Drug Topics - November 19, 2007 - (Page 24)

24 DRUG TOPICS NOVEMBER 19, 2007 www.drugtopics.com CONTINUING EDUCATION Table 1 Insulin formulations available in the United States Maintenance insulins Insulin detemir Insulin glargine Insulin NPH Levemir Lantus Humulin N Novolin N 10-mL vial, 3-mL cartridge, prefilled disposable insulin pen 10-mL vial, 3-mL cartridge 10-mL vial, prefilled disposable insulin pen 10-mL vial, 3-mL cartridge Mealtime insulins Insulin aspart Insulin glulisine Insulin lispro Insulin regular NovoLog Apidra Humalog Humulin R Novolin R 10-mL vial, 3-mL cartridge, prefilled disposable insulin pen 10-mL vial, 3-mL cartridge 10-mL vial, 3-mL cartridge, prefilled disposable insulin pen 10-mL vial 10-mL vial, 3-mL cartridge Premixed insulins 30% insulin aspart and 70% insulin aspart protamine 50% insulin lispro and 50% insulin lispro protamine 25% insulin lispro and 75% insulin lispro protamine 50% insulin NPH and 50% insulin regular 70% insulin NPH and 30% insulin regular NovoLog Mix 70/30 Humalog Mix 50/50 Humalog Mix 75/25 Humulin 50/50 Humulin 70/30 Novolin 70/30 10-mL vial, 3-mL cartridge, prefilled disposable insulin pen 10-mL vial, prefilled disposable insulin pen 10-mL vial, prefilled disposable insulin pen 10-mL vial, 3-mL cartridge, prefilled disposable insulin pen 10-mL vial, 3-mL cartridge, prefilled disposable insulin pen perglycemia such as confusion, drowsiness, polyuria, polydipsia, polyphagia, and tachycardia. Patients should monitor urine ketones if they experience symptoms of diabetic ketoacidosis such as fruity-smelling breath, fast and deep respirations, or abdominal pain. If severe hyperglycemia is not treated, diabetic ketoacidosis may progress to loss of consciousness or death. An increased circulating level of insulin occurs in patients with renal failure, and patients with hepatic dysfunction have a reduced capacity for gluconeogenesis and reduced insulin metabolism. Therefore, careful glucose monitoring and dose adjustments of insulin are necessary in patients with renal or hepatic dysfunction. Adverse effects Common adverse effects of insulin therapy include weight gain and hypoglycemia. Symptoms of hypoglycemia may occur when the blood glucose is less than 60 to 72 mg/dL. The threshold for hypoglycemia varies between patients and should be defined based on symptoms. Hypoglycemia ranges from mild to severe and may have a gradual or rapid onset. Autonomic symptoms of hypoglycemia include trembling/shaking, sweating, heart pounding, tachycardia, tingling extremities, and heavy breathing. Neuroglycopenic symptoms of hypoglycemia include slow thinking, blurred vision, slurred speech, poor coordination, numbness, poor concentration, dizziness, and fatigue/sleepiness. Additional symptoms include hunger, nausea, weakness, headache, and a general feeling of uneasiness. Common causes of hypoglycemia include missed meals, increased physical activity, vomiting, diarrhea, alcohol use, emo- tional or physical stress, and progression of renal or hepatic disease. Sympatholytic medications such as beta-blockers, clonidine, and reserpine may mask the symptoms of hypoglycemia mediated by the sympathetic nervous system, but will not block symptoms of the cholinergic nervous system, such as sweating. Caffeine may increase the autonomic symptoms of hypoglycemia, while alcohol may decrease symptoms of hypoglycemia. In addition, patients with a long history of diabetes or neuropathy may not experience symptoms of hypoglycemia. Frequent monitoring of blood glucose is especially important in these patients. Patients should treat symptoms of hypoglycemia or blood glucose less than 70 mg/dL with 15 to 20 gm of carbohydrate sources. Examples include three to four glucose tablets, eight to 10 hard candies, 4-6 oz of fruit juice or soft drinks containing sugar, or 8 oz of milk. If the patient’s blood glucose is less than 50 mg/dL, 20 to 30 gm of carbohydrates may be needed. Severe hypoglycemia may result in coma, seizure, or neurologic impairment. If the patient is unconscious, caregivers should administer glucagon 1 mg IM for adults, 0.5 mg IM for children less than five years of age, and 0.25 mg IM for infants. In hospitalized patients, IV dextrose 50% may be used. Sustained carbohydrate intake and close observation are necessary because hypoglycemia may recur after apparent recovery. Less common adverse effects include lipoatrophy and lipohypertrophy. Lipoatrophy is a dimpling in the skin at the injection site caused by local antibody formation, leading to the breakdown of fat at the injection site. Lipohypertrophy is an increase in fat mass at the injection site and occurs when insulin is repeatedly injected into the http://www.drugtopics.com

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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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