin dose given

Hold needle in for 5 seconds after injection

Roll 70/30 pens

Insulin Teaching Keys

Sharps Disposal: Product and Info Look in the Government section

white pages for a household hazardous waste listing for your city or county.

Call 1‐800‐CLEANUP (1‐800‐253‐2687)

Search for collection centers on the California Integrated Waste Management Board (CIWMB) Web site: http://www.ciwmb.ca.gov/HHW/HealthCare/Collection/


Thank You Questions?

Email [email protected]

Web www.DiabetesEdUniversity.net

dm fundamentals –class 3 insulin and pattern management

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