1. Use of Insulin in treatment of diabetes mellitus Prof. Hanan Hagar

2. Objectives: by the end of this lecture, students should be able to: Define diabetes and mention different types of diabetes Differentiate between difference in treating type I and type II diabetes. Understand mechanism of action, secretion, and actions of insulin. Describe different types of insulin analogues Be able to recognize the difference in pharmacokinetic of different insulin analogues. Know the uses of different insulin analogues

3. Diabetes mellitus Is a chronic metabolic disorder characterized by high blood glucose level caused by insulin deficiency and sometimes accompanied with insulin resistance.

4. Diabetes mellitus Fasting plasma glucose > 7 mmol/L ( 126 mg/dl) is diagnostic of diabetes or Plasma glucose > 11.1 mmol/L (200 mg/dl), 2h after a meal confirms a diagnosis of diabetes.

5. Complications of diabetes Cardiovascular problems – Micro-and macrovascular complications Renal failure (nephropathy). Blindness (retinopathy). Neuropathy Risk of foot amputation

6. Types of diabetes Type I diabetes (IDDM) Type II diabetes (NIDDM)

7. Type I Diabetes absolute deficiency of insulin. Pancreatic β-cells are destroyed. due to autoimmune or viral diseases Treated by insulin.

8. Type II Diabetes Partial deficiency of insulin. β-cells produce inadequate quantity of insulin Insulin resistance in peripheral target tissues. Obesity and genetic factors are involved Treated by oral hypoglycemic drugs.

9. CharacteristicType 1Type 2 Onset (Age)Usually during childhood or puberty Usually over age 40 Type of onsetAbruptGradual Prevalence10-20%80-90 % Genetic predispositionModerateVery strong Defectsβ-cells are destroyedβ-cells produce inadequate quantity of insulin Endogenous insulinAbsentPresent (not enough) Insulin resistanceabsentpresent Nutritional statusUsually thinUsually obese KetosisFrequentUsually absent Clinical symptomsPolydipsia, polyphagia, polyuria, Wt loss Often asymptomatic Related lipid abnormalities Hypercholesterolemia frequent Cholesterol & triglycerides often elevated TreatmentInsulinOral hypoglycemic drugs

10. INSULIN

11. 1.Basal level of insulin is 5-15 µU/ml. 2.Half life of circulating insulin is 3-5 min. Endogenous Insulin

12. Insulin release during day time meals

13. Insulin receptors – Present on cell membranes of most tissues as liver, muscles and adipose tissues

14. Effects of insulin

15. I. Carbohydrate Metabolism: Insulin decreases blood glucose level by: –  glucose uptake & utilization by peripheral tissues. –  Glycogen synthesis –  Conversion of carbohydrate to fats. –  Glycolysis (muscle). –  Glycogenolysis. –  Gluconeogenesis.

16. II. Fat Metabolism: Liver: –  Lipogenesis &  lipolysis. – Inhibits conversion of fatty acids to keto acids Adipose Tissue: –  Lipolysis –  Triglycerides storage. –  Fatty acids synthesis.

17. III. Protein Metabolism: Liver: –  protein catabolism. Muscle: –  amino acids uptake. –  protein synthesis. –  glycogen synthesis (glycogenesis).

18. IV. potassium –  potassium uptake into cells.

19. Sources of Exogenous Insulin Beef Insulin Porcine Insulin Human Insulin – Less immunogenic. – Prepared by recombinant DNA techniques – Modifications of amino acid sequence of human insulin can change its pharmacokinetics

20. Can not be given orally (why ?) Insulin is given subcutaneously (s.c) – Insulin syringes (arms, abdomen, thighs). – Portable pin injector (pre-filled). – Insulin pump Routes of administrations of exogenous insulin

21. Pin injectorInsulin pump

22. – Insulin pump more convenient no need for multiple daily injection programmed to deliver basal rate of insulin. Achieve better control of diabetes – Intravenously (in a hyperglycemic emergency) – http://www.youtube.com/watch?v=BfG4-YMu0Vo Routes of administrations of exogenous insulin

23. Differs in pharmacokinetic properties mainly Rate of absorption Onset & duration of action Variation is due to : Change of amino acid sequence. Size and composition of insulin crystals in preparations. Types of insulin preparations

24. Ultra-short acting insulins – e.g. Lispro, aspart – very fast onset of action and short duration Short acting insulins – e.g. regular insulin – fast onset and short duration. Types of insulin preparations Insulin Analogues

25. Intermediate acting insulins – e.g. NPH, Lente slow onset, intermediate duration of action Long acting insulins – e.g. glargine, detemir – delayed onset and long duration of action Types of insulin preparations

26.  monomeric analogue  Clear solutions at neutral pH.  Very fast onset of action (5-15 min)  S.C. (5 min no more than 15 min before meal).  mimic the prandial mealtime insulin release  Short duration of action (3-5 h).  2-3 times/day. Ultra-short acting insulins Insulin lispro, insulin aspart

27. Uses: – Control postprandial hyperglycemia (s.c.) – In emergency situations as in diabetic ketoacidosis (i.v). Ultra-short acting insulins Insulin lispro, insulin aspart

28. Insulin aspart

29. Soluble crystalline zinc insulin Clear solutions at neutral pH Forms hexamers. Fast onset of action 30-45 min (s.c.). Short duration of action (6-8 h). 2-3 times/day. Can mimic postprandial insulin release. Short acting insulins (Regular insulin) Humulin R, Novolin R

30. Uses: – control postprandial hyperglycemia (s.c.) – In emergency situations as in diabetic ketoacidosis (i.v). – Can be used in pregnancy. Short acting insulins (regular insulin)

31. Short-acting (regular) insulins e.g. Humulin R, Novolin R Usespostprandial hyperglycemia & emergency diabetic ketoacidosis Physical characteristics Clear solution at neutral pH chemistryHexameric analogue Route & time of administration S.C. 30 – 45 min before meal I.V. in emergency (e.g. diabetic ketoacidosis) Onset of actionrapid 30 – 45 min ( S.C ) Peak level2 – 4 hr Duration6 – 8 hr Short Usual administration 2 – 3 times/day Ultra-Short acting insulins e.g. Lispro, aspart, glulisine postprandial hyperglycemia & emergency diabetic ketoacidosis Clear solution at neutral pH Monomeric analogue S.C. 5 min (no more than 15 min) before meal I.V. in emergency (e.g. diabetic ketoacidosis) Fast 5 – 15 min ( S.C ) 30 – 90 min 3 – 5 hr Shorter 2 – 3 times / day

32. Advantages of Insulin Lispro vs Regular Insulin  Rapid onset of action (due to rapid absorption)  Reduced risk of postprandial hypoglycemia (due to short duration of action)  Decreased risk of hyperinsulinemia (due to short duration of action)

33. Isophane (NPH) insulin Lente insulin Intermediate acting insulins

34.  NPH, is a Neutral Protamine Hagedorn insulin in phosphate buffer.  a combination of protamine & crystalline zinc insulin.  Turbid suspension at neutral pH.  Given S.C. only NOT i.v. Isophane (NPH) Insulin

35.  Slow onset of action 1-2 h.  Relatively long duration of action 13-18 h  NPH is NOT used in emergencies (diabetic ketoacidosis). Isophane (NPH) Insulin

36. Can be mixed with ultrashort or short insulin NPL= NPH / lispro NPA= NPH / aspart NPH/regular = 75/25 - 70/30 - 50/50. Isophane (NPH) Insulin

37. Prandial and basal insulin replacement

38. Mixture of 30% semilente insulin and 70% ultralente insulin. Turbid suspension at neutral pH Given S.C., not intravenously Slow onset of action (1-3 h) Peak serum level 4-8 h. Relatively long duration of action 13-20 h. Lente insulin (Humulin L, Novolin L)

39. Lente is not used in emergency or diabetic ketoacidosis. Lente and NPH insulins are equivalent in activity. Lente insulin (Humulin L, Novolin L)

40. Clear solution BUT forms precipitate at injection site. Slow onset of action 2 h. Given s.c., not intravenously absorbed less rapidly than NPH & Lente insulin. Prolonged duration of action (24 h). Once daily Should not be mixed with other insulin Long acting insulins Insulin glargine (lantus) Insulin detemir (Levemir)

41. produce broad plasma concentration plateau (low continuous insulin level over 24 hr low). Long acting insulins Insulin glargine - Insulin detemir

42. Advantages of long acting insulin over intermediate-acting insulins: Constant circulating insulin over 24 hr with no pronounced peak. safer than NPH & Lente insulins ( reduced risk of nocturnal hypoglycemia).

43. Glargine NPH NPH vs Glargine

44. Insulin preparations

45. Hypoglycemia Lipodystrophy at injection site Weight gain (due to anabolic effects of insulin ) Hypokalemia Insulin resistance (rare) Hypersensitivity reactions (rare). Complications of Insulin Therapy:

46. Summary Insulin analogues are used to treat type I diabetes. Fast acting insulins (lispro, aspart), given s.c. or i,.v., produce very fast action, used to mimic postprandial insulin & emergency Short acting insulin (Regular insulin), given s.c. or i.v. produce fast action, used to mimic postprandial insulin, emergency & pregnancy. Intermediate acting insulin (lente, Isophane) produce slower action, than regular insulin, given s.c. not i.v. Long acting insulins (glargine) produce constant circulating insulin over 24 hr with no peak (peakless profile), s.c. not i.v.