Insulin

A Brief Overview
Aims

 Brief physiologic overview of insulin

 Principles of insulin dosing in T2DM
 Available forms
 Overdose
The hormone (made by us)

 2 Amino acid chain polypeptide hormone.

 Synthesized in the pancreatic beta cells.
 Very short half life
 Cleared by both liver and kidneys.

(1)
Release

Increase in BGL
 Presence of fatty acid

 Gastrin

 CCK

 Beta adrenergic stimulation

 Sulfonylurea drugs

 Acetylcholine

 Arginine

 Leucine

 Independent release over prolonged time.

(1,2)
Actions

 Reduces BSL’s in many ways:

 Promotes translocation of GLUT’s into cell membranes to encourage glucose
uptake.
 Inhibits glycogenolysis.
 Inhibits gluconeogenesis
 Promotes glycogenesis.

(1,2,3)
Also

 Increases intracellular potassium uptake. (3)

(4)
Types available

 Ultra long acting

 Long acting
 Intermediate
 Short acting
Table
Type Onset Peak Duration of action

Novorapid, actrapid, humalog 5-15min 45-75min 2-4 hours

Humalin (Regular) 30min 2-4 hours 5-8 hours

NPH (Humalin N, Novolin N,

Protaphane) 2 hours 4-12 hours 18-28

Glargine (lantus) 2 hours No peak 20-24 hours

6-24 hours (dose

Detemir (Levemir) 2 hours 3-9 hours dependent)

NPL (Lispro) 2 hours 6 hours 15 hours (5)

Degludec 2 hours No peak >40 hours
T2DM Treatment philosophy
Sliding scale
Correctional/Basal Bolus
Overdose

 Increasingly common problem with minimal literature regarding the situation.

 94.7% of patient’s make full recovery. 2.7% mortality. 2.7% persistent
neurological deficits.

(6)
Accidental overdose

 ALL Synthetic insulin is cleared renally

(1, 2, 5)
Clinical features

 Diaphoresis (5,6)
 Tremor
 Confusion
 Blurred vision
 Irritability
 Nausea
 Abdo pain
 Decreased GCS
Classification

 Severe
 Documented symptomatic
 Asymptomatic

(6)
Treatment

 Glucagon s/c or IM
 Dextrose
 Monitoring of electrolytes
 Inotropic support if needed.
 Wait for effects to subside.

(5)
References
1. Guyton, A, 2011. Textbook of medical physiology. 5th ed. Philadelphia:
Saunders/Elsevier.
2. Uptodate/Mantzoros. 2015. Insulin action. [ONLINE] Available
at:http://www.uptodate.com/contents/insulin-
action?source=search_result&search=insulin&selectedTitle=4~150. [Accessed
28 February 16].
3. Gennari FJ. Disorders of potassium homeostasis. Hypokalemia and
hyperkalemia. Crit Care Clin. 2002;18:273–88.
4. http://www.uptodate.com/contents/management-of-hypoglycemia-during-
treatment-of-diabetes-
mellitus?source=machineLearning&search=insulin+overdose&selectedTitle=1
~150&sectionRank=1&anchor=H26#H29Epidemio
5. BMJ Best practice. 2015. Hypoglycaemia overview. [ONLINE] Available
at:http://bestpractice.bmj.com/best-
practice/monograph/509/highlights/overview.html. [Accessed 28 February
16].