8/8/2018 1 How to Find The Right Insulin at the Right Time for Each Individual Patricia Garnica MS, ANP-BC, CDE, CDTC Inpatient Diabetes Nurse Practitioner North Shore University Hospital Department of Medicine Division of Endocrinology Manhasset, N.Y. Disclosure to Participants • No Conflict of Interest (COI) and Financial Relationship to Disclose • No Endorsement of Products • No Off-Label Use Learning Objectives • At the completion of this presentation, the participant will be able to recognize new available insulins agents including their pharmacological action, side effects and contraindications. • At the completion of this presentation, the participant will be able to define the benefits and limitations including cost and safety issues in relation to different types of patient populations. • At the completion of this presentation, the participant will be able to identify who, how and when to prescribe these new agents. Insulin Overview INSULIN
Transcript
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How to Find The Right Insulin at the Right Time for Each Individual
North Shore University HospitalDepartment of MedicineDivision of Endocrinology Manhasset, N.Y.
Disclosure to Participants• No Conflict of Interest (COI) and Financial
Relationship to Disclose
• No Endorsement of Products
• No Off-Label Use
Learning Objectives• At the completion of this presentation, the participant will
be able to recognize new available insulins agents including their pharmacological action, side effects and contraindications.
• At the completion of this presentation, the participant will be able to define the benefits and limitations including cost and safety issues in relation to different types of patient populations.
• At the completion of this presentation, the participant will be able to identify who, how and when to prescribe these new agents.
Insulin Overview
INSULIN
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INSULIN HISTORY• In 1921, Frederick Grant Banting and
Charles H. Best discovered insulin • In 1922 they used it successfully on a 14-
year-old boy with diabetes.• In 1923, James B. Collip discovered that
purifying the extract prevented many of the side effects.
• In 1923, Banting and Macleod were awarded the Nobel Prize.
INSULIN HISTORY• The US Food and Drug Administration (FDA)
first approved insulin in 1939.
• Insulin was the first hormone to be synthesized completely in the laboratory in 1966.
• The first recombinant human insulin was approved by the FDA in 1982.
Insulin Recombinant• Genetic engineering processes can make human insulin. Human
insulin DNA is placed into the DNA of a second organism. The host organism becomes an insulin-producing factory.
Human Insulin Recombinants
Changing Times
1900’s 2000’s
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Insulin Analogs
Insulin Analogs• Synthetic-made insulins of human insulin• Designed to mimic the body’s natural pattern of
insulin release. • They have minor structural or amino acid changes
that give them special desirable characteristics when injected under the skin
• Once absorbed, they act on cells like human insulin, but are absorbed from fatty tissue more predictably
Special considerations:• Must be given prior to meals• Patients MUST eat 3 meals a day • Challenging adjustments.
Insulins Action Profiles
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Older Insulin Profiles
Newer Insulin PreparationsSame insulin analogs with minor changes on insulin molecular or amino acid structure that affect:- Duration (half life and bioavailability)- Action profile- Time of administration- Volume- Presentation (Only available in insulin pens)
Rapid acting inhaled human insulin (Afrezza®) 2014
Rapid acting inhaled human insulin (Afrezza®) 2014PROS
• Inhaled instead of injected
• Faster peak and shorter duration than other rapid acting insulins
CONS• Set up dosing: Inhaler with
4units, 8units or 12 units cartridges
• Use limitations and contraindications
• Needs follow up spirometry after initiation
• Not for patients who smoke or with abnormal spirometry.
Rapid acting inhaled human insulin (Afrezza®) 2014
Lispro U-200 (Humalog U-200®) 2015
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Lispro U-200 (Humalog U-200®) 2015PROS• First rapid acting concentrated
insulin U-200(2 pens per box)• Delivers same amount of insulin
than U-100 in half the volume (max dose 60 units per injection)
• Holds total of 600 units of insulin per pen compared to 300 of U-100 insulin
• Benefit patients who need large amounts of meal time insulin
• Half life is 1 hour• Bioavailability up to 3 hours
CONS• Limited benefits to patients
requiring large amounts of rapid acting insulin
• Same benefits/price than Lispro U-100 except for less volume
• Slow titration on patients with kidney disease and older age
Aspart Insulin Injection U-100 (Fiasp®) 2017
Vitamin B3 (niacinamide) and a naturally occurring amino acid (L-Arginine)were added to increase the speed of absorption and stability.
Aspart Insulin Injection U-100 (Fiasp®) 2017PROS• Improves post prandial
hyperglycemia• One to one dose
conversion from other rapid acting insulins
CONS• Caution while switching
patients with kidney/liver disease and older age
• Not recommended on patients with gastroparesis
• Price: 100% more than other rapid acting insulins
Lispro Insulin Injection U-100 (Follow on insulin). (Admelog®) 2017 • Onset 5 minutes after injection• Peaks within 1 hour and last up to 5 hours• Price: More than double the price of Lispro
Degludec and aspart insulin mix U-100 (Ryzodeg ®70/30). 2015
Degludec and aspart insulin mix (Ryzodeg ®70/30). 2015PROS• Administer once or twice
a day with meals.• Insulin conversion
depends of what patient was taken prior to conversion (basal, basal/bolus, Mix insulin)
CONS• Patients of basal/bolus
insulin regimen will need to take rapid acting insulin with other meals
• Careful insulin dosing for insulin naive patients and patients who are not on a mixed insulin
• Not available in pharmacies in USA. Expensive
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Regular insulin U-500 (Humulin R U-500®). 1994 and 2016
• Insulin U-500 is FIVE times (x5) more concentrated that U-100 insulins (1994).
• Indicated on patients requiring 200 or more units of insulin per day. • Action profile is similar to a combination of regular/NPH insulins (Use
of U-500 with another insulin is NOT recommended) • Administer twice or three times day ½ hour before meals (Mean action
ranges from 13 to 24 hours)• -Prescribe U-500 insulin syringes or Humulin R U-500 Kwik pen to
avoid dosing medication errors. No need for conversion of doses (2016).
Regular insulin U-500 (Humulin R U-500®). 1994 and 2016BEFORE 2016• Careful conversion from U-100
to U-500 insulin required in order to prevent serious insulin dosing errors
AFTER 2016• No need for dosing conversion
if using U-500 insulin syringe or U-500 insulin pen
U-500 Pharmacokinetics
Basal and GLP-1 agonists 2016• Basal insulin glargine plus
lixisenatide (Soliqua 100/33®)
• Basal insulin degludec plus liraglutide (Xultophy 100/3.6®)
How many types of insulin do we really need?
American Diabetes Association 2018
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Bottom line about insulin in USA
https://makeinsulinaffordable.org/
REFERENCES• Standards of Medical Care in Diabetes. American Diabetes Association: Standards of
Medical Care in Diabetes 2018 https://professional.diabetes.org/content-page/standards-medical-care-diabetes/
• AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm 2017 https://www.aace.com/publications/algorithm
• American Diabetes Association: Insulin basics. http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/insulin/insulin-basics.html
• An Overview of Concentrated Insulin Products http://spectrum.diabetesjournals.org/content/29/3/136
• How did they make insulin from recombinant DNA? https://www.nlm.nih.gov/exhibition/fromdnatobeer/exhibition interactive/recombinant-DNA/recombinant-dna-technology-alternative.html
• Insulin Analogs—Are They Worth It? Yes! http://care.diabetesjournals.org/content/37/6/1767
• Pharmacologic Approaches to Glycemic Treatment http://care.diabetesjournals.org/content/40/Supplement_1/S64
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