1. Diabetes Treatments: Options for Insulin Delivery Bonnie Pepon, RN, BSN, CDE Certified Diabetes Educator Conemaugh Diabetes Institute

2. Diabetes 21 million people in the U.S. have diabetes $132 billion each year ◦Type 1 diabetes – no insulin production ◦Type 2 diabetes – some insulin production

3. Type 1 Diabetes

5. Insulin Production of Type 2

8. Healthy Eating

13. Classes of Medications Sulfonylureas Meglitinides Biguanides Alpha Glucosidase Inhibitors Thiazolidinediones-TZD’s Incretin Mimetics DPP IV Inhibitors

14. Sulfonylureas Most common drugs in this class: Glipizide (Glucotrol, Glucotrol XL) Glyburide (Micronase, Diabeta, Glynase) Glimepiride (Amaryl) How do they work? Stimulate the pancreas to make more insulin Work for up to 24 hours Lowers fasting and post prandial blood sugar Advantages: May decrease AIC 1.5-2% Inexpensive Side effects: Weight gain (4.5-11 lbs.) Low blood sugar How to take: Take glipizide 30 min before the first meal of the day All others take with first meal of the day

15. Meglitinides Most common drugs in this class: Repaglinide(Prandin) Nateglinide (Starlix) How do they work? Stimulate the pancreas to make more insulin Work only for about 4 hours after meals Only effects post prandial sugars – NOT FASTING! Advantages: May decrease A1C by 1-2% Side effects: Weight gain Low blood sugar How to take: Take up to 30 minutes before meals No meal= No pill

16. Biguanides Most common drugs in this class: Metformin (Glucophage, Glucophage XR) Liquid Form (Riomet) How do they work? Helps your body produce less glucose from the liver Helps insulin work better Reduces glucose absorption in the intestines Takes up to 2 weeks to see maximum effect Advantages: Can decrease AIC 1.5-2% Does not cause low blood sugar or weight gain May also lower triglycerides and cholesterol Side effects: Nausea and Diarrhea How to take: Take with breakfast and supper

17. Alpha Glucosidase Inhibitors Most common drugs in this class: Acarbose (Precose) Miglitol (Glyset) How do they work? Slows the digestion of carbs in the small intestine, thus decreasing the post prandial blood sugar spike Advantages: May decrease A1C by 0.5 to 1% Does not cause low blood sugar or weight gain Side effects: Gas and diarrhea How to take: Take with first bite of food of 3 largest meals of the day

18. Insulin Sensitizers-TZD’S Most common drugs in this class: Rosiglitazone (Avandia) Pioglitazone (Actos) How do they work? Helps insulin work better Enhances glucose uptake by the muscle tissue Reduces glucose production by the liver Takes up to 3 months to see maximum effect Advantages: May decrease A1C by 0.5-1% Does not cause low blood sugar May decrease triglycerides and increase HDL Side effects: Swelling in legs and weight gain (caution in heart failure) If on oral contraceptive, may increase risk of pregnancy Liver damage (<1% chance) Liver function is monitored every 2 months for the first year

19. Combination Drugs Glucovance (glyburide/metformin) Metaglip (glipizide/metformin) Avandamet (avandia/metformin) Duetact (amaryl/actos) New Ones: Fortamet (metformin SR) Glumetza (metformin SR) Actoplus (actos/metformin) Avandryl (avandia/glimepiride)

20. Incretin Mimetics: Gut Hormones ◦Byetta (Exenatide) approved for type 2 ◦Symlin (Pramlintide) approved for type 1 and type 2 using mealtime insulin

21. Byetta How do they work? Prevents stored sugar from entering the blood stream Stimulates insulin release Slows gastric emptying Lowers post prandial blood sugar spike Makes you feel full Reduces food intake and appetite Advantages: May decrease A1C by 1% after 6 months Promotes weight loss (5-6 lbs) Dosing: Comes in a prefilled pen that lasts one month 5 mcg twice a day for 1 month, then increase to 10mcg twice a day Give within 60 minutes of morning and evening meal Do NOT give after a meal If you miss a meal, skip the dose Side effects: Nausea (will go away with time and dose titration) Vomiting and diarrhea Low blood sugar May need to decrease dose of sulfonylurea to avoid low blood sugar

22. Symlin How do they work? Slows gastric emptying Lowers the post prandial blood sugar spike Makes you feel full Reduces food intake and appetite Slows production of glucose from liver Advantages: May lower A1C by 0.6% in Type 2 after 6 months Promotes weight loss (4 lbs) Side effects: Nausea (will decrease over time) Loss of appetite Vomiting Hypoglycemia (3 hours after dose) Decrease amount of rapid acting insulin by 50%

23. DPP IV Inhibitors DPP IV Inhibitors Januvia (Sitagliptin) Oral active, selective inhibitor for the DPP-4 enzyme A1C effect-decreased by 0.65-0.8% Can be administered with or without food Not for type 1 diabetes

25. Rapid Acting Insulin InsulinOnset of action PeaksDuration Humalog or lispro 5 to 15 minutes 30 to 60 minutes 3 to 5 hours Novolog or aspart Apidra or glulisine Short Acting Insulin Humulin R or Novolin R 30 minutes 2 to 3 hours 3 to 6 hours Clear in appearance Available in vials and pens

26. Intermediate Acting Insulin InsulinOnset of action PeaksDuration Humalin N (NPH) or Novolin N (NPH) 2 to 4 hours 4 to 12 hours 12 to 18 hours Cloudy in appearance Available in vials and pens Long Acting Insulin Levimir (detemir) 1 to 2 hours 6 to 8 hours 6 to 23 hours Lantus (glargine) 1 hourno peak24 hours Clear in appearance Available in vials and pens Cannot be mixed in the same syringe with any other type of insulin

28. Insulin Injection Sites

29. Insulin Delivery Systems Available Now

30. Syringe/Needle/Vial Insulin comes in U–100 in the U.S. ◦orange cover and black scale ◦100 units of insulin per milliliter of fluid in the vial U–500 available ◦high insulin resistance using more than 200 units a day Outside the U.S.: U-40 ◦red cover and red scale

31. Syringe/Needle/Vial Most common method of delivery Syringes (range of sizes) needle gauge needle length syringe capacity 3/10cc, 1/2cc, 1cc

32. Insulin Needles Syringes available 1/2 in or 12.7 mm 5/16 or 8mm Pen needles available ½ in 5/16 in 3/16 in Gauges available 31, 30, 29, 28

34. Insulin Devices Syringes ◦Syringes are most widely available ◦Can be adjusted to 1 or ½ units ◦Can use most types of insulin ◦Require good vision to measure a dose

35. Insulin Devices Pens ◦Easy to set the correct dose by a dial ◦Can be adjusted with ½ units or 1 unit ◦Can use most types of insulin ◦Very convenient and accurate for the vision impaired and those on the go

36. Insulin Devices Pumps ◦Results in better diabetes control ◦More flexible eating schedule ◦Dose adjusted by 1/10 to 1/20 units ◦Requires higher level of involvement & more advanced diabetes education and skills

37. Insulin Syringes Multiple manufacturers ◦BD, Monoject, SureComfort, Ulticare Precision Sure Dose, UltiGuard, Medicore, Aimsco Injection aides ◦Inject-Ease by BD and Palco, Instaject (can be combined with a lancet device), NeedleAid, NovoPen 3 Penmate

38. Insulin Pens Uses an insulin needle ◦available in different sizes and gauges ◦units can be counted as dialed by a click ◦plunger is pushed in and held for several seconds before removing the needle

39. Insulin Pens Storage in refrigerator until the pen is started ◦storage life ranges from 7 to 42 days Pre-filled pens ◦28 days: Humalog/Novolog/Novolin R ◦14 days: Novolin N ◦10 days: Novalin 70/30

40. Insulin Pens: Insulin Cartridges 1.5 ml InsulinDays Humalog28 days Novolin R30 days Novolin 70/30 and Novolin N 7 days 3 ml Novolin R/Novolog/Lantus 28 days Novolin N14 days Novolin 70/3010 days Levemir42 days

41. Pre-mixed Insulin InsulinOnset of action PeaksDuration Humalog mix 75/25 or 50/50 30 minutes 2 to 4 hours 22 to 24 hours Humulin mix 70/30 or 50/50 Novolog mix 70/30 Novolin mix 70/30 Helpful for those with poor eyesight, dexterity problems or those who have trouble mixing from 2 different vials

45. Insulin Pumps

46. Inhaled Insulin Delivers rapid acting dry powder insulin Absorbed through the lungs into the bloodstream ◦1mg and 3mg blister packets ◦Cannot be used for smokers, children, pregnant women or anyone with lung problems Will be taken off the market in January 2008

47. Jet Injector

48. Insulin Infuser Minimize needle sticks by creating a portal to inject insulin into A small tube is inserted into the fatty tissue of the injection site It is taped in place for 2-3 days Insulin injected into the tube via pen or syringe instead of the skin

49. Insulin Delivery Systems In the Future Oral insulin Transdermal insulin Buccal insulin Artificial pancreas Implantable insulin pump

50. Case Study 45 year old African-American male Diagnosed with Type 2 DM Initial glucose 280mg/dl, A1C–9.9% ◦Started on nutrition and physical activity ◦3 months later still having symptoms ◦PMH –hypertension, obesity, high lipids ◦Smoker, occasional alcohol, no drug use What therapy should be started?

52. The Pharmacist Part of the Healthcare Team