Diabetes Treatments:
Options for Insulin Delivery
Bonnie Pepon, RN, BSN, CDE
Certified Diabetes Educator
Conemaugh Diabetes Institute

21 million people in the U.S. have
diabetes

$132 billion each year
◦ Type 1 diabetes – no insulin production
◦ Type 2 diabetes – some insulin production
Diabetes
Type 1 Diabetes
Type 1 Diabetes
Insulin Production of Type 2
Healthy
Eating
•
Sulfonylureas
•
Meglitinides
•
Biguanides
•
Alpha Glucosidase Inhibitors
•
Thiazolidinediones-TZD’s
•
Incretin Mimetics
•
DPP IV Inhibitors
Classes of Medications
Sulfonylureas
Most common
drugs in this
class:
•
•
•
How do they
work?
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Advantages:
•
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Side effects:
•
•
How to take:
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Glipizide (Glucotrol, Glucotrol XL)
Glyburide (Micronase, Diabeta, Glynase)
Glimepiride (Amaryl)
Stimulate the pancreas to make more insulin
Work for up to 24 hours
Lowers fasting and post prandial blood sugar
May decrease AIC 1.5-2%
Inexpensive
Weight gain (4.5-11 lbs.)
Low blood sugar
Take glipizide 30 min before the first meal of
the day
All others take with first meal of the day
Meglitinides
Most common
drugs in this
class:
How do they
work?
•
•
•
•
•
Advantages:
•
Side effects:
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How to take:
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•
Repaglinide(Prandin)
Nateglinide (Starlix)
Stimulate the pancreas to make more insulin
Work only for about 4 hours after meals
Only effects post prandial sugars – NOT
FASTING!
May decrease A1C by 1-2%
Weight gain
Low blood sugar
Take up to 30 minutes before meals
No meal= No pill
Biguanides
Most common
drugs in this
class:
How do they
work?
•
•
•
•
•
•
Advantages:
•
•
•
Side effects:
•
How to take:
•
Metformin (Glucophage, Glucophage XR)
Liquid Form (Riomet)
Helps your body produce less glucose from the
liver
Helps insulin work better
Reduces glucose absorption in the intestines
Takes up to 2 weeks to see maximum effect
Can decrease AIC 1.5-2%
Does not cause low blood sugar or weight gain
May also lower triglycerides and cholesterol
Nausea and Diarrhea
Take with breakfast and supper
Alpha Glucosidase Inhibitors
Most common
drugs in this
class:
How do they
work?
Advantages:
•
•
•
•
•
Side effects:
•
How to take:
•
Acarbose (Precose)
Miglitol (Glyset)
Slows the digestion of carbs in the small
intestine, thus decreasing the post prandial
blood sugar spike
May decrease A1C by 0.5 to 1%
Does not cause low blood sugar or weight
gain
Gas and diarrhea
Take with first bite of food of 3 largest meals
of the day
Insulin Sensitizers-TZD’S
Most common
drugs in this
class:
How do they
work?
•
•
•
•
•
•
Advantages:
•
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Side effects:
•
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Rosiglitazone (Avandia)
Pioglitazone (Actos)
Helps insulin work better
Enhances glucose uptake by the muscle tissue
Reduces glucose production by the liver
Takes up to 3 months to see maximum effect
May decrease A1C by 0.5-1%
Does not cause low blood sugar
May decrease triglycerides and increase HDL
Swelling in legs and weight gain (caution in
heart failure)
If on oral contraceptive, may increase risk of
pregnancy
Liver damage (<1% chance)
Liver function is monitored every 2 months for
the first year
Combination Drugs
•
Glucovance (glyburide/metformin)
•
Metaglip (glipizide/metformin)
•
Avandamet (avandia/metformin)
• Duetact (amaryl/actos)
New Ones:
• Fortamet (metformin SR)
• Glumetza (metformin SR)
• Actoplus (actos/metformin)
• Avandryl (avandia/glimepiride)
◦ Byetta (Exenatide) approved for type 2
◦ Symlin (Pramlintide) approved for type 1
and type 2 using mealtime insulin
Incretin Mimetics: Gut Hormones
Byetta
How do they
work?
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Advantages:
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Dosing:
•
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Side effects:
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Prevents stored sugar from entering the blood stream
Stimulates insulin release
Slows gastric emptying
Lowers post prandial blood sugar spike
Makes you feel full
Reduces food intake and appetite
May decrease A1C by 1% after 6 months
Promotes weight loss (5-6 lbs)
Comes in a prefilled pen that lasts one month
5 mcg twice a day for 1 month, then increase to 10mcg twice a
day
Give within 60 minutes of morning and evening meal
Do NOT give after a meal
If you miss a meal, skip the dose
Nausea (will go away with time and dose titration)
Vomiting and diarrhea
Low blood sugar
May need to decrease dose of sulfonylurea to avoid low blood
sugar
Symlin
How do they
work?
•
•
•
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•
Advantages:
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Side effects:
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•
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•
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Slows gastric emptying
Lowers the post prandial blood sugar spike
Makes you feel full
Reduces food intake and appetite
Slows production of glucose from liver
May lower A1C by 0.6% in Type 2 after 6
months
Promotes weight loss (4 lbs)
Nausea (will decrease over time)
Loss of appetite
Vomiting
Hypoglycemia (3 hours after dose)
Decrease amount of rapid acting insulin by
50%
Januvia (Sitagliptin)

Oral active, selective inhibitor for the
DPP-4 enzyme

A1C effect-decreased by 0.65-0.8%

Can be administered with or without food

Not for type 1 diabetes
DPP IV Inhibitors
Rapid Acting Insulin
Insulin
Onset of
action
Peaks
Duration
5 to 15
minutes
30 to 60
minutes
3 to 5
hours
Humalog
or lispro
Novolog
or aspart
Apidra
or glulisine
Short Acting Insulin
Humulin R
or Novolin
R
30
minutes
Clear in appearance
Available in vials and pens

2 to 3
hours
3 to 6
hours
Intermediate Acting Insulin
Insulin
Humalin N
(NPH) or
Novolin N
(NPH)
Onset of
action
Peaks
Duration
2 to 4
hours
4 to 12
hours
12 to 18 hours
Cloudy in appearance
Available in vials and pens

Long Acting Insulin
Levimir
(detemir)
1 to 2
hours
6 to 8
hours
Lantus
(glargine)
1 hour
no peak
6 to 23
24 hours
Clear in appearance
Available in vials and pens
Cannot be mixed in the same syringe with any other type of insulin

hours
Insulin Injection Sites
Insulin Delivery Systems
Available Now
Syringe/Needle/Vial

Insulin comes in U–100 in the
U.S.
◦ orange cover and black scale
◦ 100 units of insulin per milliliter of
fluid in the vial

U–500 available

Outside the U.S.: U-40
◦ high insulin resistance using more
than 200 units a day
◦ red cover and red scale
Syringe/Needle/Vial


Most common method of
delivery
Syringes (range of sizes)

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needle gauge
needle length
syringe capacity
3/10cc, 1/2cc, 1cc
Insulin Needles

Syringes available

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
Pen needles available


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1/2 in or 12.7 mm
5/16 or 8mm
½ in
5/16 in
3/16 in
Gauges available

31, 30, 29, 28
Syringes
◦
◦
◦
◦
Syringes are most widely available
Can be adjusted to 1 or ½ units
Can use most types of insulin
Require good vision to measure a dose
Insulin Devices
Pens
◦
◦
◦
◦
Easy to set the correct dose by a dial
Can be adjusted with ½ units or 1 unit
Can use most types of insulin
Very convenient and accurate for the vision
impaired and those on the go
Insulin Devices
Pumps
◦
◦
◦
◦
Results in better diabetes control
More flexible eating schedule
Dose adjusted by 1/10 to 1/20 units
Requires higher level of involvement & more
advanced diabetes education and skills
Insulin Devices

Multiple manufacturers
◦ BD, Monoject, SureComfort,
Ulticare Precision Sure Dose,
UltiGuard, Medicore, Aimsco

Injection aides
◦ Inject-Ease by BD and Palco,
Instaject (can be combined
with a lancet device),
NeedleAid, NovoPen 3
Penmate
Insulin Syringes

Uses an insulin needle
◦ available in different sizes and gauges
◦ units can be counted as dialed by a click
◦ plunger is pushed in and held for several
seconds before removing the needle
Insulin Pens

Storage in refrigerator until the pen is
started
◦ storage life ranges from 7 to 42 days

Pre-filled pens
◦ 28 days: Humalog/Novolog/Novolin R
◦ 14 days: Novolin N
◦ 10 days: Novalin 70/30
Insulin Pens
Insulin Pens:
Insulin Cartridges
1.5 ml
Insulin
Days
Humalog
28 days
Novolin R
30 days
Novolin 70/30 and
Novolin N
7 days
3 ml
Novolin
R/Novolog/Lantus
28 days
Novolin N
14 days
Novolin 70/30
10 days
Levemir
42 days
Pre-mixed Insulin
Insulin
Onset of
action
Peaks
Duration
30
minutes
2 to 4
hours
22 to 24
hours
Humalog
mix 75/25
or 50/50
Humulin mix
70/30 or
50/50
Novolog mix
70/30
Novolin mix
70/30
Helpful for those with poor eyesight, dexterity problems or
those who have trouble mixing from 2 different vials

Insulin Pumps
Delivers rapid acting dry powder
insulin
 Absorbed through the lungs into
the bloodstream

◦ 1mg and 3mg blister packets
◦ Cannot be used for smokers, children, pregnant
women or anyone with lung problems
Will be taken off the market in
January 2008
Inhaled Insulin
Jet Injector
Minimize needle sticks by creating a portal
to inject insulin into
 A small tube is inserted into the fatty
tissue of the injection site
 It is taped in place for 2-3 days
 Insulin injected into the tube via pen or
syringe instead of the skin

Insulin Infuser
Insulin Delivery Systems
In the Future
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Oral insulin
Transdermal insulin
Buccal insulin
Artificial pancreas
Implantable insulin pump

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
45 year old African-American male
Diagnosed with Type 2 DM
Initial glucose 280mg/dl, A1C–9.9%
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◦
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Started on nutrition and physical activity
3 months later still having symptoms
PMH –hypertension, obesity, high lipids
Smoker, occasional alcohol, no drug use
What therapy should be started?
Case Study
The Pharmacist
Part of the Healthcare Team