Drug Topics - November 19, 2007 - (Page 25)

25 same site over time. Patients should rotate injection sites to minimize the risk of lipohypertrophy. In order to help ensure consistency of insulin absorption, patients should use the same body area (i.e., abdomen), but alternate the site of injection within this body area. Patients may use any area of the abdomen with the exception of a two-inch radius around the navel. Patients may experience redness, swelling, or itching at the injection site. These minor reactions usually resolve within days to weeks. In some cases, these reactions may be related to factors other than insulin, such as irritants in skin cleansers, poor injection technique, or injecting through wet alcohol. Generalized insulin hypersensitivity rarely occurs, but when it does, the patient may experience a skin rash over the body, dyspnea, tachycardia, sweating, and hypotension. Ensuring there are no air bubbles in the syringe prior to injection minimizes injection-site pain. Additional patient education for reducing injection-site pain includes: relaxing muscles in the injection area when injecting, waiting until topical alcohol has evaporated completely before injecting insulin, quickly penetrating the skin, not changing needle direction during insertion or withdrawal, not reusing needles, and injecting insulin at room temperature. periods of time compared with other insulins. Although insulin detemir has a less pronounced peak effect than insulin NPH, which may result in a lower risk of nocturnal hypoglycemia, this advantage has not been consistently demonstrated in clinical trials comparing the two agents. A disadvantage of insulin detemir is its incompatibility with mealtime insulins, resulting in an increased number of required injections for patients using both mealtime and maintenance insulins. Patients may administer insulin glargine at anytime during the day, as long as they are relatively consistent. If a patient is switched from insulin NPH dosed twice daily to insulin glargine dosed once daily, the initial dose of insulin glargine should be 80% of the total daily dose of NPH. If the patient is switched from insulin NPH dosed once daily to insulin glargine, the initial dose of insulin glargine does not require a dose reduction. Advantages of insulin glargine include a lack of a significant peak effect, decreased risk of nocturnal hypoglycemia, and a longer duration of action, allowing for oncedaily injections. Disadvantages of insulin glargine include its incompatibility with mealtime insulins and a higher incidence of injection-site pain due to its acidic pH. Maintenance insulins Mealtime insulins Maintenance insulins meet the patient’s need for an appropri- Mealtime insulins include regular human insulin, insulin ate level of insulin between meals and during sleep. Mainte- lispro, insulin glulisine, and insulin aspart. All mealtime innance insulins include insulin NPH, insulin detemir, and in- sulins have a clear appearance, and they should be discarded if sulin glargine. Insulin detemir and insulin glargine have a clear they appear cloudy, thickened, slightly colored, or if visible solappearance, while insulin NPH has a cloudy appearance. id particles are present. If a mealtime insulin is mixed in the Insulin NPH (Humulin N, Novolin N) is a suspension of hu- same syringe as insulin NPH, patients should be counseled to man insulin protamine and zinc. After initial use, cartridges for in- draw the mealtime insulin in the syringe prior to drawing the sulin pens and prefilled disposable insulin pens should be stored at insulin NPH. Differences in the time course of action among room temperature and discarded after 14 days. An advantage of in- the mealtime insulin preparations do not result in significant sulin NPH is its ability to be mixed with mealtime insulins, thus de- differences in overall glycemic control. creasing the required number of injections for patients using both Regular human insulin is available in two concentrations. The mealtime and maintenance insulins. Disadvantages of insulin NPH U-100 formulation contains 100 units/mL, and the U-500 coninclude a peak effect, which results in a higher risk of nocturnal hy- tains 500 units/mL. Regular human insulin U-500 is intended for poglycemia compared with other maintenance insulins. use in patients requiring more than 200 units/day to control their Insulin detemir may be used once or twice daily. When dosed diabetes. Regular human insulin should be administered 30 minonce daily, insulin detemir should be administered with the utes prior to meals. Advantages of regular human insulin include: evening meal or at bedtime. Insulin detemir has been compared It may be administered intravenously, it is the least expensive with insulin NPH and insulin glargine. Clinical trials have mealtime insulin, and it is available in a concentrated formulation demonstrated that higher doses of insulin detemir (0.77 (500 units/mL). Disadvantages of regular human insulin include units/kg) are required to achieve similar glycemic control com- a more variable absorption compared with other mealtime inpared with insulin NPH (0.52 units/kg). Insulin detemir dosed sulins; a longer duration of action compared with other mealtime twice daily resulted in similar glycemic control compared with insulins, which may result in postprandial hypoglycemia; and a insulin glargine dosed once dailess convenient dosing regimen Table 2 ly. Since insulin detemir once with regard to meals. Adjusting once-daily maintenance daily has not been compared Insulin lispro should be adwith insulin glargine once daily, insulin for patients with Type 2 diabetes ministered within 15 minutes these insulins should not be prior to a meal or immediately Most fasting blood-glucose considered to possess comparaafter a meal. Advantages of inreadings over past three ble durations of action. sulin lispro include a more rapid to seven days Insulin adjustment After initial use, vials, caronset of action, a shorter dura≥180 mg/dL Increase by 6 units tridges, and prefilled disposable tion of action, and less intra-pa140 to 179 mg/dL Increase by 4 units insulin pens may be stored at tient variability in time course of room temperature but must be action compared with regular 110 to 139 mg/dL Increase by 2 units discarded after 42 days. An adhuman insulin. These advan80 to 109 mg/dL No change vantage of insulin detemir is tages give insulin lispro a more Less than 80 mg/dL Decrease by 2 units that it may be used for longer flexible dosing schedule and de-

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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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