1. Quality of Life Matters NOT TOO HIGH… NOT TOO LOW… A PLAN FOR OPTIMIZING DIABETES MANAGEMENT IN NURSING HOMES 5. Insulin: Part 1

2. Insulin What you need to know Part 1

3. Insulin produced in the pancreas. promotes absorption of glucose from the blood  muscles to used for energy  Causes fat to be stored  inhibits glucose production by liver http://en.wikipedia.org/wiki/Insulin

4. Insulin use … Type 1 & Type 2 Type 1:Type 2: Need insulin at diagnosis! eventually “…Pooped out pancreas”…needs to helped out.

5. Type 1 Diabetes treatment goals… 1.administer insulin to mimic action of pancreas as closely as possible 2.Usually 4-5 injections a day 3.Strive for glycemic control in range to decrease risk of complications and minimize, if possible, avoid hypoglycemia! Healthy eating and active lifestyle important!

6. Type 2 Diabetes treatment goals… 1.Lifestyle 2.oral medications 3.+/- insulin 4.Goal  blood sugars under control  decrease risk of complications minimize; Avoid hypoglycemia!

7. Type 2 Diabetes and Insulin When insulin is needed… often started with 1 injection a day Background or basal insulin (long acting) Use fasting BG to guide dose titration

8. Meal time insulin Added when blood sugars trend up during day. When body cannot manage sugar from the meal Blood sugar 2 hours after a meal or before next meal help titrate each meal dose.

9. INDIVIDUALIZE Insulin needs are based on each individuals needs!

10. The heavy duty stuff… Types of insulin: Basal (background) Bolus (meal insulin) Mixed ….lets get to know them

11. Basal Insulins (work in background) Glargine = Lantus Determir = Levemir Onset of action 90 minutes, lasts 24 hours (Detemir may last 12 – 24 hours) Flat …no peak of action FBG gives a good indication re appropriate dose Pros: less hypoglycemia; once daily dose

12. Basal Insulins (work in background) Humulin N and NPH Onset of action 1 – 3 hours, lasts approximately 18 hours Peak of action 5 – 8 hours Can be given once or twice daily FBG gives a good indication re appropriate dose Pros: less expensive Cons: more hypoglycemia risk, more variability of action

13. Serum Insulin Level Time Analogue Bolus: Apidra, Humalog, NovoRapid Human Basal: Humulin-N, Novolin ge NPH Analogue Basal: Lantus, Levemir Human Bolus: Humulin-R, Novolin ge Toronto Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca Copyright ©2013. Canadian Diabetes Association

14. Type 2 Diabetes Sometimes a basal insulin will be enough…. Especially in the frail elderly But not always… Meal insulins are sometimes necessary (can be 1 – 3 /day)

15. Bolus/ Meal insulins Humulin R or Toronto Onset of action 30 – 60 minutes Duration of action 5 - 8 hours Peaks 2 – 4 hours Should be given 30 minutes before meal - Pros: less expensive - Cons: wider variability of action INCREASED HYPOGLYCEMIA RISK

16. Bolus/ Meal insulins Lispro = Humalog Aspart = Novo Rapid Glusiline = Apidra Onset 15- 20 minutes, lasts 3.5 - 5 hours Peak of action 90 minutes Should be given 15 minutes before meal (no more) Pros: Easier to titrate dose MORE FLEXIBILITY WITH MEALS DECREASED HYPOGLYCEMIA RISK

17. Serum Insulin Level Time Analogue Bolus: Apidra, Humalog, NovoRapid Human Basal: Humulin-N, Novolin ge NPH Analogue Basal: Lantus, Levemir Human Bolus: Humulin-R, Novolin ge Toronto Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca Copyright ©2013. Canadian Diabetes Association

18. Pre-mixed insulin 30/70 Humalog Mix 25 Pros: give 1-2 times a day Cons: glycemic variability Hypoglycemia risk 2400 – 0200

19. Time Serum Insulin Level Human Premixed : Humulin 30/70, Novolin ge 30/70 Analogue Premixed: Humalog Mix25, NovoMix 30 Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca Copyright ©2013. Canadian Diabetes Association

20. Types of Insulin Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca Copyright ©2013. Canadian Diabetes Association

21. Types of Insulin (continued) Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca Copyright ©2013. Canadian Diabetes Association

22. Responsibilities of insulin administration 1.Know what you are giving… 2.Give at the right time 3.Assess individual – e.g. what if not eating? i.e. no meal? –should meal insulin be given? 4.Understand when most likely to cause hypoglycemia

23. INSULIN REGIMENS THERE IS NO ONE SIZE FITS ALL!! – INDIVIDUALIZE treatment – BG and A1C tools to evaluate … – NEEDS may CHANGE as health status changes! – IS CURRENT REGIMEN WORKING ?

24. Questions

25. Thank you