insulin types,how to use insulin-treatment of diabetes mellitus

basal bolus regimen using various insulin types- insulin aspart and insulin glargine

Everything about insulin-types of insulin,how to use insulin,different delivery methods (pen,insulin pump,jet injector),side effects and drug interactions.

  • In patients with type 1 diabetes the main problem is that the pancreas do not produce insulin.
  • Therefore the treatment of type 1 diabetes mellitus is giving exogenous insulin to the patient.
  • Insulin is not always necessary in type 2 diabetes.
  • It can be given to type 2 diabetes patient only when the blood glucose is not controlled with lifestyle modifications (that is changes in diet, weight loss and doing exercise), oral medicines.

must read-types of diabetes mellitus,diabetes insipidus & brittle diabetes

INSULIN TYPES

Insulin can be divided into four types based on their onset, peak and duration of action.

Four types of insulin are:

1. RAPID ACTING

  • onset: 12-18 min
  • peak: 1-1.30 hrs
  • duration: 3-5 hrs
  • appearance: clear
  • examples are: insulin lispro, insulin aspart, insulin glulisine.
  • Can be mixed with: regular, NPH

2. SHORT ACTING

  • onset: 30 min-1 hr
  • peak: 2-3 hrs
  • duration: 6-8 hrs
  • appearance: clear
  • examples are: regular insulin
  • Can be mixed with: all preparations (except insulin glargine or detemir)

3. INTERMEDIATE ACTING

  • onset:1-2hrs
  • peak:8-10 hrs
  • duration:20-24 hrs
  • appear:cloudy
  • examples are:NPH, insulin lente
  • Can be mixed with: regular

4. LONG ACTING

  • onset:2-4 hrs
  • duration:20-24 hrs
  • appearance:clear
  • examples are: insulin glargine, insulin detemir
  • cannot be mixed with any other insulin

Insulin regimens using various insulin types like NPH,regular insulin,aspart,glargine

1) split mixed regimen using various insulin types.

In this regimen a total daily dose of 30:70 or 50:50 mixture of regular insulin (RI) and NPH insulin is usually split into two and injected before breakfast and before dinner.

Advantage: only 2 daily injections required as both the types of insulin comes in a premixed vial.

Disadvantages:

  • post lunch hyperglycemia is not adequately covered.
  • Late post prandial hypoglycemia can occur.
split mixed regimen using various insulin types-regular insulin and NPH insulin

2. Basal bolus regimen using various insulin types.

In this regimen a long acting insulin glargine (GLAR) is injected once a day either before breakfast or before bedtime for basal coverage.

Along with it 2- 3 injections of rapidly acting insulin like insulin lispro or aspart (ASP) is also given to combat meal time glycaemia.

Advantage: takes care of post lunch glycaemia.

Disadvantage:

  • 3-4 injections are required.
  • Expensive
  • 2 different types of insulin requires 2 different syringes to administer drug.
basal bolus regimen using various insulin types- insulin aspart and insulin glargine

Delivery systems for various insulin types-Ways to administer/take insulin.

  • Needle and syringe
  • Insulin Pen
  • Insulin Pump
  • Inhaler
  • Injection port
  • Jet injector

1. Insulin Needle and syringe

Sites:

  • Abdomen- from below the last rib till just above the pubic bone.

This site is easily accessible and therefore self administration can be done.

  • Upper and outer arm – in the region in between the shoulder till the elbow.

Therefore self  administration is not possible.

  • Upper and outer thigh- from a little below the.

This site is easily accessible and therefore self administration can be done.

  • Buttock

Procedure:

    • Clean the area of injection.
    • Withdraw the amount of insulin that you require from the ampule. (this step is missed when you use prefilled insulin)
    • Do priming of the needle, that is needle is held upright and upto 2 units of insulin is expelled into the air in a steady stream  as a test shot.
    • Priming helps get rid of the air bubble from inside the
    • Select the site for injection.
    • Pinch and lift the soft part in between your index finger and your thumb.
    • Insert the needle inside at 90 degrees angle and push the plunger slowly to inject the insulin.
    • After the dose has been injected do not remove the syringe immediately, hold it in for about 10 seconds.
    • Withdraw the needle from the skin and dispose off the needle safely.

You may sometimes notice a small amount of blood oozing out at the puncture site and may cause bruising.

The blood leak is because a small capillary wall might be punctured by the needle.

Some people might complain of pain while injecting insulin, to prevent this following measure can be taken:

  • Learn the injection technique properly.
  • Use new needle each time
  • Do not move the needle while it is inside the skin
  • Inject the insulin which is at room temperature.

Insulin like NPH which is stored in the fridge can be brought to room temperature by rolling it in between palms of both hands.

How to avoid complications like lipo hypertrophy?

  • One of the complication of insulin injection is that it causes lipohypertrophy
    • When insulin injections are given at the same place it leads to accumulation of subcutaneous fat and it presents as a lump underneath the skin.
    • When insulin is injected at this site again the insulin might not get absorbed adequately.
    • To prevent this from happening the doctor may advice you to rotate the injection site.
    • It means once you select a particular area for injection then you have to try injecting the insulin at a new spot within that area.

You can try injecting in circles, this way the injection site will also be rotated and you will get a new site for injection each time.

FAQ’s-insulin for diabetes mellitus tratment.

 

2) Insulin pen

Earlier a diabetes patient would have to roam around with the syringe, needle, vials, and cotton swab to administer insulin.

To make it easier for the patient pharmaceutical companies have developed a device called insulin pen.

This pen has a needle at its tip, and is loaded with a cartridge filled with insulin.

Patient just have to rotate the knob at the end of the pen to adjust the dose of insulin which is visible on the dose viewing window and the dose is injected.

Advantages over the syringe.

  • – Easy to use
  • – Easy to get an accurate dose
  • – Rather painless (good for using in children)
  • – Portable
  • – Less time consuming

Disadvantages

  • – Cost is more
  • – Two types of insulin cannot be mixed in the pen, will require to different pens to administer 2 different types of insulin

Procedure:

  • Uncap the insulin pen.
  • Put the needle onto the tip of the pen.
  • Rotate the knob at the bottom of the pen to set to 1-2unit.
  • Now prime the needle if you are using it for the first time.
  • For priming- hold needle upright, remove the needle cap, and press the plunger to release the insulin into the air in the form of a thin stream.
  • Priming is an important step to remove the air bubbles.
  • Now rotate the knob again to the desired dose as seen on the dose viewing window.
  • Clean the area to be injected with a swab and pinch it with your thumb and index finger.
  • Uncap the needle and insert it into the skin perpendicularly.
  • Inject the insulin, and without removing the needle out release the pinch and wait for 10second and then remove the needle.
  • Do not rub the injection site after injection.
  • Some of the pens come with prefilled insulin in it, these types of pens are to be disposed of after all the units are used.
  • Other types of pens are the one which can be reused by replacing the empty insulin cartridge with a new one.
  • Replace the needle frequently.

3) Insulin pumps

  • These are devices that administer small and continuous amount of insulin throughout the day and night directly into the subcutaneous tissue from where it is then absorbed by the body.
  • Parts: insulin reservoir, a pump, computer chip for controlling the dose of insulin to be administered, and lastly the infusion set with cannula.
  • The reservoir contains the insulin which is pumped into the subcutaneous tissue via the insulin infusion set.
  • The cannula of the infusion set is placed underneath the skin,most preferred site is the abdomen.
  • The infusion set can be left inside for 2-3 days after that a new infusion set is to be used and should be inserted at a different area.
  • Just like the insulin injections it is important to rotate the site of inserting the infusion set to prevent lumpy skin.
  • The cannula is inserted into the skin, the plastic tubing of the infusion set is adhered to the abdominal wall with adhesive tape.
  • Whereas the pump device is connected to the infusion set and held close to the body in different way such as a waist belt, or a pouch, o keeping it in the pocket etc.
  • The dose of the insulin can be adjusted by clicking on the buttons present on the pump.
  • The newer insulin pumps are developed with an inbuilt sensor which can sense the amount of insulin required by the body and adjust the dose accordingly.
  • This is called sensor-augmented insulin pump therapy.
  • In such devices the basal insulin doses are adjusted automatically by the device but the doses prior to meals have to be manually set.

4) insulin Inhaler

  • Yes it is possible to administer insulin without getting any pricks.
  • Here powdered insulin is used.
  • It is only suitable to use it for meal time insulin to lower the sudden rise in the blood sugar levels which occur after eating meal.
  • This is because when the insulin powder is inhaled it reaches the lungs and gets absorbed faster.
  • It takes around 1minute for the insulin to reach the blood circulation from the lung.
  • It acts for 12 minutes after administration.
  • It is easy to use just like an inhaler.
  • Procedure:
  • Open the inhaler device.
  • Load the insulin cartridge into it.
  • Close the inhaler device, once u hear the click sound it ensures that the device is closed properly.
  • Do not shake the inhaler.
  • Open the mouth piece, by keeping it little away from the mouth expire normally.
  • Now place the mouth piece of the inhaler into the mouth and inhale completely.
  • Hold your breath for minimum 10 seconds and then exhale and breath normally.
  • Now open the inhaler device and discard the used cartridge into waste bin.
  • Note: insulin inhalers are not adviced to patients with chronic lung problems such as asthma or chronic lung disease (COPD) as it can cause sudden narrowing of the airway (bronchospasm).

5) Insulin jet injector

  • It is device which delivers the insulin into the skin without use of needle.
  • This device delivers insulin in a very high speed through a small orifice on the nozzle of the injector which creates a very minute stream of insulin which can easily penetrate the skin without the need of a needle.
  • Advantage:
  • No need to use needles therefore painless, no issues regarding disposal of needles
  • Safe and convenient
  • Portable
  • Easy to use
  • Reusable
  • Faster absorption of insulin

Disadvantage: it is expensive

6) Insulin port

  • It is a small device used to reduce the amount of pricks a person has to go through to take insulin.
  • This devise is little bigger then a 10rupees coin or a standard bottle cap.
  • It has a soft port which is inserted into the skin.
  • The device sticks to the body with the help of adhesive.
  • It can be used for 2-3 days and then has to be replaced.
  • It can be left on even while exercising or even bathing.
  • Patient has to just inject the insulin into the port and it delivers it under the skin via its soft port.
  • As the needle pierced into the port it never touches the skin therefore it can decrease the number of pricks from 15 over 3 days to 1over 3 days.

Advantage:

  • Painless
  • Reduces the anxiety of multiple pricks
  • Easy to use

Side effects of various insulin types

1) Hypoglycaemia

  • low blood glucose levels or hypoglycaemia is the most common side effect of insulin.
  • This can occur if high doses of insulin is taken or if not enough food is eaten after giving insulin.

complications of diabetes mellitus type1,type2,gestational dm

Patient presentation:

  • Excessive sweating
  • Irritable
  • Agitated
  • Anxiety and panic
  • Weakness

If you get low blood glucose levels after insulin consult your doctor. He will make changes in your doses or make changes in your meal plan.

2)Allergic reaction in certain insulin types

  • In some individuals there can occur severe allergic reactions to the insulin, including life threatening anaphylactic reaction.
  • This could be because of the additives that are added to the insulin to increase its shelf life and make it longer acting.
  • However its very uncommon nowadays as insulin undergoes various purity checks to prevent allergic reactions.

3) Hypokalemia

  • This is one of the serious side effect which occurs because insulin helps the potassium to move into the cell cause the fall in the amount of insulin in the blood.
  • Patient presentation:
    Weakness and Fatigue
  • Digestive problems
  • Muscle stiffness, and muscle pain
  • Muscle spasms or cramps
  • Tingling sensation in limbs
  • Arrhythmias

4) Lipohypertrophy

  • When insulin injections are given at the same place it leads to accumulation of subcutaneous fat and it presents as a lump underneath the skin.
  • To prevent this insulin injections are not given at the same site again and again.

5) Edema/ swelling

  • When the insulin treatment is started some patients may develop dependent edema due to sodium retention.
  • It is not permanent and goes away in few days.

drug interactions with various insulin types

  1. Beta adrenergic blockers-
  •  They prolong the hypoglycemia by inhibiting the compensatory mechanism and also warning signs of hypoglycemia such as tremors, palpitations, anxiety are masked.
  1. Thiazide, furosemide, corticosteroids, oral contraceptives, salbutamol, nifedipine-
  • They cause  hyperglycemia  (increases blood sugar levels) and reduces effectiveness of insulin.
  1. Alcohol-
  • can precipitate hypoglycemia by depleting hepatic glycogen stores.
  1. Lithium, high dose aspirin, theophylline-
  • These drugs  exaggerate the hypoglycemia by increasing the insulin secretion and increases the uptake of glucose by the cells of the body.
  1. Rapaglinide, rosiglitazone-
  • Both causes hypoglycemia and can affect the heart.

Can cause heart attack and angina respectively.

  1. Sulfonylureas
  • Causes hypoglycemia
  1. Monoamine oxidase inhibitors
  • Can cause prolonged hyperglycemia as it increases insulin secretion.
  1. Thyroid hormones- may increase the bodies insulin requirement
  2. Antibiotics like levofloxacin and other fluoroquinolones
  • Can cause hyperglycemia or  hypoglycemia
  1. Yohimbe
  • Decreases blood glucose levels.

Precautions while taking various insulin types

  • Liver failure or liver dysfunction can reduce the amount of insulin required by the body.
  • Dose of insulin should be reduced if patient has real failure or renal impairement.
  • Insulin requirement may fluctuate in cases of stress or illness.
  • In above conditions dose adjustment may be required.
  • Insulin injection should be given at the same site by rotating the area of injection, this is because the rate of absorption of insulin is different for different site.

more articles-diagnosis of diabetes mellitus & gestational diabetes in 2020

to know about diabetic diet in detail-Diabetes mellitus diet & exercise tip.Do’s & donts for diabetes

FAQ’s-insulin for diabetes mellitus tratment.

 

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