Insulin Therapy-What’s New Veronica Brady, PhD, FNP-BC, BC-ADM, CDE April 21, 2016

Diabetes warrior

Insulin

Objectives Overview of Insulin Therapy Describe New Insulin Therapies Identify Candidates for New Insulins Questions

Normal Insulin Secretion Basal: continuous insulin to compensate for liver glucose Bolus: surge for food 1st phase: rapid rise in serum insulin levels inhibits glucagon release and therefore inhibits glycogenolysis 2nd phase: to maintain normoglycemia postprandially

Gycemic control algorithm When insulin is needed

Therapy options When insulin is needed

Everything you should know about the new insulins

New Insulins Rapid Acting Short Acting Intermediate Acting Long Acting Ultra Long Acting Inhaled

Insulin chart

Rapid Acting Insulin Lispro/Humalog-U-200 Glulisine/Apidra Aspart/Novolog Onset: 15 minutes Peak: 30-90 minutes Duration:3-5 hours 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Meal and Snack times AM / PM Onset Peak Duration 1st meal______ AM/PM _____ ____to____ 1st snack______ 2nd meal______ 2nd snack_____ 3rd meal______ 3rd snack _____ Bedtime______

Long Acting Insulin Detemir/Levemir Onset: 0.8-2 hrs Peak: 3.2-9.3 hrs Duration: up to 24 hrs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Meal and Snack times AM / PM Onset Peak Duration 1st meal______ AM/PM _____ ____to____ 1st snack______ 2nd meal______ 2nd snack_____ 3rd meal______ 3rd snack _____ Bedtime______

Long-Acting Insulin Glargine/Lantus Basaglar/Lantus** Onset: 1-2 hrs Peak: peakless Duration: 24 hrs Meal and Snack times AM / PM Onset Peak Duration 1st meal______ AM/PM _____ ____to____ 1st snack______ 2nd meal______ 2nd snack_____ 3rd meal______ 3rd snack _____ Bedtime______ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 x B L D

Ultra Long Acting Insulin Glargine U-300/Toujeo Onset: 6 hrs Peak: peakless Duration: 36 hrs

Ultra Long Acting Insulin Degludec/Tresiba Onset: ½-1.5 hrs Peak: peakless Duration: 42 hrs

Rapid acting

Afrezza Generic Name: insulin human Brand Name: Afrezza Manufacturer: Sanofi Form: human Delivery:packets 4,8, & 12 units (90 packets & 2 inhalers) Storage: inhaler good for 15 days (packet = 1 month-fridge or 10 days sealed and 3 days opened) Onset: 10-20 minutes Peak: 12-15 minutes Duration:180 minutes

Afrezza Considerations: Lung function-no smoking (none within 6 months) Set doses—not possible to get 3 units Amount of insulin needed for each meal Must be at room temp for 10 minutes before use

Humalog U-200 Generic Name- lispro U-200 Brand Name: Humalog U-200 Manufacturer: Eli Lilly Form: analog Delivery: pre-filled pen (600 units) Storage: in use 28 days—do not refridgerate Onset: 15 minutes Peak: 30-90 minutes Duration: 3-5 hours

Intermediate acting

U-500 pens Generic Name-regular U-500 Brand Name: Humulin R U-500 Manufacturer: Eli Lilly Form: human Delivery: 3 ml pen fill (1500 units) Storage- in use do not refrigerate—28 days Onset: 30 minutes Peak: 8 hours Duration: up to 24 hours

U-500 pens Considerations: Indicated for patients requiring more than 200 units of insulin/day. Administer 2-3 times a day 30 minutes before meals Do not mix with other insulins

Long acting

Basaglar(coming 12/15/16) Generic Name-glargine Brand Name: Basaglar Manufacturer: Eli Lilly Form: analog Delivery: 3 ml pen fill Storage-pen in use 28 days Onset: one hour Peak: no peak Duration: 24 hours

Toujeo Generic Name: glargine U-300 Brand Name: Toujeo Manufacturer: Sanofi Form: Analog Delivery: (450unit) prefilled pen Storage-pen in use good for 42 days Onset: 6 hours Peak: No peak Duration: 36 hours Maximum single injection: 80 units

Comparison of U-100 & U-300 insulin glargine

Tresiba Generic Name: degludec Brand Name: Tresiba Manufacturer: Novo Nordisk Form: Analog Delivery: prefilled pen u-100 (300) u-200 (600) Storage: in use room temperature up to 48 days Onset: one hour Peak: No peak Duration: 42 hours Maximum single dose: 160 units

Candidates for New Insulins-Basal Patients requiring large doses of insulin Those with overnight hypoglycemia Those with variable schedules that interfere with consistent insulin injections

New Insulins Advantages Disadvantages Basals-longer duration of action Less overnight hypoglycemia Small volume Cost

Patient education

Which one? They look so much alike, I can’t remember. Oops!!! Did I just use the Humalog pen or the Lantus pen?

Administration Instructions Read label carefully if using more than one pen filled device. Do not draw insulin out of pen with syringe Be sure to rotate sites **No need to perform dosage conversions when using u-200 or u-300 insulins

Coming soon!!!??

New on the Horizon Smart Insulin- Merck Insulin+GLP-1

Questions