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Premium member Presentation Transcript Insulin: Insulin The ultimate treatment of diabetesBefore Insulin: Before Insulin Before insulin was discovered in 1921, everyone with type 1 diabetes died within weeks to years of its onset JL on 12/15/22 and 2 mos laterPowerPoint Presentation: 1922 Banting and Best use bovine insulin extract on human 1923 Lilly produces commercial quantities of bovine insulin 1936 Hagedorn discovers that adding protamine to insulin prolongs the effect of insulin 1946 Nordisk formulates Isophane® porcine insulin aka Neutral Protamine Hagedorn or NPH insulin 1950 Nordisk markets NPH insulin 1953 Novo formulates Lente® porcine and bovine insulins by adding zinc for longer lasting insulin 1978 Genentech produces human insulin in Escheria coli bacteria using recombinant DNA 1981 Novo Nordisk chemically and enzymatically converts bovine to human insulin 1982 Genentech human insulin approved 1983 Lilly produces recombinant human insulin, Humulin® 1988 Novo Nordisk produces recombinant human insulin 1996 Lilly Humalog® "lyspro" insulin analogue approved 2003 Aventis Lantus® "glargine" insulin analogue approved in USA  2006 Novo Nordisk's "Detemir" approved in USATypes of Insulin: Types of Insulin Beef Porcine Human Insulin Regular NPH (Neutral Protamine Hagedorn) 70/30 Insulin Analogues Ultra Short Acting Long ActingPowerPoint Presentation: Animal insulins The amino acid sequence for insulin is highly conserved in mammals. Porcine insulin has only a single amino acid variation from the human variety B ovine insulin varies by three amino acids. Both are active on the human receptor with approximately the same strength. Non human insulins can cause allergic reactions in some people, and human insulin replaced animal analoguesPre- recombinant era of insulin production: Pre- recombinant era of insulin production Insulin could be obtained from cows’ or pigs’ pancreases (used since 1922) (7-10 lb pancreatic tissue per patient per year )Pre- recombinant era of insulin production: Pre- recombinant era of insulin production Bovine insulin = 3 amino acid difference Porcine insulin = 1 amino acid difference Amino acid differences stimulate allergic responsesPowerPoint Presentation: Human insulin also cause formation of antibodies in substantial number of users (55%) lipoatrophy Nevertheless human insulin is preferredWhy Human Insulin ?: Why Human Insulin ? Although bovine and porcine insulin are similar to human insulin, their composition is slightly different Consequently, a number of patients' immune systems produce antibodies against it, neutralizing its actions and resulting in inflammatory responses at injection sites Added to these adverse effects of bovine and porcine insulin, were fears of long term complications ensuing from the regular injection of a foreign substance, as well as a projected decline in the production of animal derived insulin These factors led researchers to consider synthesizing Human Insulin by inserting the insulin gene into a suitable vector, the E. coli bacterial cell, to produce an insulin that is chemically identical to its naturally produced counterpart This has been achieved using Recombinant DNA technologyCommonly used Insulins: Commonly used Insulins Rapid-acting, are presently insulin analogs , such as the insulin analog lispro – begins to work within 5 to 15 minutes and is active for 3 to 4 hours. Short-acting, such as regular insulin – starts working within 30 minutes and is active about 5 to 8 hours. Intermediate-acting, such as NPH , or lente insulin – starts working in 1 to 3 hours and is active 16 to 24 hours. Long-acting, such as ultralente insulin – starts working in 4 to 6 hours, and is active 24 to 28 hours. Insulin glargine and Insulin detemir – both insulin analogs which start working within 1 to 2 hours and continue to be active, without major peaks or dips, for about 24 hours, although this varies in many individuals. A mixture of NPH and regular insulin – starts working in 30 minutes and is active 16 to 24 hours. There are several variations with different proportions of the mixed insulins.PowerPoint Presentation: Type of insulin Generic and brand names How long it takes to begin working (onset) When it has the most effect on your blood sugar (peak) How long the overall effect lasts (duration) Rapid-acting Absorbed more quickly than short-acting insulin, but effects wear off sooner Insulin aspart (NovoLog) Insulin glulisine (Apidra) Insulin lispro (Humalog) 10 to 30 minutes 30 minutes to 3 hours 3 to 5 hours Short-acting Works quickly, but effects don't last as long as intermediate-acting insulin Insulin regular (Dongsulin R, Humulin R, Actrapid, others) 30 to 60 minutes 2 to 5 hours Up to 8 hours Intermediate-acting Starts working later than short-acting insulin, but effects last longer Insulin NPH human (Dongsulin N, Humulin N, Insulatard) 1 to 2 hours 4 to 12 hours 16 to 24 hours Background/bolus together Humalog 75/25 (NPL/Lispro) 5-15 minutes Early peak - late peak: 1-12 hours about 18 hours 70/30 or 50/50 (NPH/ Regular) 30-60 minutes Early peak - late peak: 2-12 hours about 18 hours Long-acting Takes several hours to work, but provides insulin at a steady level for up to 24 hours Insulin glargine (Lantus) Insulin detemir (Levemir) 1 to 5 hours No clear peak Up to 24 hoursSynthetic Insulin: Synthetic Insulin Synthetic insulin has given an alternative to animal insulin’s, which have previously been used to counteract forms of diabetes with insulin dependencies Synthetic insulin is synthesized using recombinant DNA technology The insulin produced is identical in structure to its human counterpart, which as a result reduces any antibody production in response to the introduced insulinPowerPoint Presentation: Chemically, insulin is a small, simple protein. It consists of 51 amino acid, 30 of which constitute one polypeptide chain, and 21 of which comprise a second chain. The two chains are linked by a disulfide bond. Source: Chance, R. and Frank B. - Research, development, production and safety of Biosynthetic Human Insulin. Chemical Structure Human InsulinAnalogues: AnaloguesInsulin Analog: Insulin Analog An insulin analog is an altered insulin, different from the insulin secreted by the human pancreas, but still available to the human body for performing the same action as human insulin Through genetic engineering of the underlying DNA, the amino acid sequence of insulin can be changed to alter its ADME (absorption, distribution, metabolism, and excretion) characteristics.PowerPoint Presentation: Human Insulin PHE A-CHAIN B-CHAIN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 S S S S S S VAL ASN GLN HIS LEU CYS GLY SER HIS LEU VAL GLU ALA LEU TYR LEU VAL CYS GLY GLU ARG GLY PHE PHE TYR THR PRO LYS THR GLY ILE VAL GLU GLN CYS CYS THR SER ILE CYS SER LEU TYR GLN LEU GLU ASN TYR CYS ASN 30 1 8 9 10 2 3 4 5 S GLY SER VAL GLU Insulin Lispro PHE A-CHAIN B-CHAIN 2 3 4 5 6 7 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 1 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 S S S S S VAL ASN GLN HIS LEU CYS HIS LEU VAL GLU ALA LEU TYR LEU VAL CYS GLY GLU ARG GLY PHE PHE TYR THR LYS PRO THR GLY ILE GLN CYS CYS THR SER ILE CYS SER LEU TYR GLN LEU GLU ASN TYR CYS ASN 30 DiMarchi et al. Peptides-Chemistry and Biology 1992:26-28. Howey et al. Diabetes 1994; 43:396-402.PowerPoint Presentation: Lispro insulin Lilly had the first insulin analogue with "lispro" as a rapid acting insulin analogue. It is marketed under the trade name Humalog®. It was engineered through recombinant DNA technology so that the penultimate lysine and proline residues on the C-terminal end of the B-chain were reversed. This modification did not alter receptor binding, but blocked the formation of insulin dimers and hexamers. This allowed larger amounts of active monomeric insulin to be available for postprandial (after meal) injections.Structure of insulin aspart: Structure of insulin aspart Glu Thr Lys Thr Tyr Phe Phe Gly Arg Glu Gly Cys Val Leu Tyr Leu Ala Val Leu His Ser Gly Cys Leu His Gln Asn Val Phe B1 Asn Cys Tyr Asn Glu Leu Gln Tyr Leu Ser Cys Ile Ser Thr Cys Cys Gln Glu Val Ile Gly A21 B28 B30 Asp Pro AspPowerPoint Presentation: Aspart insulin Novo Nordisk created "aspart" and marketed it as NovoLog®/NovoRapid (UK) as a rapid acting insulin analogue. It was created through recombinant DNA technology so that the amino acid, B28, which is normally proline, is substituted with an aspartic acid residue. The sequence was inserted into the yeast genome, and the yeast expressed the insulin analogue, which was then harvested from a bioreactor. This analogue also prevents the formation of hexamers, to create a faster acting insulin. Can be used in CSII pumps and Flexpen, Novopen delivery devices for subcutaneous injection.PowerPoint Presentation: S. No. Formulation Company Onset Peak Duration 1 HUMALOG Eli Lilly 15 – 30 min 30 min – 2.5 hour 3 – 5 hour 2 NOVO MIX 30 Novo Nordisk 10 – 20 min 1 – 4 hour Upto 24 hour 3 HUMALOG MIX 25 Eli Lilly 15 min 30 min – 2.5 hour 16 – 20 hour RAPID ACTINGStructure Insulin Glargine: Structure Insulin Glargine Vajo & Duckworth, 2000. Pharmacological Reviews, 52:1-9; Heinemann L et al. Diabetes Care 2000;23:644–649 ; Hilgenfeld R et al. Diabetologia 1992;35[Suppl 1]:A193 These changes cause a shift in the isoelectric point from 5.4 in native insulin to 7.0 in insulin glargine NH 2 COOH NH 2 COOH S S S S S A21[Gly] B-chain A-chain S B31[Arg] B32[Arg] Arg extension Asp subtitutionGlargine insulin: Glargine insulin Aventis developed glargine as a longer lasting insulin analogue, and markets it under the trade name Lantus® It was created by modifying three amino acids Two positively charged arginine molecules were added to the C-terminus of the B-chain, and they shift the isoelectric point from 5.4 to 6.7, making glargine more soluble at a slightly acidic pH and less soluble at a physiological pH Replacing the acid-sensitive asparagine at position 21 in the A-chain by glycine is needed to avoid deamination and dimerization of the arginine residue. These three structural changes and formulation with zinc result in a prolonged action when compared with regular human insulin. When the pH 4.0 solution is injected, most of the material precipitates and is not bioavailable A small amount is immediately available for use, and the remainder is sequestered in subcutaneous tissue As the glargine is used, small amounts of the precipitated material will move into solution in the bloodstream, and the basal level of insulin will be maintained up to 24 hour The onset of action of subcutaneous insulin glargine is slower than NPH human insulin. It is clear solution.Insulin Glargine Structure: Insulin Glargine Structure Asparagine at position A21 replaced by glycine Provides stability Addition of 2 arginines at the C-terminus of the B chain Soluble at slightly acidic pH 1. Lantus ® (insulin glargine) EMEA Summary of Product Characteristics. 2002. 2. McKeage K et al. Drugs . 2001;61:1599-1624. Substitution Extension A chain B chain 1 15 10 5 10 15 20 Asn 30 Gly Arg Arg 5 10 15 19 25 1PowerPoint Presentation: Insulin detemir Thr Glu Lys Val Phe Asn Glu Leu Gln Tyr Leu Ser Cys Ile Ser Cys Cys Gln Glu Val Ile Gly Tyr Cys Asn Lys Pro Thr Tyr Phe Phe Arg Gly Glu Gly Cys Val Leu Tyr Leu Ala Val Leu His Ser Gly Cys Asn Gln Leu His B1 A21 A1 B29 14-carbon fatty acid chain (Myristic acid) ThrLevemir: Levemir Insulin detemir is a long-lasting human insulin analogue for maintaining the basal level of insulin Novo Nordisk markets it under the trade name Levemir It is an insulin analogue in which to the lysine amino acid at position B29 a fatty acid (myristic acid) is bound It is quickly resorbed after which in the blood it binds to albumin through the fat acid at position B2 It then slowly dissociates from this complexPowerPoint Presentation: S. No. Formulation Company Onset Peak Duration 1 LANTUS Sanofi Aventis 1 – 1.5 hour No peak 20 – 24 hours 2 DETEMIR Novo Nordisk LONG ACTING ANALOGUESInsulin Action: comparison of new Insulin Analogs: Insulin Action: comparison of new Insulin AnalogsPowerPoint Presentation: An insulin pump is a medical device used for administering insulin in the treatment of diabetes mellitus , also known as continuous subcutaneous insulin infusion therapy. The device includes: the pump itself (including controls, processing module, and batteries) a disposable reservoir for insulin (inside the pump) a disposable infusion set , including a cannula for subcutaneuos insertion (under the skin) and a tubing system to interface the insulin reservoir to the cannula. An insulin pump is an alternative to multiple daily injections of insulin by insulin syringe or an insulin pen and allows for intensive insulin therapy when used in conjunction with blood glucose monitoring and carb countingExubera: Exubera Inhalable insulin is a new (as of mid-2006) method of delivering insulin, a drug used in the treatment of diabetes, to the body. It is the first new treatment option of insulin since the discovery of insulin in 1921, traditionally administered by subcutaneous injection. It is a powdered form of recombinant human insulin, which is delivered through an inhaler into the lungs where it is absorbed. As of March 2007, the currently available type (Exubera) is a fast or rapid acting form of insulin , meaning that once it has been absorbed, it begins working within the body over the next few hours. Diabetics still need to take a longer acting basal insulin by injectionDifferent Patterns Of Insulin Dosage : Different Patterns Of Insulin DosageTwice daily insulin injections : Twice daily insulin injectionsThree times daily injections : Three times daily injectionsFour times daily injections (basal—bolus): Four times daily injections (basal—bolus )Conventional Insulin Therapy: Conventional Insulin Therapy Conventional insulin therapy has these characteristics: Insulin injections of a mixture of rapid and intermediate acting insulin are performed two or three times daily. Meal are scheduled to match the anticipated peaks in the insulin profiles.Intensive Insulin Therapy: Intensive Insulin Therapy The trade-off is the increase from 2 or 3 injections per day to 4 or more injections per day, which was considered "intensive" relative to the older approach.Intensive or Flexible Therapy: Intensive or Flexible Therapy A working pancreas continually secretes small amounts of insulin into the blood to prevent the body from shifting into "starvation metabolism.“ Insulin levels rise immediately as we begin to eat, remaining higher than the basal rate for 1 to 4 hours. This meal-associated ( prandial ) insulin production is roughly proportional to the amount of carbohydrate in the meal.PowerPoint Presentation: Insulin regimens for type 2 diabetes. Regimen Advantages Disadvantages Approx. Cost Once daily Twice daily isophane Twice daily pre-mixed Multiple injection (basal-bolus) regimen Glargine + bolus regimen or combine with an oral Simple Can be combined with continued oral hypoglycaemic therapy Dose titrated against fasting glucose results Can be administered by relative or district nurse if necessary Relatively simple Controls symptoms Low risk of hypoglycaemia Relatively simple Suitable for patients with a routine daiy lifestyle Greater flexibility with meals Suitable for patients with non-routine daily lifestyle Newer short and long acting analogues allow good glucose control at low risk of hypoglycaemia Good basal coverage No nocturnal hypoglycemia Daytime hyperglycaemia can be a problem Morning and evening hyperglycaemia likely due to inadequate insulin post breakfast and post evening meal Sometimes presents with titration difficulties since ratio is fixed Four or more injections per day More complex regimen needing good understanding by patient Has to be combined with a bolus regimen or risk post meal hyperglycaemia Cost Rs 10/day Rs 14/day Rs 15/day Rs 19/day Rs 65 to 70/dayHow to Inject Insulin: How to Inject InsulinSupplies Required: Supplies Required Syringe Insulin Bottle 2 alcohol swabs Sharps containerStep 1: Wash Hands: Step 1: Wash HandsStep 2: Roll Bottle (if cloudy): Step 2: Roll Bottle (if cloudy) Gently roll between hands NEVER shake Inspect for particulate matter that doesn’t dissolve – If found – discard vial/ cartridgeStep 3: Remove Cap & Wipe: Step 3: Remove Cap & Wipe Wipe bottle(s) with alcohol Wipe the top of the bottles in 1 direction Allow to air dry before proceedingStep 4: Fill syringe with air: Step 4: Fill syringe with air needed for cloudy insulin Pull back an amount of air equal to the amount of cloudy insulin you will withdrawPush needle into cloudy insulin: Push needle into cloudy insulinStep 6: Inject air into cloudy insulin: Step 6: Inject air into cloudy insulin Push air into vial Withdraw syringe DO NOT withdraw insulin at this timeStep 7: Fill syringe with air: Step 7: Fill syringe with air Pull back an amount of air equal to the amount of clear insulin you will withdrawStep 8: Push needle into clear insulin : Step 8: Push needle into clear insulin Push air into vial Withdraw syringe DO NOT withdraw insulin at this timeStep 9: Inject air into clear insulin: Step 9: Inject air into clear insulin DO NOT REMOVE the syringe from the bottleStep 10: Invert bottle: Step 10: Invert bottle Keep syringe inside of insulin vialStep 11: Withdraw clear insulin: Step 11: Withdraw clear insulin Extract insulin equal to the amount of air you injected Pull slowly to avoid air bubblesStep 12: Check for air bubbles: Step 12: Check for air bubbles Air bubbles = less insulin Push insulin back into vial if necessary and then pull back again Confirm proper dose of insulin Remove needle from bottleStep 13: Push syringe into cloudy insulin : Step 13: Push syringe into cloudy insulin Syringe now has dose of clear insulin in it After insertion, invert bottleStep 14: Withdraw cloudy insulin : Step 14: Withdraw cloudy insulin Pull slowly DO NOT OVERDRAW Must waste entire syringe DO NOT PUSH INSULIN BACK INTO VIAL You are now ready to injectInjecting: Injecting Choose Site Gently pinch skin fold Let needle rest on skin for 1-2 seconds to desensitize the area Gently push needle into skin at 90º angle Push in plunger Hold for 3-5 seconds Remove Dispose of syringe properlyWhich injection sites are recommended these days to inject insulin? : Which injection sites are recommended these days to inject insulin? Possible sites to inject insulin for Diabetes mellitus: Abdomen quick insulin absorption Upper thigh + buttocks slow insulin absorptionWhich scheme should be followed for rotation of injection sites?: Which scheme should be followed for rotation of injection sites? Possible injections sites: Change injection sites on a regular basis by rotating site Minimum distance of 3 cm between two injection sites Minimum distance of 3 cm to the navelMinimizing Painful Injections: Minimizing Painful Injections Inject insulin at room temperature Remove air bubbles Wait for alcohol to evaporate from skin Keep muscles relaxed Do not change the direction of the needle during insertion or withdrawalSpeed of Absorption: Speed of Absorption Abdomen (fastest) Avoid 2 inch circle around the navel Arms Legs Buttocks Massaging of area and/or exercise speeds absorption Therefore, rotation within an area is preferred over rotation between areasWhich needle length shall be chosen?: Which needle length shall be chosen?Reusing Syringes: Reusing Syringes Sterility Safety/Comfort Silicone coating Cost ADA Recommendation Only if sterility is assured & patient is competent to inspect needle for reuse Association to lipodystrophy?PowerPoint Presentation: How does multiple use change a pen needle? New needle Needle after multiple use (partly with tissue residues attached)Other issues: Other issues Clothing – Injecting insulin through clothing is preferable to delaying a dose – Clothing must be clean – Patient must not be immunocompromised • Storage – Vials in use: room temperature for 28 days – Vials not in use: refrigerate – Pre-measured syringes: refrigerate for 21 days Do not allow to freezePowerPoint Presentation: How to avoid problems when injecting insulin?Prefilled syringes: Prefilled syringes • Can fill syringes prior to use • Stable for 21 days • Store vertically with needle facing upwards – Prevents needle from clogging • Useful for those with poor eyesight/dexterity • Monitor more closely to assure no decrease in potency & no effect on BGSigns of Hypoglycemia: Signs of Hypoglycemia • Glucose level < 80 mg/dl or <90 mg/dl with symptoms • Fatigue • Nervousness • Irritability • Trembling • HA • Hunger • Cold Sweats • Rapid Heart Rate • Blurry or Double Vision • ConfusionSigns of Hypoglycemia : Signs of Hypoglycemia Nighttime Symptoms: – Nightmares – Waking up very alert – Damp night clothes or sheets – Waking up with fast heart rateWait between Injection and Meal: Wait between Injection and Meal With standard short—acting insulins (Dongsulin R) waiting 20—30 minutes is generally recommended after the injection to allow the insulin to start being absorbed For very short—acting insulins (Humalog Novorapid) the patient should eat within 5—10 minutes of the injection otherwise hypoglycaemia is likelyPowerPoint Presentation: Insulin therapy Insulin therapy aims to replicate the normal physiological insulin response Insulin regimens should be individualized type of diabetes willingness to inject lifestyle blood glucose monitoring age dexterity glycaemic targetsPowerPoint Presentation: Indications for insulin therapy Type 1 diabetes Women with diabetes who become pregnant or are breastfeeding Transiently in type 2 diabetes in special situations In type 2 diabetes, inadequately controlled on glucose-lowering medicines (secondary failure)PowerPoint Presentation: Commencing insulin therapy Starting dose will depend on many factors age weight type and duration of diabetes glycaemic targets In type 2 diabetes, consider continuing maximum tolerated oral glucose-lowering medicines 10 units of intermediate-acting insulin once a dayPowerPoint Presentation: Diabetes Care Dose Calculation and Adjustments Begin modestly with 0.3 to 0.5 U/kg/day insulin (total) 2/3 of this dose in the morning and 1/3 in the evening 2/3 of the insulin should be NPH and 1/3 should be regular or simply use 70/30 combination Begin with loose control and tighten with experience Tight control is dependant on the stage of the diseaseStarting insulin in type 2 diabetes: Starting insulin in type 2 diabetes Start small dose intermediate- acting insulin at night Aim for target fasting levels first Adjust by 2-4 units or 10% Second injection only added once fasting targets reachedPowerPoint Presentation: Diabetes Care Insulin - Combination with Oral Agents With Sulphonylureas – BIDS Therapy With Metformin With Rosiglitazone or PioglitazoneInsulin Adjustment Guidelines: Insulin Adjustment Guidelines Insulin Pattern Adjustments Adjust insulin from 3- days pattern Determine which insulin is responsible for pattern Adjust by 2-4 units Adjust only one dose at a time Correct hypoglycemia first. If hyperglycemia throughout the day, correct highest SMBG first; if all within 50 mg/dl, correct AM first.PowerPoint Presentation: Which insulin to adjust when? Blood glucose Insulin to be changed Fasting Bedtime or supper intermediate- or long-acting Post-breakfast Morning short- or rapid-acting insulin Pre-lunch Morning intermediate-acting insulin Post-lunch Morning intermediate-acting insulin or lunchtime short- or rapid-acting insulin Pre-supper (dinner) Morning intermediate-acting insulin Post-supper (dinner) Supper-time short- or rapid-acting insulin During the night Supper-time or bedtime intermediate-actingPowerPoint Presentation: Adjust insulin based on BG pattern R/N – 0 –R/N – 0 or LP/N –0 – LP/N – 0 pm R or LP 2-4 U (f) pm R or LP 1-2 U (f) pm R or LP 1-2 U (e) BEDTIME >250 mg/dl 160-250 mg/dl < 100 mg/dl If BG am N 2-4 U (f.h) am N 1-2 U (f.h) am N 1-2U (d.e) P.M. am R or LP 2-4 U (f.g) am N 1-2 U (f.h) am R or LP 1-2 u.(c.e.) MIDDAY Pm N 1-2 u (a.b.) pm N 1-2 u (a) Pm N 1-2 u (a.b.) A.M. > 250 mg/dl 140-250 mg/dl < 80 mg/dl If BGPowerPoint Presentation: Defined glycaemic targets in T2DM FPG=fasting plasma glucose. American Diabetes Association. Diabetes Care 2004;27(suppl 1):S15 ― 35. American Association of Clinical Endocrinologists. Endocr Pract 2002;8(suppl 1):43―84. Japan Diabetes Society. Available at: http://www.jds.or.jp. International Diabetes Federation. Diabet Med 1999;16:716―30. *1 ― 2 hours postprandial; **2 hours postprandial. Glucose control Healthy ADA 1 AACE 2 JDS 3 IDF 4 HbA 1c (%) <6 <7 6.5 5.8―6.4 6.5 Mean FPG mmol/l (mg/dl) <5.6 (<100) 5―7.2 (90―130) <6 (<110) 5.6―6.6 (100―119) <6 (<110) Mean postprandial PG mmol/l (mg/dl) <7.8 (<140) <10* (<180) <7.8** (<140) ― <7.8** (<140)Example 1: Insulin: NPH 25 units, Reg. 10 units before breakfast NPH 15 units, Reg. 10 units before supper Example 1 Pre-breakfast mmol/L (mg/dl) Pre-lunch Pre-supper 2 hours post-supper Day 1 10.4 (187) 6.5 (117) 7.0 (126) 9.2 (165) Day 2 9.6 (172) 5.4 (97) 6.8 (122) 10.2 (183) Day 3 11.0 (198) 6.2 (112) 6.5 (117) 8.8 (158)Example 2: Example 2 Insulin: rapid-acting before each meal and NPH at bedtime Pre-breakfast mmol/L (mg/dl) Pre-lunch Pre-supper 2 hours post-supper Day 1 7.0 (126) 6.5 (117) 15.1 (272) 10.3 (185) Day 2 6.7 (120) 5.4 (97) 14.6 (263) 12.2 (219) Day 3 6.5 (117) 6.2 (112) 12.5 (225) 11.8 (212)What would you advise if….: What would you advise if…. The insulin had been taken and the restaurant meal was late Regular insulin should be taken before a meal but the pre-meal blood glucose is 3.5 mmol/L (63 mg/dl) A tennis match is scheduled an hour after lunch A person wakes up nauseated and does not want to eat Blood glucose levels do not coincide with how a person feelsSummary: Summary All people with type 1 diabetes must be treated with insulin The majority of people with type 2 diabetes will need insulin within 5 to 10 years of diagnosis Insulin therapy should not be used as a threat Insulin regimens should be individualized Insulin should be adjusted to achieve blood glucose as close to target range as possibleEnd Of Module 9: End Of Module 9 You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.