Multiple Insulin Injection Therapy

I N S U L I N I N J E C T I O N
Multiple Insulin Injection Therapy
The presentation
Introduction:
Goals of multiple insulin injection. High light of treatment method. Glycemic control effect. Diet treatment.
Type of insulin:
Insulin preparation. What to mix and what not to mix.
Type of regimen:
Western regimen. Our regimen. Future regimen.
Important phenomena:
Somogyi phenomena. Dawn and predawn phenomena.
Goals
Clinical Goals:
Elimination of ketosis. Elimination of hyperglycemia and its symptoms. Prevention of chronic complications.
Additional Goals:
Maintaining desirable weight. Maintaining normal growth and sexual maturation. Maintaining psychosocial well-being. Achieving normal fertility and pregnancy. Sustaining normal family and sexual life.
Control Goals:
HbA1c <7%. Pre-meal SMBG 80-120 mg/dl (4.4-6.7 mmol/l). Bed time SMBG 100-140 mg/dl (5.6-7.8 mmol/l). No ketonuria. Mean blood glucose level 120-160 mg/dl (6.7-8.9 mmol/l).
Highlights
Insulin:
Type 1 diabetes is dependent on insulin for survival. Insulin is classified by source or duration of action. Human insulin has less allergy or lipoatrophy. More than one injection is needed and different types. Proper action During honeymoon phase. The commonest side effect is hypoglycemia.
Nutrition:
Enable near normal blood glucose level. Maintain a reasonable body weight. Protein 10-20%, Fat 15-25%, Carbohydrate 65%. Fibers, vitamins, and minerals. Food exchanges or carbohydrate counting. Total daily calorie intake adjustment.
Exercise:
Should be integrated. Weight control and improve well being. Pre-exercise medical evaluation.
Monitoring:

Glucometer use SMBG to monitor blood glucose level. Adjustment of insulin, diet, and exercise. Urine testing for both glucose and ketones. HbA1c the best index for control.
I N S U L I N I N J E C T I O
Glycemic control
9
Conventional
8 HbA1c (%)
Intensive
7
6.2% upper limit of normal range
6 0 0 3 6 9 12 15 Years from randomization
UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352:837853.
I N S U L I N I N J E C T I O N Breakfast
Carbohydrate (65%) Protein (10%) Fat (25%)
Carbohydrate Protein (10%) Fat (25%)
Diet Arabian bread Cheese Honey Glass of milk Total
Diet
Body weight
The total calories intake depends on patients age and activity but have to related to the desirable body weight. Total daily calories = IBW X Estimated daily energy Add 300 kcal/day during pregnancy. Add 500 kcal/day during lactation. Fibers, sweeteners, vitamins, and minerals.
25 years male IBW 60 kgm 60 Kg X 30 kcal = 1800 kcal
30 25 20
35 30 25
40 35 30
Physical activity
600 kcal
390 60 150
100 gm 15 gm 17 gm
Carbohy. Protein Fat _ 30 gm ----5 gm 10 gm 10 gm 50 gm 2 gm 3 gm 10 gm 5 gm 5 gm_ 95 gm 17 gm 18 gm
Lunch
Diet Rice chicken Salad Orange Total
800 kcal
520 80 200
130 gm 20 gm 22 gm
Carbohy. Protein Fat _ 80 gm --6 gm 5 gm 15 gm 12 gm 30 gm 4 gm 4 gm 10 gm -----___ 125 gm 19 gm 22 gm
Dinner
Diet Tuna sandwich Apple Tea Total
400 kcal
260 40 100
65 gm 10 gm 11 gm
Carbohy. Protein Fat _ 45 gm 12 gm 10 gm 15 gm ----------- _ 95 gm 17 gm 18 gm
0
1 2 3 4 5 6 7
Glucose sensor The plan of insulin type and dose will depend on:
- The shape of glucose curve. - The diet and exercise.
20 Day 1 Day 2 Day 3
10
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
I N S U L I N I N J E C T I O
0 3 6
Insulin Preparations
Action
Very rapid Rapid Intermediate
Name
Lispro / Novo rapid Crystalline zinc (CZI) Neutral Protamine Hagedorn (NPH) Lente zinc Ultralente zinc Lantus (glargine) 80% NPH+20%CZI 70% NPH+30%CZI 50% NPH+50%CZI
Onset
10-15 min 30-45 min
Duration
2-3 hrs 4-6 hrs
1-2 hrs
6-8 hrs 4-8 hrs 30-45 min 30-45 min 30-45 min
6-12 hrs
18 hrs 24 hrs 6-12 hrs 6-12 hrs 6-12 hrs
Long acting Premixed
INSULIN TYPES DURATION OF ACTION

9 12 15 18 21 24
(1) (2)
Insulin Mixing Action

Very rapid
Name
Lispro / Novo rapid
Mix
Yes
(2) (2)
(1)
Rapid
Intermediate
Crystalline zinc (CZI)

Neutral Protamine Hagedorn (NPH) Lente zinc
Yes
Yes (2) Yes (2) Yes
(2)
Long acting
Ultralente zinc Lantus (glargine)

80% NPH+20%CZI 70% NPH+30%CZI 50% NPH+50%CZI
No No_
No No No_
Premixed
Mixing different type of insulin has to be fron the same source (ie same company) Mixing different type of insulin has to be fron the same source (ie same company)
Pre-mixed insulin
10/90
30/70
40/60
50/50
Pre-prandial hyperglycemia
Post- prandial hyperglycemia
20/80
Adapted from Polonsky et al. 1988
Western regimen
70
Normal free insulin levels (Mean) Simulated s.c. injected soluble human insulin + NPH Simulated s.c. injected insulin aspart + NPH Meal
60
Insulin (mU/l)
50 40 30 20 10 0
0600 0900 1200 1500 1800 2100
2400 0300
0600
Time of day
Breakfast Lunch Dinner NPH
Western regimen
Two doses:
150
The usual dosing commonly used. Initial insulin therapy

50
Three doses:
12
12
Used for active patients. Patients taking two main meals.
150
50
Four doses:
12
12
150
Brittle diabetic patient. Pregnant mothers specially type 1.

50
Four doses:
12
12
150
Brittle diabetic patient. Pregnant mothers specially type 1. Motivated patients.
50
12
12
Western regimen
Two doses:
150
The usual dosing commonly used. Initial insulin therapy

50
Three doses:
12
12
Used for active patients. Patients taking two main meals.
150
50
Four doses:
12
12
150
Brittle diabetic patient. Pregnant mothers specially type 1.

50
Four doses:
12
12
150
Brittle diabetic patient. Pregnant mothers specially type 1. Motivated patients.
50
12
12
I N S U L
150 250
Blood Glucose Curve

Glucose variations in our culture:
Nondiabetic
I N I N J E C
Diabetic week end day
250 150 50 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
Diabetic week day

250
50 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
T I O
50 150
10
11
12
10
11
12
I N S U L I N I N
50 250
Insulin Use
Regular and NPH use twice daily the commonest regimen used. Premixed with different concentration (30/70, 40/60, 50/50). Lunch is the biggest meal usually but no insulin dosing.
150
J E
250
10
11
12
10
11
12
Diabetic week day
C T I
50 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 150
O N
I N S U
250
Hyper-glycemia window
Diabetic week
Hyperglycemia Window day
L I N
50 6 7 8 9 10 11 12 1 2 3 150
I N J E C
250
Cause: Lack of insulin Lunch effect afternoon snacks

4 5 6
10
11
12
Effect: Pre-meal hyperglycemia HbA1c by 1.7%
T I O
50 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 150
I N S U L I
Treat by adding regular dose pre-lunch
Diabetic week day
N I N
250
150
50 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5
J E
250
C T I
50 150
O N
10
11
12
10
11
12
I N S U L I N
250
Treat by adding regular dose pre-meals and small one before sleep
Diabetic week day
I N J E C T I O N
150 250 150
50 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5
50 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5
I N S U L I N
150
Hypo-glycemia window
Week end Problem

250
Hypoglycemia Window
I N J E
250 50 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5
Cause: NPH evening dose ? Late sleep Effect: Somogyi effect
C T I
50 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 150
O N
I N S U L I N
150
Treat by moving am dose late and regular dose pre-supper and NPH at night
250
I N J E
250 50 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5
C T I
50 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 150
O N
I N S U L I N
150
Treat by moving am dose late and regular dose pre-supper and another dose pre bed

250
I N J E
250 50 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5
C T I
50 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 150
O N
0
1 2 3 4 5
Somogyi Phenomenon
20
10
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Cause:
Counter regulatory hormones response to hypoglycemia at med-night. Increase in hepatic glucose production. Insulin resistance because of the Counter regulatory hormones.
Treatment:
Decrease pre-supper intermediate insulin.
Defer the dose to 9 PM.

Change or start pre-bed snack.
I N S U L I
10 20
Dawn Phenomenon
N I
0
N J E C T I O N
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Cause:
Less insulin at bed time.
Treatment:
Use enough dose.
More food at bed time.

Not using NPH at night.
Reduce bed time snack.

Add NPH pre-supper.

Multiple Insulin Injection Therapy

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