Drug Topics - November 19, 2007 - (Page 28)

28 DRUG TOPICS NOVEMBER 19, 2007 www.drugtopics.com CONTINUING EDUCATION pens, and the pen should be primed before each use. Priming is important because it confirms that the pen is working properly and removes any air in the insulin cartridge. Next, patients should clean their injection site and the top of the insulin vial with alcohol and allow them to air dry. If patients are mixing insulins, they should draw up their mealtime insulin before drawing up insulin NPH. It is important for patients to know that insulin detemir and insulin glargine should never be mixed with other insulins. Most patients should completely inject the needle at a 90-degree angle. However, if the patient is thin, the needle should be completely injected at a 45-degree angle. Patients should inject into a pinch of skin to avoid the risk of administering insulin intramuscularly. Particularly with the use of insulin pens, the needle should be embedded within the skin for five seconds after complete depression of the plunger to ensure appropriate delivery of the insulin dose. Patients sometimes have difficulty understanding how their morning blood sugars can be higher than their bedtime blood sugars even though they have not consumed a bedtime snack. Morning hyperglycemia may be a result of either the dawn phenomenon or the Somogyi effect. The term dawn phenomenon describes the rising of blood sugar levels in the hours of the morning prior to waking. This rising blood sugar results from increased nocturnal growth hormone secretion, increased resistance to insulin action, and increased hepatic glucose production. The dawn phenomenon is treated by increasing the dose of the maintenance insulin. If the patient is using maintenance insulin twice daily, only the bedtime dose of the maintenance insulin needs to be increased. If patients are using insulin NPH before their evening meal, the dose should be moved from evening to bedtime to shift insulin NPH’s peak effect to match the timing of the dawn phenomenon. The Somogyi effect describes post-hypoglycemic hyperglycemia or rebound hyperglycemia. Somogyi’s hypothesis is that morning hyperglycemia may result from a low blood sugar in the middle of the night which then stimulates an increase in counter-regulatory hormones (i.e., glucagon), leading to an increase in glucose in the morning. This is identified by checking blood glucose in the middle of the night. The Somogyi effect is treated by decreasing the dose of maintenance insulin. If the patient is using maintenance insulin twice daily, only the bedtime dose of maintenance insulin should be decreased. If the patient is using insulin NPH before the evening meal, the dose should be moved from evening to bedtime to shift insulin NPH’s peak effect to match the timing of the dawn phenomenon and decrease the risk of nocturnal hypoglycemia. Conclusion Since over five million patients with diabetes in the United States are currently using some form of insulin therapy, there is a tremendous opportunity for pharmacists to assist patients in the appropriate use of insulin to achieve therapeutic goals. Classifying insulins as mealtime, maintenance, or premixed insulins helps simplify patient education. Pharmacists should be able to categorize currently available insulin products in each of these classifications and differentiate the insulins within each classification with regard to their advantages and disadvantages. Additionally, counseling patients on the proper storage, use, and administration of their insulin helps optimize drug therapy. Pharmacists should also utilize the latest consensus guidelines to optimize the management of patients with Type 2 diabetes mellitus. References available upon request TEST QUESTIONS Write your answers on the answer form appearing on page 30 (photocopies of the answer form are acceptable) or on a separate sheet of paper. Mark the most appropriate answer. 1. Currently, more than how many patients with dia- betes in the United States use insulin to help control their diabetes? a. Five million b. 10 million c. 50 million d. One billion 2. Which of the following insulin preparations has the highest risk of allergic reactions? a. Humalog b. Humulin U Ultralente c. NovoLog d. Regular Iletin II Pork Insulin 3. Which of the following would be an appropriate b. Continue current dose of insulin glargine and replace inhaled human insulin with regular insulin 19 units qam ac and 14 units qpm ac. c. Replace insulin glargine and inhaled human insulin with regular insulin 14 units qam ac and 19 units qpm ac. d. Replace insulin glargine and inhaled human insulin with regular insulin 19 units qam ac and 14 units qpm ac. 4. Which of the following insulin mixtures is compat- ible? a. Insulin detemir (Levemir) and regular human sulin (Humulin R) b. Insulin glargine (Lantus) and regular human sulin (Humulin R) c. Insulin NPH (Humulin N) and regular human sulin (Humulin R) d. Insulin NPH (Novolin N) and regular human sulin (Humulin R) inininin- conversion of inhaled human insulin to susbcutaneous regular insulin for a patient with Type 2 diabetes mellitus who was using one 3-mg and two 1-mg bister packets qam ac and two 3-mg and one 1-mg blister packets qpm ac in addition to insulin glargine 40 units daily? a. Continue current dose of insulin glargine and replace inhaled human insulin with regular insulin 14 units qam ac and 19 units qpm ac. 5. Which of the following injection sites provides the most rapid absorption of insulin? 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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