Insulin

Beta cells of the Islets of Langerhans in the pancreas

Where is Insulin produced?

Alpha cells of the Islets of Langerhans in the pancreas.

Where is Glucagon produced?

Insulin lowers glucose by promoting glucose uptake to the cells, where it is stored or used for energy. Glucose cannot enter the cell without insulin.

Simple Terms: Insulin transfer glucose FROM THE BLOOD into THE CELL

What is the mechanism of action of Insulin?

Decrease glucose & Decrease serum potassium

What is the effect of Insulin to the body?

1. Type 1 Diabetes Mellitus

2. Type 2 Diabetes Mellitus

3. Gestational Diabetes

4. Diabetic Ketoacidosis

5. Hyperglycemic Hyperosmolar Non-Ketotic Syndrome (HHNS)

6. Hyperkalemia

What is insulin for? Where is it indicated?

DM Type 1

• ABSENCE of Insulin due to the destruction of the Beta cells.

• Since there’s no insulin to promote glucose uptake to the cells, the body uses FAT to produce energy.

DM Type 2

• The body becomes RESISTANT to Insulin, so glucose cannot enter the cells properly. As a result, glucose builds up in the blood, causing high blood sugar.

Gestational Diabetes

• Insulin resistance due to the INCREASE of MATERNAL HORMONES (e.g. estrogen, hpl, hcg).

• the only DM that is REVERSIBLE because once the maternal hormones starts to go down, everything will go back to normal.

What is the difference between DM Type 1, DM Type 2, and GDM?

DKA

• Usually seen: DM Type I

• Blood Glucose: HIGH (>300 mg/dL)

• Ketones: HIGH

• Onset: FAST (hours)

• Not enough Insulin > body breaks FAT > Ketones ↑ > Acidosis

HHNS

• Usually seen: DM Type II

• Blood Glucose: VERY HIGH (>600mg/dl)

• Ketones: little to none

• Onset: SLOW (days)

• Some insulin is present, so there are few ketones, but glucose becomes extremely high → lots of water is lost through urine → severe dehydration.

What is the difference between Diabetic Ketoacidosis & Hyperglycemic Hyperosmolar Non-Ketotic Syndrome?

Because insulin stimulates the Na⁺/K⁺-ATPase pump, which moves potassium into cells.

Why is insulin indicated for Hyperkalemia?

BIG DICK 💜

B - Bicarbonate (corrects the metabolic acidosis)

I - Insulin (for the entry of K+ to the cells)

G - Glucose (bind to K+ to enter the cell)

DI - Dialysis (filters out excess potassium in the blood)

C - Calcium Gluconate (cardioprotective; it will prevent cardiac dysrythmia)

K - Kayexalate (K+ binder, excretes potaasium via STOOL)

and K+ Wasting Diuretics (excretes K+ via URINE e.g loop, thiazide, & osmotic diuretics)

What are the management of Hyperkalemia aside from Insulin?

Types of Insulin

1. Rapid-acting (LAG)

• Lispro (Humalog)

• Aspart (Novolog)

• Glulisine (Apidra)

2. Short-acting

• Regular Insulin (Humulin R)

3. Intermediate

• Nuetral Protamine Hagedorn (NPH / Humulin N)

4. Long-acting

• Ultralente (Humulin U)

5. Very Long-acting

• Glargine (Lantus)

• Detemir (Levemir)

What are the Types of Insulin?

LAG

Lispro (Humalog)

Aspart (Novolog)

Glulisine (Apidra)

Examples of rapid-acting insulin

Regular Insulin (Humulin R)

What is an example of short-acting insulin?

NPH - Neutral Protamine Hagedorn (Humulin N)

What is an example of an Intermediate-acting insulin?

Ultralente (Humulin U)

What is an example of Long-acting insulin?

Glargine (Lantus)

Determir (Levemir)

What is an example of a Very Long-acting Insulin?

Onset

It is when the medications starts to take effect.

Peak

It is when the medication is working at its strongest.

Onset: 15-30 mins

Peak: 30 mins - 1 hour

What is the onset and peak of a Rapid-acting insulin?

Onset: 30 mins - 1 hr

Peak: 2 - 4 hours

What is the onset and peak of a Short-acting insulin?

Onset: 2-4 hours

Peak: 4-8 hours

What is the onset and peak of a Intermediate-acting Insulin?

Onset: 4-8 hours

Peak: 8-16 hours

What is the onset and peak of a Long-acting insulin?

Onset: 1 hr

Peak: No Peak

What is the onset and peak of a Very Long-acting insulin?

Hypoglycemia

What do we watch out for in taking insulin?

HIWASH

H - Headache

I - Irritable

W - weak

A - Anxiety

S - Sweating

H - Hunger

SHOCK

• Tachycardia

• Tremors

• Palpitations

• Cool, clammy skin

What are the signs and symptoms of hypoglycemia?

15/15 RULE: 15 grams of simple sugar every 15 minutes

Maximum: 3 doses

What is your management for Mild Hypoglycemia (still conscious and responsive)?

1. Fruit Juices

2. Hard Candy

3. Chocolates

4. Honey

5. Jam

6. Soda

What are examples of simple sugars?

After the third dose: Give D50W (IV) or Glucagon (IM)

D50W first line, if no patent IV line then switch to Glucagon (IM)

What if the patient is unrelieved after taking 15 grams of simple sugar every 15 minutes in 3 doses?

Administer D50W (IV) or Glucagon (IM)

Close monitoring of glucose every 15-30 mins

What is the management for patients experiencing Severe Hypoglycemia (unconscious/unresponsive)?

Insulin is sensitive to EXTREMES in TEMPERATURE

Unopened: Refrigerator (2-8 ℃)

Opened: Room temperature (shelf life: 28 days/ 4 weeks/ 1month)

What is the proper storage of insulin?

Yes, but ONLY regular (Humulin R) and intermediate (Humulin N) insulin.

Is it okay to mix different types of insulin in the same syringe?

NPH (cloudy)

Regular (clear)

1. Put Air: NPH > Regular

2. Withdraw: Regular > NPH

What is the procedure in mixing regular and intermediate acting insulin?

Subcutaneous (SQ): ALL insulin

Intravenous (IV): Regular Insulin ONLY

What is the route for insulin administration?

1. Upper shoulder

2. Posterior Arm

3. Abdomen

4. Lower Back

5. Anterior Thigh

(Rotate injection sites to prevent lipodystrophy)

What are the sites for insulin administration?

NO (massage and hot compress can cause rapid absorption of the medication, which increases the risk for hypoglycemia)

Are we allowed to massage or give hot compress to the site after administration?

YES, but only 1-3 hours after meals to prevent hypoglycemia.

Are we allowed to exercise while taking insulin?