Insulin Therapy

Lynda Astbury Lead DSN

Insulin Therapy

Insulin first used as a treatment for diabetes in 1922

Had a short duration period and required several injections per day

Had to be given through re-useable glass syringes with needles which were large and blunt

1. www.discoveryofinsulin.com/Home.htm

Insulin secretion in the non- diabetic1

• Insulin is secreted at two rates

• Slow basal over 24 hours

• Bolus in response to rising blood glucose

1. Barnett AH. Insulin Made Easy. 2001 (figure)

Insulin types • Human

• Analogues- short acting and long acting

• Higher strength insulins (New)

• Pork (Porcine)

• Beef (Bovine)

Insulin Types • Short Acting

• Rapid Acting

• Intermediate Acting

• Long Acting Analogues

• Mixtures

Rapid Acting Analogues

0nset 5-15 minutes (e.g. Apidra, Humalog, Novorapid)

Duration of clinically effective action 4 hours

Can be injected immediately before meals or up to 15 minutes after

Fewer hypoglycaemic events

May be more effective in reducing post prandial hyperglycaemia than soluble insulin

Used pre-meals with intermediate or long acting background insulin (multiple injection therapy)

Short-acting (Soluble) Insulin

E.g. Actrapid, Humulin S

Onset 30-45 minutes

Peaks 2-4 hours

Duration 5-8 hours

Often used pre meals combined with intermediate or long acting background insulin (basal bolus) or in a ‘free-mix”

Intermediate acting insulin

E.g. Insulatard, Humulin I Onset of action 2-4 hours Peak action 4-6 hours Duration 8-14 hours Can be used daily/ twice daily on its own or in combination with

analogue or short acting insulin Cloudy insulins need to mix well before use

Long Acting Analogue Insulins

Lantus

Duration of action 18-24 hours once daily

Levemir

Duration of action 12-18 hours once/twice daily

Peakless profile

Mixtures ( Bi- Phasic insulins)

Premixed short acting and intermediate insulin e.g. Humulin M3

Or analogue insulin combined with intermediate acting insulin e.g. Humalog Mix 25, Humalog Mix 50 or NovoMix 30

Generally used twice daily

Suits people with regular lifestyle pattern

Mixtures - not re-suspending alters mix

Multiple Injection Therapy

Produces an insulin profile that is closest to natural insulin production by the body

Short acting soluble or rapid acting analogue insulin prandially

Intermediate or long acting insulin usually before bed

Offers greater flexibility for people with irregular lifestyle pattern

Newer Insulins • Tresiba (Dugludec) 100units/1ml

Long acting Analogue, available in 3ml cartridges or pre filled pen device

• Tresiba (Degludec) 200units/1ml

Available in pre filled pen device- dose counter shows number of units irrespective of strength

More expensive than Humulin I, Lantus and Levemir

Abasaglar- newer insulin

• Abasaglar is a basal insulin for once daily use and is bioequivalent to insulin glargine (Lantus).

• Abasaglar is given once daily by subcutaneous injection, and is available as 100 units/ml in cartridges or as a pre-filled pen.

Newer Insulins continued…

• Toujeo (insulin Glargine) 300units/1ml

High strength insulin available in 3x 1.5ml pens, dose counter shows number of units irrespective of strength

Not interchangeable with other insulins, needs specialist supervision

• Humulin R U500 high strength insulin

Can only be prescribed by Consultant, available in 10ml vial

Insulin dose measured in ‘marks’ not units

Combination therapy

Different insulins can be combined into different regimens

You will probably have to support patients on a variety of regimens

Changes to the insulin regimen may be needed as the disease progresses

So…

Many different insulins available - one type does not fit all!

Optimal control is not always obtained due to limitations of insulin and factors which affect blood glucose control

Developments continue to try to improve insulin profiles