Drug Topics - November 19, 2007 - (Page 23)

23 an overview of the available insulins and describes their role in the management of patients with diabetes. GOAL To provide pharmacists with the knowledge necessary to teach patients about the intricacies of insulin therapy, ultimately enhancing patient adherence to therapy General considerations Most insulin formulations are available in 10-mL vials containing concentrations of 100 units/mL. The only exception is insulin regular U-500 (500 units/mL), which is available in a 20-mL vial. Some formulations are available in prefilled disposable pens or reusable pens with disposable insulin cartridges (see Table 1). Although they are more expensive, they can make insulin administration simpler, more convenient, and less prone to error compared with administering insulin using syringes. Moreover, injections with an insulin pen may be less painful; the needle is a smaller size, and it is not dulled by the withdrawal of insulin from a vial to a syringe. Jet injectors allow the administration of insulin without injection by a needle. These devices are more expensive than pens and require frequent sterilization. Most insulin vials, cartridges, and disposable pens are stable at room temperature for four weeks. A few exceptions to this rule are described later in this article. Patients should discard any insulin remaining in their vial after four weeks of use even if insulin is stored in the refrigerator to decrease the risk of skin infections resulting from microbial contamination. Unopened insulin products should be stored in the refrigerator. In-use insulin pens and cartridges should be stored at room temperature. Caregivers of patients with diabetes may premeasure syringes for patients. Premeasured syringes containing insulin or mixtures of insulins should be stored in the refrigerator and discarded after 21 days. Insulin aspart, insulin glulisine, and insulin lispro may be used in insulin pumps but should not be used for more than 48 hours. Two insulin diluents are available from Eli Lilly. Regular diluent is intended for use with insulin regular (Humulin R). NPH diluent is intended for use with insulin lispro (Humalog); 25% insulin lispro and 75% insulin lispro protamine (Humalog Mix 75/25); insulin NPH (Humulin N); 50% insulin NPH and 50% insulin regular (Humulin 50/50); and 70% insulin NPH and 30% insulin regular (Humulin 70/30). Opened and unopened vials of diluent should be stored at room temperature. Opened vials of diluent and diluted insulin are both stable for one month at room temperature. Diluted insulin lispro is stable at room temperature for 14 days. Insulin NPH is the only maintenance insulin that may be mixed in the same syringe with mealtime insulins. There is no information on the compatibility between Novolin and Humulin insulins. Incompatibility could result from differences in buffering agents between the two product lines, so they should not be mixed in the same syringe. Numerous factors influence the absorption of insulin, and thus affect its duration of action. A faster rate of absorption results in a shorter duration of insulin action, while a slower rate of absorption results in a longer duration of action. Lipohypertrophy and smoking decrease the rate of absorption of insulin. Higher ambient temperature, local massaging of the injection CREDIT This lesson provides two hours of CE credit and requires a passing grade of 70%.* OBJECTIVES Upon completion of this article, the pharmacist should be able to: Differentiate the time course of action of insulin preparations Recommend treatments for the management of hypoglycemic episodes Educate patients on the proper storage and administration of insulins Apply clinical guidelines to adjust insulin therapy for patients with Type 2 diabetes *To receive credit you must score 70% or higher on the quiz and complete the evaluation. Upon successful completion, the University of Florida College of Pharmacy will mail Statements of Credit for written quizzes within 10 working days. Participants completing the program on-line may print a Statement of Credit after successfully completing the program. site, and a lower insulin dose increase the rate of insulin absorption. Young children with less subcutaneous fat have a faster rate of absorption of insulin compared with adults. Exercise of the injection area increases the rate of absorption most likely by increasing blood flow to the skin. The site of injection also affects the rate of absorption. The following injection sites are listed in order of most rapid to least rapid rate of absorption: abdomen, arm, hip, thigh, and buttocks. Time course of action (onset, peak, and duration of action) may vary between patients or at different times in the same patient. Therefore, the time course of action available from manufacturers of insulins should serve only as a general guideline. Time course of action is also influenced by location of the injection site, dose of insulin, blood supply to the injection site, temperature, and physical activity. As patients adjust their physical activity or their meal plan, adjustments of insulin dosages are often necessary. Physical activity may decrease the need for insulin during exercise and for a period following exercise. Insulin doses may need to be increased when patients use medications with hyperglycemic adverse effects (i.e., oral contraceptives, corticosteroids, thyroid replacement therapy). Patients may experience hyperglycemia when they skip insulin doses, consume larger meals, or during infections or stressful situations. Patients should be counseled on symptoms of hy-

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Drug Topics - November 19, 2007 Contents Latebreakers Letters Leukemia Patients Now Have More Options First-in-Class HIV Drug Boon to Patients at End of Tether 150 Years of American Pharmacy Pharmacy Schools Confront New Pressures From Pariah to Patient ACCP Releases Position Paper on Ethical Interactions New Injectable Antibiotic Welcomed with Open Arms NCCN Updates Head and Neck Cancer Guide Improved Phosphate Binder Approved for Dialysis Patients Considering Combination Concern Ensuring Seamless Care Bill Would Create Center for Comparative Effectiveness Hospital Improves Patient Safety with Automatic Drug Distribution System Infection Rates, Patient Stays Drop with New Drug Device How R.Ph.s Helped Three Hospitals Win Quality and Safety Awards A Pharmacist and Dog in Tow are Alzheimer’s Patients’ Best Friends More PBMs Agreeing to Pricing Transparency New Insulins in the Management of Diabetes New Products Advertisers Index Classified VIEWPOINT: Reflections on Pharmacy School After 30 Years

Drug Topics - November 19, 2007

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