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Page 1Diabetes Education Services© 1998-2019 www.DiabetesEd.net
DM Fundamentals – Class 3Insulin and Pattern Management
Beverly Thomassian, RN, MPH, BC-ADM, CDEPresident, Diabetes Education Services
2019
Insulin – Ultimate Hormone
Replacement Therapy
� Incorporating National
Guidelines into practice
� Using basal/bolus insulin therapy
to improve glucose control from
hospital to home
� Glucose patterns and adjustment
strategies
Insulin – the Ultimate Hormone Replacement
Therapy
Objectives: •Discuss the actions of different insulins•Describe using pattern management as an insulin adjustment tool.
Page 2Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Insulin Finally Available - 1922
The Nobel Prize in Physiology or
Medicine 1923
Born: 14 November 1891, Alliston, CanadaDied: 21 February 1941, Newfoundland, CanadaAffiliation at the time of the award:University of Toronto, Toronto, CanadaPrize motivation: "for the discovery of insulin"Field: endocrinology, metabolism
Frederick G. Banting
Poll question
� 1. A patient tells you she doesn't want to start
on insulin. What is your best response?
a. The needles are so small, you won't feel a thing.
b. You might die if you don't take insulin.
c. Tell me why.
d. There is a doctors' order to start insulin.
Page 3Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Psychological Insulin Resistance (PIR)
� 50% of providers in study threatened pts “with the needle”.
� Less than 50% of providers realized insulins’ positive effect on type 2 dm
� Most pts don’t believe that insulin would “better help them manage their diabetes”.
� Solutions: Find the root of PIR and address it, use more insulin pens
Diabetes Attitudes, Wishes, Needs Study - Rubin
Needle Size often a Barrier
Size Does Matter
� Use more short needles – 4 mm
� Effective for pts with BMI of 24- 49
� Keeps it subq
� If pt thin, inject at angle
� To avoid leakage, count to 10 before withdrawing needle
� ½ the patients who could benefit from insulin are not using it due to needle phobias
Poll question
� 2. What best describes the role of bolus
insulins?
a. cover carbs at meals and hyperglycemia
b. helps to lower fasting blood glucose
c. keeps overnight blood sugars under control
d. should be used during hypoglycemic
episodes
Page 4Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Insulin(µU/mL)
Glucose(mg/dL)
Physiologic Insulin Secretion: 24-Hour Profile
150
100
50
07 8 9 10 11 12 1 2 3 4 5 6 7 8 9
A.M. P.M.
Basal Glucose
Time of Day
50
25
0 Basal Insulin
Breakfast Lunch Dinner
Bolus Insulin
Mealtime Glucose
Insulin Action Teams� Bolus: lowers after meal glucose levels
� Very Rapid Acting – Aspart (Fiasp)� Rapid Acting
� Aspart, Lispro, Admelog, Glulisine, Afrezza� Short Acting - Regular
� Basal: controls glucose between meals, hs� Intermediate
� NPH� Long Acting
� Detemir (Levemir)� Glargine (Lantus, Basaglar)� Degludec (Tresiba)
Page 5Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Bolus Insulins
(½ of total daily dose ÷ meals)
Name Onset Peak Action
� Aspart (Fiasp) 2.5 min 1 hour
� Aspart (NovoLog) 15-30 min 1-1.5 hrs
� Lispro(Humalog, Admelog)
� Glulisine (Apidra)
� Afrezza (Inhaled)
� Regular 30 mins 2-4 hrs
Aspart (Fiasp)� New Aspart formulation, which
includes the addition of niacinamide (vitamin B3) to increase absorption speed
� Appears in blood in ~ 2.5 mins.� Faster onset and offset. � Starts working within minutes
� Can be taken as long as 20 minutes after starting a meal.
� Fiasp available in Flex Touch Pens and 10mL vials.
Biosimilar Insulins –Lispro (Admelog) – bolus Glargine (Basaglar) – basal
� Copy cat insulins
� Can’t use the term generics for large molecule
biologicals because they are manufactured in
living organisms (bacteria and yeast)
� Each batch may be slightly different
� Currently - Pharmacist to contact Provider
before switching to biosimilar
� Future – may be same as generics
Insulin – Large Molecule
Aspirin – Small Molecule
Page 6Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Poll question
� 3. Which insulins are cheapest?
a. Lantus, Levemir
b. Novolog, Humalog
c. Reg, NPH
d. Insulin pens
Cost Per Vial in Northern CA
Afrezza – Inhaled Insulin –
Approved 2014 – Type 1 or 2
Only studied in adults over 18
Not indicated for pregnancy, while breastfeeding
Page 7Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Steps, Cost, Terms� Afrezza is regular human
insulin in powder form using Technosphere technology.
� Pricing –similar pricing as pens ~ $300 a month
� Dosing: 4, 8 and 12 unit cartridges� Convert with 1:1 ratio to existing
insulin dose
� Lung function test before start (FEV1)
Bolus Insulin Summary
� Regular, aspart, lispro, glulisine,
� Starts working fast (15-30 mins)
� Gets out fast (3-6 hours)
� Post meal BG reflects effectiveness
� Should comprise about ½ total daily dose
� Covers food or hyperglycemia.
� 1 unit
� Covers ≈ 10 -15 gms of carb
� Lowers BG ≈ 30 – 50 points
Bolus Insulin Timing
� How is the effectiveness of bolus insulin determined?� 2 hour post meal (if you can get it)
� Before next meal blood glucose
� Glucose goals (ADA) – may be modified by provider/pt� 1-2 hours post meal
Page 8Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Bolus – Insulin Sliding ScaleStarts at 150, 2 units for every 50 mg/dl >150
Break Lunch Dinner HS
Day 1 94 no insulin
212 4 uR
148 no insulin
254 6 uR
Day 2 243 4uR
254 6 uR
201 4uR
199 no insulin
Day 3 189 2uR
243 4uR
162 2uR
244 4uR
Day 4 66 No insulin
287 6uR
144 none
272 6uR
Basal Insulins
(½ of total daily dose)
Intermediate Acting Peak Action Duration� NPH 4-12 hrs 12-24
Long Acting Peak Action Duration� Detemir (Levemir) No Peak 20 hrs� Glargine (Lantus) 24 hrs
� Glargine (Basaglar) 24 hrs� Degludec (Tresiba) 42 hrs
Fasting BG reflects efficacy of basal
Degludec
� Degludec (Tresiba)
� An ultra long acting insulin - lasts
up to 42 hours
� Takes 3-4 days to reach steady state
� Available in u-100 and u-200 pens
� Seems to cause less hypo
� Adjust dose every 3-4 days
� Wait at least 8 hours between doses
� Good at room temp for 8 wks
� Ryzodeg 70/30
� mixture of insulin degludec and aspart
Page 9Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Basal Insulin Summary
� NPH, Detemir, Glargine, Degludec
� Covers in between meals, through night
� Starts working slow (4 hours)
� Stays in long (12-24 hours)
� NPH 12 hrs
� Detemir, Glargine 20-24 hrs
� Degludec – up to 42 hrs
� Fasting blood glucose reflects
effectiveness
Pattern Management
American Diabetes Association
Page 10Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Poll Question
� 4. When looking at glucose patterns, which
problem do you fix first?
a. hyperglycemia
b. hypoglycemia
c. non-compliance
d. legible writing
Pattern Management� Safety 1st!! - Evaluate 3 day patterns
� Hypo: eval 1st and fix:
� If possible, decrease medication dose
� Timing of meals, exercise, medications
� Hyperglycemia: evaluate 2nd
� Identify patterns
� Before increase insulin, make sure not missing
something (carbs, exercise, omission)
Type 2 – Amaryl 4mg AM, 10u Lantus pm
Break Lunch Dinner HS
Day 1 164 94 66 162
Day 2 169 59 195
Day 3 84 81 242
Day 4 159 43
211
Page 11Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Case Study
� 70 yr old, avid walker
� BMI 24, Weighs 60kg, GFR 58
� A1c – 10.1%, BG 250 – 300s during day
� Complaining of frequent urination
� Insulin – 30 units Lantus (solostar pen)
� Oral Meds: metformin 2000mg daily
� What medication changes?
� What insulin changes?
� Other possibilities?
Basal + Metformin 2000mg daily
Type 2, 60kg – A1c 10.1%
Break Lunch Dinner HS
Mo 1 170s
298 10uLan
Mo 2 160s
233 20uLan
Mo 3 140s
303
335
206 30uLan
Starting insulin key points – Type 2 � ADA Standards of Care 2019
� Start basal insulin at 10 units or 0.1 to 0.2 units/kg day
� Keep metformin and sometimes one other oral agent
� Consider NPH insulin at HS if cost is a factor
� When is it too much basal insulin?� If basal insulin is >0.5 units/kg day, advance to combo
injectable therapy� Add bolus, switch premixed 70/30 or to Basal + GLP-RA
� Medication Therapy Based on Situation
� If on 2-3 meds and still not at target, start GLP-1 RA
� If A1c 10% + consider combo insulin and injectable therapy.
� If A1c is 11% + and/or wt loss & symptoms, start insulin
Page 12Diabetes Education Services© 1998-2019 www.DiabetesEd.net
ADA Glycemic Treatment of Type 2 - 2019
To avoid clinical inertia, reassess and modify
treatment every 3-6 mos
Page 13Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Insulin Type Onset Peak
Humalog Mix
75/25: 75% NPL, 25% lispro
50/50: 50% NPL, 50% lispro
0.25 - 0.5 hr 0.5-6.5 hrs
NovoLog Mix
70/30: 70% NPA, 30% aspart
0.25 - 0.5 hr 1 – 4 hrs
NPH + Reg Combo 70/30: 70%N /30%R 50/50: 50%N /50%R Ryzodeg Mix 70% Degludec / 30% aspart
0.5 – 1.0 hr 0.25 – 1.0 hr
2 - 16 hrs 24 hours
Combo Sub-Q Insulin
Case Study� 70 yr old, avid walker
� BMI 24, Weighs 60kg, GFR 58
� A1c – 10.1%, BG 300s for past weeks
� 30 units Lantus Pen (60kg x .5 = 30units max dose)
� Oral Meds: Metformin 2000 mg daily
� What medication changes? Keep metformin
� Add on changes?
� Add 1 bolus injection at largest meal
� Switch to 70/30 (20 units am and 10 units pm)
� Add GLP-1 RA or basal insulin/GLP combo (iGlarlixi or IDegLira)
� Consider adding SGLT2 to preserve kidney function
20u 70/30 am, 10u 70/30 pm
Patterns? Changes needed?
Break Lunch Dinner HS
Day 1 102 63 92 181
Day 2 112 67 106 195
Day 3 98 56 112 201
Day 4 99 71 132
211
Page 14Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Poll Question
� 5. Which of the following are suggested insulin
teaching keys? (multiple)
a. Monitor, inject, eat
b. Abdomen is preferred injection site
c. Use a sharps container to dispose of
needles/lancets
d. Always have treatment for hypo available
Basal Bolus – What Adjustments?
Pt weighs 80kg Break Lunch Dinner HS
Day 1 69 7H
79 5H
245 8H
190 22u Det
Day 2 81 7H
87 5H
170 8H
133 22u Det
Day 3 73 7H
94 5H
194 8H
110 22u Det
Day 4 62 7H
83 5H
211 8H
127 22u Det
Intensive Diabetes Therapy
Insulin Dosing Strategy
50/50 Rule
� 0.5-1.0 units/kg day
� Basal = 50% of total
Glargine QD
NPH or Detemir BID
Bolus = 50% of total
usually divided into 3 meals
Example
� Wt 50kg x 0.5 = 25 units of insulin/day
� Basal dose: 13 units
Glargine 13 units QD
Degludec 13 units QD
NPH/Detemir 6u BID
� Bolus dose: 12 units
� 4 units NovoLog, ApidraHumalog, Regular each meal
Page 15Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Intensive Diabetes Therapy
Insulin Dosing Strategy - poll question
50/50 Rule
� 0.5-1.0 units/kg day
� Basal = 50% of total
Glargine QD
NPH or Detemir BID
Bolus = 50% of total
usually divided into 3
meals
Example – You Try
� Wt 60 kg x 0.5 = ___ units of insulin/day
� Basal dose: ____ unitsGlargine ____ QD
Deguldec ____ QDNPH/Detemir __ BID
� Bolus dose: ____ units___units NovoLog, Apidra
Humalog, Reg each meal
Intensive Diabetes Therapy
Insulin Dosing Strategy
50/50 Rule
� 0.5-1.0 units/kg day
� Basal = 50% of total
Glargine QD
NPH or Detemir BID
Bolus = 50% of total
usually divided into
3 meals
Example – You Try
� Wt 60kg x 0.5 = 30 units of insulin/day
� Basal dose: 15 unitsGlargine 15 QD or
Degludec 15 QDNPH/Detemir 7u BID
� Bolus dose: 15 units� 5 NovoLog, Apidra,
Humalog, Reg each meal
Basal Bolus – Using 50/50 Rule - Pt
weighs 80kg
Break Lunch Dinner HS
Day 1 84 6H
89 7H
145 7H
190 20 u Det
Day 2 81 6H
97 7H
107 7H
133 20u Det
Day 3 79 6H
104 7H
124 7H
110 20u Det
Day 4 69 6H
103 7H
208 7H
193 20u Det
Page 16Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Insulin Dosing Type 1 & 2
U-500 Insulin: When More With Less Yields Success: Diabetes
Spectrum March 20, 2009 vol. 22 no. 2 116-122
More than 200 units a day?
Quick Question 6:
6. What best describes U-500 Regular Insulin?
a. Regular insulin delivered in 5xs the volume of
U-100
b. High potency inhaled insulin
c. Regular insulin that is 5xs the concentration
of U-100
d. Insulin that is given 5 times a day
Page 17Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Humulin Regular U-500
Consider U-500 High Potency Insulin
� U-100 = 100 units insulin per mL
� U-500 = 500 units per mL
� U- 500 is 5 x’s the concentration of u100
� 20 mL a vial. 500 units per mL= 10,000 units/vial
� Costs ~ $400 $1,600+ per vial
� Less volume
Dosing Strategies u-500� Dosing – take total daily needs and split
into 2-3 doses
� 2 doses: 60% am / 40% pm or
� 3 doses: 40/30/30 or 40/40/20
� No basal insulin needed, because U-500
has bolus and basal action
� Needs careful monitoring/ education
� Example - Pt on 240 units of insulin a day
� 140 units am / 100 units pm (2 doses)
� 100 / 70 / 70 or 100 / 100/ 40
Page 18Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Lispro (Humalog) U-200 Kwik Pen
� 2 xs the concentration of U-100
� 200 units per mL
� Humalog U-200 Kwik Pen
� Comes in 3mL pen/ 600 units (2 pack)
� Once opened, keep at room temp. Toss after 28 days.
� Not approved for use in insulin pump
Humalog 200 units/mL KwikPen
3 mL/Kwik Pen = 600 units insulin
Page 19Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Degludec (Tresiba) FlexTouch U-200 Pen
� Concentration – 200 Units/mL
� Max 160 units injection
� Comes in 3mL pen/600 units (3 pack)
� Dose increments – 2 units
� Once opened, keep at room temp. Good for 8 weeks
For example, if order reads:
“160 unitsTresiba U-200 FlexTouch Pen”
Dial the pen to 160 units.
Toujeo U-300 Solostar Pen
For example, if order reads:
“30 units Toujeo U-300 Solostar Pen”
Dial the pen to 30 units.
Glargine (Toujeo) Solostar Pen U-300
� Glargine 300 units / mL� Need 10-14% higher dose than previous U-100 dose
� Start with 1:1 conversion and adjust based on FBG
� Less nocturnal and hypoglycemia.
� Similar weight gain to U-100
� Extend release of U-300 results in smoother, stable more prolonged profile
� More injection site reactions with U-300
� Max 80 units injection
� Comes in 1.5mL pen/450 units (3 or 5 pack)
� Once opened, keep at room temp. Toss after 42 days.
Page 20Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Quick Question 7:
� Which of the following is true about all
concentrated insulins?
a. Need to convert to get correct dose
b. Delivers the same amount of insulin in more
volume.
c. Delivers the correct dose in less volume
d. No calculation or conversion required
e. C & D
Key Teaching Points� Never withdraw concentrated
insulin from a pen into a syringe
� All concentrated insulin pens and the U-500 insulin syringe automatically deliver the correct dose in less volume.
� No conversion, calculation or adjustment required.
� When writing Rx include type of insulin, concentration, delivery device and dose.
� Bolus insulin with meals
� Basal 1-2xs daily
� Abdomen preferred injection
site
� Stay 1” away from previous
site
� Don’t re-use ultra fine
syringes
� Keep unopened insulin in
refrigerator
� Toss opened insulin vial after 28 days
� Proper disposal
� Review patients ability to withdraw and inject.
� Side effects include hypoglycemia/wt gain
� Insulin pens –� Prime needle to assure
accurate insulin dose given
� Hold needle in for 5 seconds after injection
� Roll 70/30 pens
Insulin Teaching Keys
Page 21Diabetes Education Services© 1998-2019 www.DiabetesEd.net
Sharps Disposal: Product and Info
� Look in the Government section
white pages for a household
hazardous waste listing for your
city or county.
� Call 1-800-CLEANUP (1-800-253-
2687)
� Search for collection centers on
the California Integrated Waste
Management Board (CIWMB)
Web site
Thank You� Questions?
� Email bev@diabetesed.net
� Web www.DiabetesEdUniversity.net
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