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Insulin Use
Insulin Use
IN DIABETES MELLITUS
Dra. WIDYATI, Apt, MClin
Pharm
PENGGUNAAN INSULIN
Insulin therapy can be used to
overcome glucose toxicity
Use in acute and chronic care
Glucose toxicity
Adults
Parameter
(mg/dL)
Fasting plasma 70130
glucose
School Age
(612 years)
(mg/dL)
90180
Adolescents
and Young
Adults (1329
years)
Pregnancy
(mg/dL)
(mg/dL)
90130
6090
2 hr
<180
postprandial
plasma glucose
24 am plasma >70
glucose
Not routinely
Not routinely
120
recommended recommended
100180
90150
>60
HbA1cb
<8.0%
<7.5%d
56%
<7.0%c
ACUTE CASES
o Decompensation due to an
intercurrent event (eg, infection,
acute injury, stress)
o Severe hyperglycemia with
ketonemia or ketonuria
o Acute events: Acute Coronary
Syndrome (ACS), Stroke
o Upcoming surgery
o Allergy or other serious reaction to
oral agents
o
o
o
o
o
o
Kombinasi OAD-Insulin
Setelah kombinasi OAD gagal mengontrol
gula
Kombinasi
FPG
(mg/dl)
SU+ insulin
60-80
Metformin+in 60-80
s
Acarbose+ins 0-16
Glimepiride+i 110
ns
HbA1c (%)
0,5-1.8
1,7-2,5
0,4-0,5
2,2
9
PEMILIHAN INSULIN
Novolin R
Intermediate Acting
NPH (isophane insulin
Humulin N
suspension)
Novolin N
Long Acting
Insulin glargine
Lantus
Insulin detemir
Levemir
Combination Insulins
NPH/regular mixture
Humulin 70/30
(70%/30%)
Novolin 70/30
NPH/regular mixture
Humulin 50/50
(50%/50%)
Insulin aspart
Novolog Mix 70/30
protamine/insulin aspart
mixture (70%/30%)
Insulin NPL/insulin lispro Humalog Mix 75/25
Manufacturer
Lilly
Novo Nordisk
Sanofi-Aventis
Lilly
Novo Nordisk
Lilly
Novo Nordisk
Sanofi-Aventis
Novo Nordisk
Lilly
Novo Nordisk
Lilly
Novo Nordisk
Lilly
Insulin
Onset (hr)
Rapid acting 525 min
(insulin lispro,
aspart and
glulisine)
Peak (hr)
3090 min
Duration
(hr)
<5
Regular
0.51
23
58
Clear
NPH
24
412
1218
Cloudy
Insulin
glargine
1.5
No
2024
pronounced
peak
Relatively flat 5.723.2
Appearance
Clear
Clearb
Insulin
38
Clearb
detemir
a
The onset, peak, and duration of insulin activity may vary considerably
from times listed in this table. See text and Table 50-12.
b
Should not be mixed with other insulins or administered IV. Some
patients require twice-daily dosing.
Factor
Route of administration
Thyroid function
Comments
Onset of action more rapid and
duration of action shorter for
IV>IM>SC137
Intrapulmonary insulin has more rapid
onset and shorter duration than SC
insulin, resembling IV
pharmacokinetics72
Types of Insulin
Insulin Glulisine (Apidra, Sanofi-Aventis)
Is a rapid-acting insulin analog that differs from human insulin by substitution
of lysine for asparagine at position B3 and glutamic acid for lysine at position
B23.
Currently not FDA approved for use in pediatric patients.
It is pregnancy category C.
Lowers postprandial glucose excursions similar to insulin lispro and insulin
aspart.
Short-Acting Insulin
Onset of action of 30 to 60 minutes, a peak effect at 2 to 4 hours, and a duration
of action of 5 to 7 hours. Use of regular insulin in patients with type 1 diabetes
is much less common with the advent of the rapid-acting insulins.
Previously, an inhaled human insulin powder (Exubera, Pfizer, New York, NY)
was available. In October 2007, Pfizer announced that it would no longer make
this insulin owing to its infrequent use. In March 2008, Lilly announced that it
was cancelling the trials of its inhaled insulin.
Types of Insulin
(CONTINUE)
Targets
A1c 6,5 %
FPG/SMBG 110mg/dl
2 hr PPG/SMBG 140-180 mg/dl
Treatment Naive
Symptomatic
FPG 260 mg/dl
A1c 10%, ketoacidosis, recent rapid
weight loss
Pilihan:
1. Once-daily Insulin
2. Multi-dose insulin
3. Intensive insulin management
Once-Daily Insulin
At bedtime : NPH or Long-acting insulin
B efore supper: short-acting insulin or
premix 70/30
Dosis awal : 0,1-0,25 U/kg or 6-10 U untuk
manula kurus
Naikkan dosis setiap 2-3 hari.
Titration schedule: >180mg/dl 6 unit
141-180mg/dl 4 unit
121-140mg/dl -2 unit
Intensive Insulin
Management
1:1 basal:bolus
Basal :NPH before breakfast, before
supper or bedtime x 2 or Long acting
Insulin
Bolus: Short acting insulin at each
meal
Starting dose: 0,3-0,5 U/kg
KASUS DM TYPE 1
A.H., Wanita 18th , 50kg, 160cm MRS
dg keluhan polydipsia, nocturia (6x
semalam), fatigue, penurunan BB 6kg
dalam 2 bulan. Hasil periksa Lab GDP
190mg/dl dan GDA 250mg/dl. HbA 1c,
14% (normal, 4%6%); and trace
urine ketones yg terukur dg KetoDiastix. Selanjutnya AH didiagnosis
dg DM Type 1 dg ketoasidosis ringan.
The use of an insulin pump is currently the most precise way to mimic
normal insulin secretion.
Consists of a battery-operated pump and a computer that can program
the pump to deliver predetermined amounts of regular insulin, insulin
lispro, insulin aspart, or insulin glulisine from a reservoir to a
subcutaneously inserted catheter or needle (e.g., MiniMed Paradigm 722,
Northridge, CA; Animas 2020).89,90 These systems are portable and
designed to deliver various basal amounts of insulin over 24 hours as well
as meal-related boluses. A bolus of regular insulin can be released by the
patient 30 minutes before food ingestion.
Most patients using an insulin pump, however, prefer to use the rapidacting insulin analogs in their pump. For meal coverage, the rapid-acting
insulin can be given 0 to 15 minutes before eating. The delivery of the
bolus can be adjusted depending on the type of food eaten (e.g., piece of
cake versus slice of pizza).
The preferred meal planning approach for patients using an insulin pump
is carbohydrate counting.
The insulin to carbohydrate ratio or how much carbohydrate is covered
by 1 unit of insulin must be determined. One method is to use the 500
Rule. The number 500 (or 450 for regular insulin) is divided by the total
daily dose of insulin the patient is using to determine the insulin to
carbohydrate ratio (see Question 13). Insulin pumps are capable of
How can insulin injections be administered to A.H. in a way that mimics the physiological
release of insulin from the pancreas?
Endocrinologists have developed a variety of insulin regimens that are intended to mimic the release
of insulin from the pancreas. A total daily dose of insulin is estimated empirically (e.g., 0.5
unit/kg/day) or according to guidelines listed in Table 50-11. The total daily dose of insulin then is split
into several doses. In general, the basal dose comprises approximately 50% of the total daily dose.
A regimen much less commonly used in patients with type 1 diabetes involves injecting a mixture of
intermediate-acting and regular or rapid-acting insulin twice daily, before breakfast and before dinner
(Fig. 50-4A).
The morning dose of regular/rapid-acting insulin is intended to take care of the breakfast meal; the
morning dose of NPH takes care of the noon meal and provides basal insulin throughout the day; the
evening dose of regular/rapid-acting insulin takes care of the evening meal; and the evening dose of
NPH provides basal insulin levels during the night and takes care of any evening snack that is
ingested.
Because NPH is an intermediate-acting insulin and has a peak effect, it does not provide true basal
insulin coverage. Also, when NPH is injected in the morning, the patient must eat lunch on time
because of this peak effect, otherwise they will experience hypoglycemia. Also, when NPH is taken
with mealtime insulin before dinner, the patient is at risk for nocturnal hypoglycemia from the peak
effect of the evening dose of NPH. The advantage of using a rapid-acting insulin (e.g., insulin lispro,
insulin aspart, or insulin glulisine) instead of regular insulin in this regimen is to facilitate the patient
being able to take their insulin doses immediately before P.50p21
a meal. However, the peak effect of the NPH component in this combined dose still presents the same
problems. Caveat: When patients are switched to a rapid-acting insulin from regular insulin in this
type of regimen, the doses of NPH may have to be increased to minimize preprandial hyperglycemia.
This type of insulin regimen does not mimic physiological insulin release.
Insulin Therapy
Physiologic insulin replacement: to
replicate normal insulin secretion,
comprise:
Basal Insulin: insulin available
overnight and between meals to
suppress hepatic glucose production
Meal-related insulin(BOLUS): given w/
each meal to promote glucose
utilization after eating
34
Meal-Related Insulin
Replacement
Regular Insulin:
May need snacks to prevent postprandial
hypoglycemia
Longer DOA as dose increase
Slows correction of hyperglycemia
Caution w/ postprandial exercise
Contributes to basal insulin when time between
meal is long
Insulin Lispro
Postprandial glucose level improved
Consistency of action as dose increases
Less need for snacks
Less hypoglycemia
Good for exercise> 2hours after a meal
35
37
PENETAPAN DOSIS
INSULIN
0.30.5 unit/kg
Honeymoon phase
0.20.5 unit/kg
1.01.5 units/kg
0.71.5 units/kg
(CONT)
Kasus 1
Tn HM 58th 160cm 85kg, MRS karena
akan menjalani ops katarak. Pada
saat MRS hasil pemeriksaan gula
puasa 216mg/dl, GD 2jamPP
234mg/dl. Menurut pengakuan Tn
HM memang memiliki riwayat DM,
namun tidak kontrol rutin, obatpun
tidak rutin dan lebih sering meminum
Glibenklamide.
Kasus 2
Tn Y, 46th 167cm, 70kg, MRS dengan
keluhan mual muntah. Pada
pemeriksaan gula puasa di lab luar
dijumpai FPG 253mg/dl; 2jPP 315
mg/dl. Pasien mengaku memiliki
riwayat DM sudah lima tahunan
dengan obat Glibenklamide 1-1-0
dan metformin 3x500mg.
Bagaimana Pharm care untuk kasus
ini?
Kasus 3
Tn K 59th, 172cm 75kg, MRS dengan
keluhan kencing tidak lancar, disertai
rasa panas dan nyeri pada saat
kencing. Pasien mengaku memiliki
DM sudah 8tahun dan masih minum
Gliklazide 1-1-0 dan Metformin 3 x
850mg. Hasil lab: FPG 265mg/dl; 2JPP
168mg/dl; Leukosit (N),
Leukosuria(+). Hasil observasi TTV
TD 140/90; Temp (N). Bagaimana
Kasus 4
Tn N 44th 168m, 78kg MRS karena
hasil SMBG puasa 328mg/dl. Pasien
selama ini sudah menggunakan
Humulin N 24-0-16 U. Bagaimana
rekomendasi penatalaksanaan pada
kasus tersebut.
Kasus 5
Tn KP 62th, 161cm, 59kg MRS
dengan diagnosa stroke infark di
hemisphere kanan yang luas. Hasil
Lab GDP 154mg/dl sehingga
diberikan 3 x 4U s.c., namun 2 hari
kemudian pasien kejang dan hasil
GDP 189mg/dl. Pengakuan keluarga
pasien hanya memakan makanan RS.
Bagaimana dengan penatalaksanaan
DM?