IDEA21(국제 당뇨병 교육 협회) : 당뇨란



		Oral Medication Use Insulin therapy 1 Insulin therapy 2 [ Oral Medication Use ] When the patient is first diagnosed with Diabetes, a healthy diet and exercise would be the initial best option for optimal blood sugar control. The patient should understand that Diabetes is a controllable disease, not curable. If the patient eats too much or does not exercise , then the patient's blood sugar levels will inevitably soar high. It is a fallacy that the patient can eat anything when he or she takes diabetic medication or lowering sugar agents. It is also misleading to think that a diabetic patient can take an diabetic agent to prevent complication even though his or her blood sugar level is normal. Patient are advised to start oral diabetic medication only with the supervision of a physician. If the patient maintains good blood sugar control with diet and exercise alone, then he should not take any oral diabetic medication. If the patient has trouble controlling his blood sugar levels with diet and exercise alone for some time, then the patient must start on a low dose of oral diabetic agent as directed by the patient's physician. At this time, the patient must check his blood sugar levels consistently to confirm if the medications are helpful in maintaining normal levels. The physician should work with the patient in titrating up the dose if the patient's blood sugar levels do not return back to normal within 2-4 weeks. The patient must be cautious not to increase the dose in a short period of time because the patient may experience signs and symptoms of hypoglycemia, or low blood sugar levels. There are several drugs that lower blood sugar levels. Some of these diabetic medications include : Diabeta, Micronase, and Amaryl, available in the U.S. These medications are classified as Sulfornylureas. These drugs are similar in activity with each other and stimulate the pancreatic cell to produce more insulin. This class of medications has a duration of action of 12-24 hours. Prandin, another type of diabetic agent, lasts only 4-6 hours and no low sugar reaction just before next meals. Prandin is taken 3 times per day before meals. Glucophage (Metformin) dose not stimulate the pancreatic cell but prolongs carbohydrate absorption from the gastrointestinal tract. It also disturbs the storing of glucose in the liver and increases insulin sensitivity. People overweight can benefit from the use of Glucophage therapy alone. Those who are not responding to Sulfornylureas alone can also benefit from the use of Glucophage in combination with their Sulfornylurea. More potent diabetic drugs include :Avandia and Actos. These are expensive medication that are newly marketed. They decreases insulin resistance and increase insulin sensitivity. In order words, it facilitates and assists in sugar transport into the cell. these drugs can be used with medications that stimulate insulin, Sulfonylureas like Diabeta, or can be used in combination therapy with insulin injections. Another class of medications, Precose, acts indirectly by lowering the blood sugar levels. This medication interrupts digestive action for carbohydrate breakdown. Side effects of this medication include abdominal fullness, gastric pain, and irritable digestion, but does not induce hypoglycemia, or low blood sugar levels, or liver toxicity. It is necessary to use insulin injection if the patient cannot control his blood sugar levels with proper diet, exercise and appropriate oral diabetic drug therapy. There are millions of people who use insulin injections in the U.S., and even 100,000 young children with juvenile onset diabetes under the age of 10 years are on insulin injections. There are no reason not to take insulin, he or she may be in risk of future diabetic complications such as hypertension, neuropathy(nerve damage), nephropathy(kidney damage), retinopathy(complication with eye), possible blindness, and possible foot/leg amputations. (Oral diabetic medication activity): 1. Simulate insulin-> Sulfonylurea, : Micronase, Glucotrol,Amaryl etc ->(lower sugar level) 2. Disturb glucose activity in liver-> Meformin -> (Lowering sugar level) 3. Increase insulin sensitivity)-> Avandia, Actos -> (Lowering sugar level) 4. Disturb digestion carbohydrate)-> Pricose -> (Lowering sugar level) [ Insulin therapy 1 ] What is Insulin ? The cause of diabetes is a lack of insulin secretion from the pancreatic insulin hormone. Historically, Mr Banting and Mr.Best in Canada discovered the first insulin product, which was of animal origin, in 1920. At that time, they could not produce pure human insulin until 1973. Animal source of insulin has a slight difference in amino acid sequence when compared to human insulin; however, there are still side effects. Some side effects with animal insulin include itching at the site of injection, skin irritation, etc. Today, human insulin is available. The drug product exactly resembles human insulin. Presently, the patient uses insulin dosages, which are reduced and have less allergic reactions. Opened insulin bottles are not required to be refrigerated, but can be stored at room temperature. However, unopened bottles must be refrigerated until opening. Unopened bottles should not be put into the freezer. there are different kinds of insulin available. Regular insulin, a short acting type, peaks about 2-3 hours after injection and lasts for 4-6 hours. This insulin is administered 30 minutes before meal. The second type of insulin available in NPH. NPH is long acting and peaks about 8 hours after injections and lasts about 24 hours. The combination of 30% Regular insulin and 70% NPH are available as "Humulin 70/30" or "Novolin 70/30". A few patients also use a "50/50" combination product, however, it is rare. Humalog (Lispro), extra short acting insulin, is also available. This type of insulin is injected 15 minutes before meals. A combination product of 75% LPH (long acting Lispro protamine) and 25% Humalog (Lispro) is available as Humalog 75/25. Some patient with diabetes do not like to carry insulin and syringes separately. Pen type insulin is designed to pre-fill insulin with the needle together. They are pre-filled with either 150 units or 300 units within each pen. They are marketed as Humulin pen or Novolin pen. Some pen products are disposable, while others are reuseable. For this reason, the patients can be confused about which product they should use and how to use them. To prevent any confusion, the patient should understand the characteristics of each insulin type such as the peak time and the duration of action. If the patient injects Regular insulin before breakfast, the sugar levels should be 150-170 mg/dl after 2 hours from ingestion. If the patient injects NPH insulin before break-fast, the plasma level of glucose should be 150mg/dl, at 4:00 pm in the afternoon to indicate good blood sugar control. Patient make an easy mistake by adjusting NPH morning dosage by looking at sugar levels before breakfast. There is no correlation between morning doses and morning test results. It is incorrect to say if the patient takes oral insulin sensitizer, like Avandia, or Actos, he could stop the insulin injection. However, some patients have good blood sugar control by using combination of insulin injections and oral insulin sensitizer like Glucophage, Avandia, and Actos. [ Insulin therapy 2 ] 1. How does Insulin react in the body ? The food we eat breaks down in the body to a small part of what is called glucose. The insulin delivers the glucose to the cells to run vital parts of the human organ. If insulin does not exist in the cell, the cell cannot live at all. Intrinsic human insulin is released from the pancreas 0.7-1.0 units per hour and increases insulin secretion 2.0 -2.5 units per hour when we eat food. For healthy people, intrinsic insulin secretes on time the proper amount so that increasing sugar level is prevented by the food consumption. Some diabetic patients who do not secrete enough intrinsic insulin or never secrete insulin at all need insulin injection from the outside of the body. The goal of the insulin therapy is to regulate and control the sugar level by injecting the proper amount of insulin on time. To accomplish this, the diabetic patient that needs insulin therapy needs to know all about insulin and may need assistance from their Doctor or Diabetic Educator. 2. How they product insulin? At one time insulin injection was made from animal sources. Now all insulin products are made from DNA composition techniques. The skill of making purified insulin is much improved and of the same quality of insulin in the intrinsic human hormones. Now we do not need to keep insulin products on ice for short periods of time. Unused bottles must stored in the refrigerator and used bottles can be stored at room temperature. 3. Different types of Insulin 1) extra short acting: Lisipro(Humalog) : acts 15 minutes after injection, peak level in 1 hour, and last 2 hours 2) Short acting: Regular(R): acts 30 minutes after injection, peak level in 2 hours, and last 4 hours 3) Intermidiate acting: NPH(N): acts 3 hours after injection, peak level in 8 hours, and last 24 hours 4) Combination (Humulin 70/30): combination of NPH 70% and Regular 30% 5) Combination(Humalog 75/25):Combination of LPH(Lisipro P)75% and Lisipro 25% 6) extra long acting:Ultra Lente: Lasts 30 hours (not used as much) 7) Long acting, no peak acting:Glargine(Lantus): no peak level,last 24 hours (relatively new) 4. Types of insulin with syringe and needle 1) insulin type: Humalog, R, N, Humulin 70/30, Humalog 75/25, Humulin 50/50 2) Insulin concentration: U-100 (100units in 1 cc ) 3) Expired Date: discard if the product expired 4) Syringe: U-100(same concentration of insulin) 5) length of syringe: 1/100, 1/50, 1/30 (100units/1cc, 50units/1cc,30units/1cc) 6) needle: 28G,29G,30G( much smaller in diameter with bigger number) 7) Pen type insulin & syringe(prefilled syringe 150units,300units) 5. Storing insulin Opened insulin bottle can be stored in a cooled room temperature, but an unopened bottle should be kept in the refrigerator without freezing. 6. How to inject insulin 1) Gently mix the insulin. You can roll the bottle between the palms of your hands and change the direction up and down, never shake the bottle vigorously because the bubbles may cause a mistake when measuring. 2) If it is a new bottle. Remove the flap , and the color cap then clean it with an alcohol swab. 3) Pull back the plunger to pull air into the syringe. Push the needle through the rubber stopper. Press in the plunger to push the air into the bottle of insulin. Turn the bottle and syringe upside down. Use the other hand to pull back on the plunger at the line of units. 4) Clean the skin at the selected place to inject with an alcohol swab. Pinch up a large area of skin. Push the needle into the skin, Push the plunger all the way down. 5) Pull the needle straight out of your skin. Dispose of used needles and syringes. 7. The important things for insulin therapy 1) One should understand various insulin functions , and discuss them with your doctor to select the kind of insulin, dosage and injection time. 2) Many insulin users inject once a day in the morning before meals. (It is important to eat each meal on time.) If you want to inject twice a day, inject 2/3 of daily dose before breakfast and 1/3 of daily dose before dinner. Be aware of the potential of a low sugar level if you do not eat the meal on time or skip a meal. 3) Patient should rotate the injection area everyday, and do not use the same area within 15 days. 4) The fastest absorption area is in the arms, the next area is abdominal and the slowest to absorb area is the legs. 5)The results of insulin therapy are different with each person, therefore insulin users should check blood tests or urine tests regularly and adjust insulin dosage by the test results. 6) Have at least one prepared bottle of insulin on hand at all times. 7) Have prepared R insulin, in case it is needed when the patient has a very high sugar level. 8) Always discard used syringe and needle.