1. Insulin Therapy NURS 108 ECC- Spring, 2008 Majuvy L. Sulse MSN, RN, CCRN

2. Insulin Exogenous substance  Purified insulin prep from beef and pork  Human insulin preparation (synthetic)- more rapid onset of action, shorter peak action Preferred for pregnant women Clients beginning insulin therapy clients going for intermittent use only Uses of Insulin therapy  Type 1 diabetes  Meet metabolic demands  Oral agents are unable to maintain satisfactory blood glucose levels

3. Types Types differ in regard to onset, peak action, and duration Available in 100 units/ml or 500 units/ml (500 unit/ml & Lispro needs Rx) Combinations are tailored according to blood glucose level, lifestyle, eating & activity patterns. Rapid Acting Short Acting Intermediate acting Long Acting Combination therapy

4. RAPID-ACTING INSULINS Humalog (insulin Lispro, aspart or Novolog), in which a chemical change has been made to the insulin molecule. This gives the insulin a very desirable property of extremely rapid absorption. Onset is 15 minutes Peak action of Lispro insulin is about 60-90 minutes after injection, and insulin levels fall off rapidly after 3 to 4 hours. This allows the insulin, if given before the meal, to control the post-meal rise of glucose much better, and to reduce the chance of hypoglycemia (because insulin levels drop faster). This may well be its greatest advantage. It can essentially substitute for any short-acting insulin.

5. SHORT-ACTING INSULINS These include Humulin R (HR), and Novolin Toronto (also known as regular) insulins. Rapid-acting insulins start being absorbed in 30-60 minutes Peak action within 2 to 3 hours of injection in most individuals. Duration of action is approximately 4 to 6 hours Short- acting insulins are often used before eating to control the large rise of blood glucose that often occurs after a meal. Ideally, short-acting insulin is taken approximately 30-45 minutes before the meal, as it takes up to 2 hours to see its main effect. However, most people take their insulin just before eating.

6. INTERMEDIATE-ACTING INSULINS Includes NPH and Lente, start being absorbed 2-3 hours after injection Peak action after 6-8 hours. Duration of action may be as much as 12- 16 hours after injection. Used in the morning, its greatest action would be in the afternoon. One of the best uses is injection at bedtime to control the morning glucose of the next day.

7. LONG-ACTING INSULINS Mainly includes the UltraLente insulin. Onset-2 hours Peak effect occurring after 16-20 hours Duration of action may be 24 hours, and vary occasionally longer. It is not a popular insulin. It is mainly used in individuals in whom intermediate-acting insulins taken at bedtime act too quickly, resulting in hypoglycemic reactions during the night. By using a human UltraLente, one can slow down the peak action by an hour or two, often preventing hypoglycemia at night, but controlling the fasting sugar of the next day.

8. LONG-ACTING INSULINS Insulin Gargline (Lantus)-long acting insulin analog is used for once daily subcutaneous injection at bedtime to provide basal insulin coverage Cannot be mixed/diluted with other types of insulin. Mixing may result in a cloudy solution and an unpredictable alteration in both the onset of action and time to peak effect

9. Pharmacokinetics of Insulin Injection site-rotation of sites Absorption rate-  larger doses prolongs absorption,  longer duration of action provides less consistent absorption  Injection into scar tissue delays absorption Injection depth- Time of injection- Mixing of insulins-mixing different types can change the timing of peak insulin action

10. Method of administration Subcutaneous IV- as a drip or IVP MDI-multiple daily insulin injections-uses immediate and long acting insulin as basal component together with frequent blood glucose monitoring Insulin pump-continuous subcutaneous injection in the abdominal wall via a small plastic tube to a catheter into subcutaneous tissue-tight glucose control, flexibility & close to normal lifestyle

11. Insulin Pump  Release an additional bolus from the same cartridge and via the same infusion set at mealtimes and to correct the blood sugar  Increase or reduce the basal insulin supply as needed for a certain period of time without having to reprogram the basal rate for every hour,  Program / adjust the basal rate himself/herself.  The insulin pump does not measure blood sugar and also does not react automatically to fluctuations in blood sugar. The pump user must handle blood sugar monitoring himself/herself and make any adjustments to the insulin dosage

12. Features of an Insulin Pump

13. Method of administration New Technology  Nasal spray administered via a nebulizer  Inhalation- regular insulin (U-500) delivered in an inhaler during inspiration  Transdermal also being tested

14. Problems associated with Insulin Therapy Hypoglycemia Allergic reaction-itching, burning, redness around site Lipodystrophy-  lipohypertrophy –increased fat deposits in the skin  Lipoatrophy-loss of fatty tissue Somogyi effect-treat with less insulin Dawn Phenomenon-hyperglycemia on awakening due to release of growth hormones or cortisol levels-treat with increase insulin for the overnight period or adjust insulin administration (intermediate) to be given at 10 pm

15. Patient Diabetic Teaching Medication Storage Dose preparation Syringes Blood glucose monitoring

16. Patient Diabetic Teaching Medication  Recognize characteristics, purpose, and action, dosage, duration, and adverse effects of medication  Inform the generic and brand names of insulin  Evaluate client’s ability to self administer medications  Instruct what to do if medication is missed  Instruct client how to mix medications

17. Patient Diabetic Teaching Storage -Store new vials of insulin in the refrigerator. The vials you will use within 30 days can be stored at normal room temperature. In case you don't finish a vial within 30 days, keep it in the refrigerator. 30 minutes before having a shot, remove the vial from the refrigerator so the shot will hurt less. Put it back in the refrigerator until you use it next time. Never store your insulin in the glove compartment of your car; extremes temperatures can spoil your insulin. If it is very cold try to keep your insulin in a pocket close to your body. In hot weather use special bags with an ice pack; insulin must be kept cool but not frozen.

18. Patient Diabetic Teaching Dose Preparation Inspect the bottle before each use for changes that may signify loss in potency (clumping, precipitation, frosting, or change in color & clarity) Rapid & short acting should be clear; all others cloudy

19. Mixing Different types of Insulin Wash hands Gently rotate NPH insulin bottle Wife off top of vial with alcohol swabs Draw back amount of air into the syringe that equals total dose Inject air equal to NPH dose into NPH vial Inject air equal to regular dose into regular vial Invert regular insulin vial and withdraw regular insulin dose Carefully withdraw NPH dose

20. Patient Diabetic Teaching Syringes-marked in insulin units Differs in unit increments Insulin syringes comes in 1 ml, 0.5ml, and 0.3 ml reuse of syringes for same client does not increase rate of infection at site

21. Patient Diabetic Teaching Injection  Rotating sites-abdomen, arms, thigh, buttocks  90 or 45 degree angle subcutaneously 90 degree angle if able to grasp a fold of skin 45 degree if individual is thin to avoid IM injections  Aspiration for blood is not necessary

22. Sites of Administration

23. Blood Glucose monitoring Cornerstone in diabetes management Detects hyper and hypoglycemic episodes Enables patient to make decisions regarding diet, exercise and medications Frequency of testing depends Pt. glycemic goals Type of diabetes Pt ability to perform test Willingness to test

24. Patient Teaching Guide Wash hands in warm water Let hands hang in dependent position or warm hands in warm water if unable to obtain adequate blood sample Use side of finger rather than the center Deep punctures unnecessary and causes pain & bruising