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886 PA R T V / Health Promotion and Disease Prevention

Table 39-4 ■ PHARMACOKINETICS OF AVAILABLE INSULIN PREPARATIONS
Insulin, Generic Name (Brand Name) Onset Peak Effective Duration
Rapid-acting, Bolus
Insulin aspart injection (NovoLog)
Insulin lispro injection (Humalog) 5 to 15 min 30 to 90 min 5 h
Insulin glulisine injection (Apidra)
Short-acting, Bolus
Regular 30 to 60 min 2 to 3 h 5 to 8 h
Intermediate, basal
NPH 2 to 4 h 4 to 10 h 10 to 16 h
,†
Insulin detemir injection (Levemir)* (3) 3 to 8 h No peak 5.7 to 23.2 h
Long-acting, basal
Insulin glargine injection (Lantus)* ,† 2 to 4 h ‡ No peak 20 to 24 h
*May require two daily injections in patients with type 1 diabetes mellitus.
†
Assumes 0.1 to 0.2 U/kg per injection. Onset and duration may vary significantly greatly by injection site.
‡
Time to steady state.
NPH, neutral protamine Hagedorn.
Adapted from American Association of Clinical Endocrinologists. (2007). Medical guidelines for clinical practice for the management of diabetes mellitus. Endocrine Practice, 13.

started at a low range with gradual increase since they can cause ingested meals to prevent postprandial (after meal) hyper-
severe flatulence and abdominal discomfort. glycemia. People with type 1 secrete no insulin in response to
Given its action, people with chronic intestinal diseases, inflam- meals and people with type 2 secrete less than normal. Replace-
matory bowel disease, or bowel obstruction should not take this class ment of this insulin is accomplished by the use of the short-acting
of medication. If a patient is taking a secretagogue and/or insulin insulin (regular) or the rapid-acting insulins including aspart,
and a glucosidase inhibitor, they need to treat hypoglycemia with lispro, and glulisine (Table 39-4). The dose of this insulin is ad-
oral glucose (dextrose) such as glucose tablets to reverse hypo- justed depending on the patient’s glucose level prior to a meal and
glycemia. Products containing sucrose (table sugar, candy, and sodas) the amount of carbohydrate they plan to eat.
are not effective because this class of agents will delay absorption. Small amounts of basal insulin are released throughout the day
to maintain between meal and nighttime blood glucose levels at
Amylin Analogs. Pramlintide is the synthetic version of the
human amylin, a hormone that lowers blood glucose by suppress- target range. People with type 1 diabetes secrete no basal insulin
ing glucagon production, slowing gastric emptying, and increasing and those with type 2 diabetes secrete diminished amounts. In
satiety. It is only available in injectable form and is given before type 2 diabetes, this lack of basal insulin is most often reflected in
meals to lower postmeal glucose levels. Patients with type 1 or 2 elevated fasting glucose levels. Insulins that imitate the basal in-
on insulin therapy can utilize this therapy that lowers A 1c by about sulin release include the intermediate-acting insulin, NPH, and
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0.5% to 7% and often result in weight loss. Teaching points in- (or) long-acting insulins such as glargine or detemir. The dose
clude reduction of rapid-acting insulin dose by about 50% while of insulin is based on the patient’s weight, morning glucose levels,
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starting amylin therapy to reduce the potential of hypoglycemia, and usually compromises about half the total dose.
which is most common after 3 hours of injection. This medica- People with diabetes who are more on insulin therapy are more
tion frequently causes nausea and should not be used in patients likely to reach glucose goals with thoughtful insulin management
with gastroparesis or hypoglycemia unawareness. 15 strategies that include a combination of bolus and basal insulins.
Insulin Replacement Therapy
Many patients regard the need to start insulin therapy as a per- SUMMARY
sonal failure to successfully manage their diabetes. Avoiding the
threat of insulin therapy if patients do not comply with self-care Diabetes is a global epidemic that will continue to affect the lives
changes is critical, since this puts a negative light on a very pow- of millions of people, their families, and health care systems. The
erful and effective hormone that will always lower blood glucose evidence is overwhelming that diabetes can be prevented through
levels. Since only 50% of U.S. adults with diabetes have A 1c lev- lifestyle changes and medications. In addition, aggressive risk fac-
els less than the target of 7% 41 in spite of a wealth of oral med- tor management, with particular focus on blood glucose, lipid,
ications, there is a movement to initiate insulin therapy earlier in and blood pressure control can mitigate the complications associ-
patients with type 2 diabetes. 59 ated with diabetes. By promoting prevention, early treatment and
Understanding the normal cycle of insulin release is helpful to risk reduction of diabetes, nurses and health care professionals can
determine strategies to replace insulin in a therapeutic and effec- improve diabetes outcomes in their own backyard and globally.
tive manner. 64 An average person releases about 0.5 to 0.1 units Educating individuals and their families, promoting changes in
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of insulin per kg per day. This insulin release happens in two dif- delivery of care, tracking outcomes and working within commu-
ferent and overlapping phases. The first phase bolus insulin is re- nities to promote access to safe places to exercise and healthy
leased in response to glucose elevations associated with meals. foods are all activities that health care professionals can participate
This bolus of insulin serves to regulate the blood glucose from the in to raise awareness and motivate change. Nurses and health care