1. Injectable Therapies in Diabetes
Diabetes Specialist Nurse
Joyce Robson

2. Learning Outcomes
Understand the place of injectible agents in diabetes
Discuss when patients may require insulin
Discuss insulin profiles and regimes
Discuss when patients may require GLP1 inhibitors
Discuss injections - delivery methods, technique and sites

3. When injectibles therapies are used in diabetes?
Type 1 diabetes – 1st line – no alternative treatment to insulin – lack of insulin leads to ketone production > ?DKA
Type 2 diabetes - insulin resistance  loss of insulin effectiveness  poor response to oral agents. Injectibles then required- Variable time line.
May require insulin or Glucagon Like Peptides 1receptors agonists (GLP-1s) by injection

4. Insulin
Often needed in type 2 diabetes with other conditions – for example
Steroid therapy
Acute infection
Pre or post surgery
Gestational diabetes
Type 2 diabetes in pregnancy

5. Normal Daily Insulin Profiles
Mealtime insulin
Background insulin required for basal metabolic requirements
Blood sugar
Daily Requirements
Breakfast
Lunch
Evening Meal
BG HIGHEST 1 ½ 2 HOURS POST MEALS
For regular eating pattern you require a background of insulin and three bolus doses of insulin.

6. Types of Insulin? Types of insulin: short acting (clear)…………
rapid acting (clear)………….
intermediate (cloudy) ……………………………….
“Fixed” (bi phasic) mixtures - combination of short an d medium insulin (cloudy) e.g …………………………
Longer acting insulin analogues (clear) e.g ………..
New insulins 300iu strength
There are 3 basic types of insulin:
Short acting or clear insulin also known as soluble insulin.
Medium or cloudy insulin also known as isophane insulin.
Mixtures of clear and cloudy in various combinations; for example:
30% short acting mixed with 70% medium acting.
20% short acting mixed with 80% medium acting.
50% short acting mixed with 50% medium acting.

8. Common insulin regimes
Match insulin profile to the needs of individual patients and follow GGC guidelines
Once daily intermediate or long acting
eg. Humulin I, Insulatard, Levemir, Lantus - Commonly used in combination with orals, good for patients requiring DN input
Twice daily mixed insulin
e.g. HumulinI, Novomix 30, Insuman Comb 50, if not achieving adequate glycaemic control on once daily regime

9. Common Insulin regimes cont.
Three times daily mixed insulin
eg. Humalog Mix 50, Insuman Comb 50 – If patient is highly insulin resistant
Multiple dose injections /basal bolus
eg. Lantus or Levemir plus Novorapid or Humalog
Insulin Pumps
Constant infusion of rapid acting insulin

10. Important points to consider in insulin therapy
Carbohydrates
Keeping stable blood sugars
Importance of injection timing/compliance
Hypos – recognition, avoidance and treatment
Delivery devices and storage of insulin
Safe sharps disposal
Lumpy injection sites
Self managing leads to improved outcomes

11. Adjustment of Insulin doses
Adjust on the basis of a trend (3-4 days results) in glucose readings rather than on just one reading. (kneejerk reactions)
Adjust the dose before the problem results
morning insulin  lunch / tea time results evening insulin  supper / breakfast results
Increase by only 2 units – never 10 units!
Decrease by 20 % to avoid a hypo recurring
Insulin Management Plans for DN use 11

13. Injectable Therapies - GLP1
GLP-1 - Incretin gut hormone
Used only in Type 2 diabetes
Generally 3rd line medication
Useful if insulin needs to be avoided – eg taxi drivers, HGV drivers

14. GLP1 – how do they work?
Increases insulin production when blood glucose levels are high.
Reduces insulin production when blood glucose levels are low… Results in No hypos unless on another agent for example gliclazide
Slows down speed of stomach emptying reduce appetite  *****weight loss*****

15. GLP1 currently in use exenatide (Byetta) twice daily injection
exenatide (Bydureon) once weekly injection
lixisenatide (Lyxumia) Once daily injection.
liraglutide (Victoza) once daily injection
dulaglutide (Trulicity) Once weekly injections
Degludec/liraglutide (Xultophy) once daily injection

16. side effects of GLP1 Nausea and GI upset common on initiation
Rare side effect of pancreatits
Weight loss

17. Injection technique Injection prompt sheets available
DSN support initially towards patient self managing
90 degree angle
Most patient using size 4 or 5mm needles now - no need to pinch
Tummy and thigh easier to self inject
If DN dependent  syringe/needle to minimise risk needlestick injuries. Otherwise patient to remove needle or use BD safe clip

18. Good Injection techniques
Rotate sites - abdomen, thighs,buttocks
Watch out for lipohypertrophy- avoid for 3/12
Do not re-use needles
Expel 2units prior to injection
Do not inject through clothing
– FIT injection technique -

19. Further Learning Previous Safer use of Insulin module now discontinued
5 Modules available on Learn Pro
Contact diabetes team if any concerns or need advice

20. Any Questions???
Thank you

21. Thank you