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This presentation is intended to allied health professional to have a overview of different types of insulin. It is meant to be a memory refresh. It was presented as part of continuing medical education session
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Overview of Insulin Products: New Developments Review
Anas Bahnassi PhD RPh
The Community Pharmacist’s Role in Diabetes Management 2
On January 11, 1922, at 14 years of age, A Canadian boy from Toronto received his first shot of insulin. This boy was Leonard Thompson
Without insulin, this young girl would have died in a matter of days or weeks.
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Possible Insulin Treatments in Type-1 Diabetes:
Patient is diagnosed with type
one diabetes
Full day “conventional” coverage Premixed insulin twice daily Custom designed split mix variant
Full physiologic insulin coverage Long acting analog at bedtime and Rapid acting before meals
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Insulin use in type-2 diabetes
• Start insulin if severe symptoms at time of diagnosis or present with DKA.
• Pregnancy.
• Add insulin when antidiabetes medictions fail:
– Basal insulin is more cost effective than a third oral agent.
– Insulin added to suboptimally controlled patients on 2 oral antidiabetes medications will result in A1C lowering by 1.5%.
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Type-2 diabetes evolving treatment paradigm
Pre-diabetes Type-2 diabetes
Diet and exercise
Oral monotherapy
Oral combotherapy
GLP-1 Analogs and DPP-4 Inhibitors
Insulin Inhaled Insulin
Amylin Pramlintide
0 -5 -10 +10 +5
Onset
Diagnosis
Year
s si
nce
dia
gno
sis
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Percentage of patients advancing when A1C >8%
Diet Sulfonylurea Metformin Combination
66.6
35.5
44.6
18.8
Percentage
When insulin was started, the average patient had: • 5 years of A1C >8% • 10 years of A1C >7%
Brown JB et al. Diabetes Care (2004) 11/15/2013
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Barriers to insulin use
Patient resistance: Compliance issues Fears of scars Administration difficulties
Physician resistance: Lack of resources. Time to plan and follow-up intensive therapy.
Perceived and real ADRs: Weight gain, hypoglycemia
Optimal glycemic control requires multiple daily injections.
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Barriers to insulin use
Troubled by the idea of multiple
shots
Avoid injection due to anxiety
High anxiety about injections
42
18
35
63
44
0
All patients High anxiety patients
Zambanini A et al. Diabetes Res. Clin. Pract.(1999) 11/15/2013
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Overcoming patient obstacles
• Set appropriate goals • Patient education • Prudent assistance by others • Use of premixed insulin
• Physiologic insulin treatment design • Balance of food, activity, and insulin • Injection devices
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Physical and Chemical Properties of Human Insulin
α-chain
β-chain
Zn++
Zn++
Self-aggregation in solution
Monomers
Dimers
Hexamers
(around Zn2+)
21 amino acids
30 amino acids
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The best insulin type for your patient’s diabetes
The best type of insulin for your patient depends on many factors:
• Individualized response to insulin • Lifestyle choices • Willing to use multiple injections daily • Frequency of glucose checking • Age • Blood glucose management goals
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Types of insulin
• Rapid acting
• Short acting
• Intermediate acting
• Long acting
• Premixed
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Rapid acting insulin
Brand Onset min
Peak min
Duration hr
Role in glucose management
Humalog or lispro
15-30 30-90 3-5 Rapid-acting insulin covers insulin needs for meals eaten at the same time as the injection. This type of insulin is often used with longer-acting insulin.
Novolog or aspart
10-20 40-50 3-5
Apidra or glulisine
20-30 30-90 1-2½
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Gly Thr Glu Phe Tyr Pro Lys Thr
Gly Thr Glu Phe Tyr Lys Pro Thr
23 24 25 26 27 28 29 30
Insulin
Lispro
Primary Structure of Lys(B28), Pro(B29)–Insulin
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Gly Thr Glu Phe Tyr Pro Lys Thr
Gly Thr Glu Phe Tyr Asp Lys Thr
23 24 25 26 27 28 29 30
Insulin
Aspart
Primary Structure of Asp(B28)-Insulin
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Phe Val Asn Gln Pro Lys Thr
Phe Val Lys Gln Pro Glu Thr
1 2 3 4 28 29 30
Insulin
Glulisine
Primary Structure of Glu(B29), Lisine(B3)–Insulin
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Asp
Lys Pro
Lys Glu
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17 Overview of insulin products - CE for Pharmacists
Hei
nm
ann
et
al. D
iab
et. M
ed. 1
99
6
Short acting insulin
Brand Onset min
Peak hr
Duration hr
Role in glucose management
Regular (R) humulin or novolin
30-60 2-5 5-8 Short-acting insulin covers insulin needs for meals eaten within 30-60 minutes
Velosulin (for use in the insulin pump)
30-60 2-3 2-3
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Intermediate acting insulin
Brand Onset min
Peak hr
Duration hr
Role in glucose management
NPH (N) 1-2 hours
4-12 hours
18-24 hours
Intermediate-acting insulin covers insulin needs for about half the day or overnight. This type of insulin is often combined with rapid- or short-acting insulin
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Action Profiles of Injected Human Insulins
0 1 2 5 3 4 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Pla
sma
insu
lin le
vels
Regular 6–8 hours
NPH 12–20 hours
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Long acting insulin
Brand Onset min
Peak hr
Duration hr
Role in glucose management
Lantus (insulin glargine)
1-1½ hour
No peak time; insulin is delivered at a steady level
20-24 hours
Long-acting insulin covers insulin needs for about one full day. This type of insulin is often combined, when needed, with rapid- or short-acting insulin Levemir
(insulin detemir)
1-2 hours
6-8 hours
Up to 24 hours
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Thr Phe Tyr Pro Lys Thr
25 26 27 28 29 30
Insulin B-chain
Glargine Thr Phe Tyr Pro Lys Thr Arg Arg
Asn Leu Glu Tyr Cys Gly
Asn Leu Glu Tyr Cys Asn
16 17 18 19 20 21
Insulin A-chain
Glargine
Primary Structure of Gly(A21), Arg(B31), Arg(B32)-Insulin
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Gly Thr Glu Phe Tyr Pro Lys Thr
Gly Thr Glu Phe Tyr Pro Lys Thr
23 24 25 26 27 28 29 30
Insulin
Detemir
(CH2)4
NH
CO
R
Primary Structure of Lys(B29)-N--Tetradecanoyl, Des(B30)-Insulin
• Fatty acid tail (myristic acid) added to human insulin
• Complexes with albumin>20 hour action
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Linkeschowa R, et al. Diabetes.1999;48(suppl 1):A97.
Action Profiles of long acting insulin analogs – Glargine
0
0
1
2
3
4
5
6
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30
NPH
Glargine
Placebo
0.4 U/kg
Time (h)
Glu
cose
infu
sio
n r
ates
(m
g/k
g/m
in)
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Action Profiles of long acting insulin analogs – Detemir
Brunner GA, et al. Exp Clin Endocrinol Diabetes. 2000;108:100-105.
Elapsed time (min)
0.0
0.5
1.0
1.5
2.0
-100 100 300 500 700 900 1100 1300 1500
Detemir - high
Detemir - low
Placebo
Glu
cose
infu
sio
n r
ate
(m
g/k
g/m
in)
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Premixed insulin
Brand Onset min
Peak hr
Duration hr
Role in glucose management
Humulin 70/30
30 2-4 14-24 These products are generally taken two or three times a day before mealtime.
Novolin 70/30
30 2-12 Up to 24
Novolog 70/30
10-20 1-4 Up to 24
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Mixed vs. Basal Insulin Regimens
Outcome Analog mix vs. Human mix
Analog mix vs. Long-acting analogs
Analog mix vs. “Other regimens”
Strength of Evidence
FPG Similar Favors long-acting analog
Unknown Moderate
PPG Favors analog mix
Favors analog mix
Unknown High
A1c Reduction Similar Favors analog mix
Unknown High
Hypoglycemia Similar Favors long-acting analog
Unknown High
Weight Similar Favors long-acting analog
Unknown Moderate
Mortality Unknown Unknown Unknown Unknown
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Qayyum R et al, Ann Intern Med 2008;149:549-559
Sum-up
• Determine who needs insulin initiation
• Design a system that includes the type of insulin that fits your patient’s lifestyle
• Be ready to explain the differences between types of insulin
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The Community Pharmacist’s Role in Diabetes Management CE program for pharmacists
abahnassi@gmail.com
http://www.twitter.com/abpharm
http://www.facebook.com/pharmaprof
http://www.linkedin.com/in/abahnassi
Anas Bahnassi PhD CDM CDE
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