Drug Topics - November 19, 2007 - (Page 26)

26 DRUG TOPICS NOVEMBER 19, 2007 www.drugtopics.com CONTINUING EDUCATION crease the risk of postprandial hypoglycemia. The safety and efficacy of the intravenous administration of insulin lispro have not been evaluated in clinical trials. Insulin aspart should be administered within 10 minutes prior to a meal. Advantages of insulin aspart include a more rapid onset of action, a shorter duration of action, and less intrapatient variability in time course of action compared with regular human insulin. These advantages give insulin aspart a more flexible dosing schedule and decrease the risk of postprandial hypoglycemia. Another advantage is that insulin aspart may also be administered intravenously. Insulin glulisine should be administered within 15 minutes before a meal to 20 minutes after starting a meal. Advantages of insulin glulisine include a more rapid onset of action, a shorter duration of action, and less intra-patient variability in time course of action compared with regular human insulin. These advantages give insulin glulisine a more flexible dosing schedule and decrease the risk of postprandial hypoglycemia. The safety and efficacy of the intravenous administration of insulin glulisine have not been evaluated in clinical trials. er that mimics the functioning of the human pancreas as it delivers mealtime insulin in two ways. First, mealtime insulin is continuously infused at a rate to provide maintenance insulin for a patient. Second, mealtime insulin is given as a bolus dose to cover food intake or to correct a high blood glucose level. This bolus dose can be given all at once to cover a highcarbohydrate meal or over time to mimic the insulin release needed for a more slowly digested meal. Patients adjust the amount of insulin they receive by regulating their pump settings based on data from frequent blood glucose self-monitoring. The delivery system for a continuous insulin infusion consists of an insulin pump and an infusion set. The pump unit contains a small reservoir filled with mealtime insulin, an electromechanical assembly that advances the insulin cartridge plunger, and a microprocessor. The infusion set consists of plastic infusion tubing joined to a needle or plastic cannula that is inserted under the skin and secured with tape or an occlusive dressing. Prior to initiating insulin therapy using an insulin pump, patients need to expect to invest more effort to control diabetes than with conventional injections. Patients will need to test their blood sugar four times each day, follow dietary modifications, and record blood glucose values in order to obtain the best results. Patients should also be prepared for occasional leaks and obstructions in the infusion set. Advantages of insulin pumps include improved control of blood glucose, improved safety profile due to an increased ability to modify insulin delivery patterns, and flexibility in matching insulin to variations in diet or physical activity. Disadvantages of insulin pumps include a high learning curve associated with pump therapy, inflammation and infection at infusion sites, susceptibility to ketoacidosis from interrupted flow of insulin due to technical failures, and increased cost as compared with conventional injections. Patients considered to be good candidates for insulin pump therapy include patients with Type 1 diabetes who are seeking an alternative to multiple daily injections, are motivated to achieve excellent blood glucose control, and have a strong desire to achieve maximal flexibility in terms of lifestyle, meal schedules, and travel. Insulin pump therapy may also be used to improve overall glycemic control, reduce the incidence of exercise-induced hypoglycemia and nocturnal hypoglycemia, and control the dawn phenomenon (see Patient Education). Patients with unrealistic expectations, such as thinking that insulin pump therapy will cure diabetes, are not good candidates for insulin pump therapy. Additional contraindications to the insulin pump include severe depression or other serious psychological disorders, inability or unwillingness to calculate bolus doses, history of nonadherence, intense needle phobia, and denial of disease. Premixed insulins Premixed insulins include combinations of a mealtime insulin and a maintenance insulin; therefore, premixed insulins should be administered before meals. Generally, premixed insulins are administered twice daily (before breakfast and before dinner), but they may be dosed once daily before a meal. They have comparable durations of action but differ with respect to onset of action. Patients who eat small, frequent meals (more than three meals per day) are not likely to achieve glycemic control with premixed insulins. All premixed insulins are suspensions that should be administered only by subcutaneous injection. Premixed insulins include 50% insulin NPH and 50% insulin regular, 70% insulin NPH and 30% insulin regular, 25% insulin lispro and 75% insulin lispro protamine, 50% insulin lispro and 50% insulin lispro protamine, and 30% insulin aspart and 70% insulin aspart protamine. Insulin NPH/regular 70/30 and 50/50 disposable prefilled pens should be kept at room temperature after initial use and discarded after 10 days. Since these premixed insulins contain insulin regular, doses should be administered 30 minutes before meals. After initial use, insulin aspart protamine/aspart 70/30 disposable prefilled pens and cartridges should be stored at room temperature and discarded after 14 days. Since this premixed insulin contains insulin aspart, this insulin has a more rapid absorption compared with premixed insulins containing insulin regular, but the significance of this effect on postprandial glycemic control has not been determined. Due to its more rapid onset, this insulin should be administered within 15 minutes of a meal. Insulin lispro protamine/lispro 75/25 and insulin lispro protamine/lispro 50/50 also have a more rapid absorption than premixed insulins containing insulin regular. These insulins should be administered within 15 minutes of a meal or immediately after a meal. After initial use, disposable prefilled pens should be stored at room temperature and discarded after 10 days. Insulin pumps Insulin pumps are a means of delivering a continuous infusion of insulin to a patient. An insulin pump is a miniature comput- Appropriate insulin use with Type 1 diabetes Type 1 diabetes patients require a combination of a maintenance insulin and a mealtime insulin to control their diabetes. The average daily requirement of insulin for patients with Type 1 diabetes is 0.5 to 0.6 units/kg. Although this is a good starting dose, most patients will need dose adjustments as the disease progresses. Patients may start with either a two-, three-, or four-injection regimen. A two-injection regimen involves a mixture of insulin NPH and a mealtime insulin administered before breakfast and before dinner. The first injection should contain two-thirds of the total daily dose 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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