A quick review of available insulin products
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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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A quick review of available insulin products
- 1. The Community Pharmacist’s Role in Diabetes Management 2 Overview of Insulin Products: New Developments Review Anas Bahnassi PhD RPh
- 2. This boy was Leonard Thompson Without insulin, this young girl would have died in a matter of days or weeks. 2 11/15/2013 Overview of insulin products - CE for Pharmacists On January 11, 1922, at 14 years of age, A Canadian boy from Toronto received his first shot of insulin.
- 3. 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 3 11/15/2013 Overview of insulin products - CE for Pharmacists Possible Insulin Treatments in Type-1 Diabetes:
- 4. Insulin use in type-2 diabetes Overview of insulin products - CE for Pharmacists • 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%. 4 11/15/2013
- 5. Type-2 diabetes evolving treatment paradigm -5 0 +5 +10 Amylin Pramlintide Diagnosis Inhaled Insulin Overview of insulin products - CE for Pharmacists Years since diagnosis -10 Insulin Onset GLP-1 Analogs and DPP-4 Inhibitors Oral combotherapy Oral monotherapy Diet and exercise Pre-diabetes Type-2 diabetes 5 11/15/2013
- 6. Percentage of patients advancing when A1C >8% 66.6 When insulin was started, the average patient had: • 5 years of A1C >8% • 10 years of A1C >7% 44.6 35.5 18.8 Diet Sulfonylurea Metformin Combination 6 11/15/2013 Overview of insulin products - CE for Pharmacists Percentage Brown JB et al. Diabetes Care (2004)
- 7. Barriers to insulin use Physician resistance: Compliance issues Fears of scars Administration difficulties Lack of resources. Time to plan and followup intensive therapy. Perceived and real ADRs: Weight gain, hypoglycemia Optimal glycemic control requires multiple daily injections. 7 11/15/2013 Overview of insulin products - CE for Pharmacists Patient resistance:
- 8. Barriers to insulin use All patients High anxiety patients Overview of insulin products - CE for Pharmacists 63 44 42 35 18 0 Troubled by the idea of multiple shots 11/15/2013 Avoid injection due to anxiety High anxiety about injections 8 Zambanini A et al. Diabetes Res. Clin. Pract.(1999)
- 9. • 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 9 11/15/2013 Overview of insulin products - CE for Pharmacists Overcoming patient obstacles
- 10. Physical and Chemical Properties of Human Insulin 21 amino acids α-chain β-chain Overview of insulin products - CE for Pharmacists 30 amino acids Monomers Dimers Zn++ Zn++ Self-aggregation in solution Hexamers (around Zn2+) 10 11/15/2013
- 11. The best insulin type for your patient’s diabetes • • • • • • Overview of insulin products - CE for Pharmacists 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 11 11/15/2013
- 12. Types of insulin Rapid acting Short acting Intermediate acting Long acting Premixed Overview of insulin products - CE for Pharmacists • • • • • 12 11/15/2013
- 13. Rapid acting insulin Duration Role in glucose Brand management hr Rapid-acting Humalog or 15-30 30-90 3-5 insulin covers lispro insulin needs for Novolog or 10-20 40-50 3-5 meals eaten at aspart the same time as the injection. This type of Apidra or insulin is often 20-30 30-90 1-2½ glulisine used with longer-acting insulin. 13 11/15/2013 Overview of insulin products - CE for Pharmacists Onset Peak min min
- 14. Lispro Gly Glu Phe Tyr Thr 23 Insulin 24 25 26 27 Gly Glu Phe Tyr Thr Pro 28 Lys Lys 29 Pro Overview of insulin products - CE for Pharmacists Primary Structure of Lys(B28), Pro(B29)–Insulin Thr 30 Thr 14 11/15/2013
- 15. Aspart Gly Glu Phe 23 Insulin 24 25 Gly Glu Phe Tyr 26 Tyr Thr 27 Thr Pro 28 Asp Lys 29 Lys Overview of insulin products - CE for Pharmacists Primary Structure of Asp(B28)-Insulin Thr 30 Thr 15 11/15/2013
- 16. Insulin Phe 1 Glulisine Phe Val 2 Val Asn Gln Pro Lys Thr 3 4 28 29 30 Lys Gln Pro Glu Overview of insulin products - CE for Pharmacists Primary Structure of Glu(B29), Lisine(B3)–Insulin Thr 16 11/15/2013
- 17. Heinmann et al. Diabet. Med. 1996 Lys Pro Asp Lys 11/15/2013 Glu Overview of insulin products - CE for Pharmacists 17
- 18. Brand Onset Peak min hr Regular (R) humulin or 30-60 2-5 novolin Velosulin (for use in 30-60 2-3 the insulin pump) Duration Role in glucose management hr Short-acting 5-8 insulin covers insulin needs for meals eaten within 30-60 2-3 minutes 18 11/15/2013 Overview of insulin products - CE for Pharmacists Short acting insulin
- 19. Intermediate acting insulin NPH (N) 19 11/15/2013 Overview of insulin products - CE for Pharmacists Brand Duration Role in glucose management hr Intermediateacting insulin covers insulin needs for about half the day or 1-2 4-12 18-24 overnight. This hours hours hours type of insulin is often combined with rapid- or short-acting insulin Onset Peak min hr
- 20. Overview of insulin products - CE for Pharmacists Action Profiles of Injected Human Insulins Plasma insulin levels Regular 6–8 hours NPH 12–20 hours 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Hours 11/15/2013 20
- 21. Brand Lantus (insulin glargine) 11/15/2013 Levemir (insulin detemir) Duration Role in glucose management hr Long-acting insulin covers insulin needs for about one full 20-24 day. This type of hours insulin is often combined, when needed, with rapid- or shortacting insulin 1-2 6-8 Up to 24 hours hours hours 21 Onset Peak min hr No peak time; insulin 1-1½ is hour deliver ed at a steady level Overview of insulin products - CE for Pharmacists Long acting insulin
- 22. Primary Structure of Gly(A21), Arg(B31), Arg(B32)-Insulin Leu Glu Asn Tyr Cys Asn 16 17 18 19 20 21 Glargine Leu Glu Asn Tyr Cys Gly Insulin B-chain Phe Tyr Thr Pro Lys Thr 25 26 27 28 29 Glargine Phe Tyr Thr Pro Lys Overview of insulin products - CE for Pharmacists Insulin A-chain 30 Thr Arg Arg 22 11/15/2013
- 23. Primary Structure of Lys(B29)-N-Tetradecanoyl, Des(B30)-Insulin Glu Phe Tyr Thr 24 25 26 27 Gly Glu Phe Tyr Thr Pro 28 Pro Lys 29 Thr 30 Lys Thr (CH2)4 11/15/2013 • Fatty acid tail (myristic acid) added to human insulin • Complexes with albumin>20 hour action NH CO R 23 Overview of insulin products - CE for Pharmacists Detemir Gly 23 Insulin
- 24. Glucose infusion rates (mg/kg/min) 6 NPH 5 4 Glargine 0.4 U/kg 3 2 Placebo 1 0 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 Time (h) 24 11/15/2013 Linkeschowa R, et al. Diabetes.1999;48(suppl 1):A97. Overview of insulin products - CE for Pharmacists Action Profiles of long acting insulin analogs – Glargine
- 25. Action Profiles of long acting insulin analogs – Detemir 1.5 1.0 Detemir - high Detemir - low 0.5 Placebo 0.0 -100 100 300 500 700 900 1100 1300 1500 Overview of insulin products - CE for Pharmacists Glucose infusion rate (mg/kg/min) 2.0 Elapsed time (min) 25 11/15/2013 Brunner GA, et al. Exp Clin Endocrinol Diabetes. 2000;108:100-105.
- 26. Brand Onset Peak min hr Humulin 70/30 30 2-4 Novolin 70/30 30 2-12 Novolog 70/30 10-20 1-4 Duration Role in glucose management hr These products 14-24 are generally taken two or Up to 24 three times a day before mealtime. Up to 24 26 11/15/2013 Overview of insulin products - CE for Pharmacists Premixed insulin
- 27. Mixed vs. Basal Insulin Regimens Analog mix vs. Human mix Analog mix vs. Long-acting analogs Analog mix vs. “Other regimens” Strength of Evidence FPG Similar Favors longacting analog Unknown Moderate PPG Favors analog mix Favors analog mix Unknown High A1c Reduction Similar Favors analog mix Unknown High Hypoglycemia Similar Favors longacting analog Unknown High Weight Similar Favors longacting analog Unknown Moderate Mortality Unknown Unknown Unknown Unknown Overview of insulin products - CE for Pharmacists Outcome 27 11/15/2013 Qayyum R et al, Ann Intern Med 2008;149:549-559
- 28. • 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 28 11/15/2013 Overview of insulin products - CE for Pharmacists Sum-up
- 29. The Community Pharmacist’s Role in Diabetes Management CE program for pharmacists Anas Bahnassi PhD CDM CDE abahnassi@gmail.com http://www.twitter.com/abpharm http://www.facebook.com/pharmaprof http://www.linkedin.com/in/abahnassi