Patient/family education regarding pharmacological management with insulin should include matching prandial insulin doses to carbohydrate intake, premeal blood glucose levels, and anticipated physical activity. Individuals with type 1 diabetes who have been successfully using continuous subcutaneous insulin infusion should have continued access to this therapy after they turn 65 years of age (ADA, 2021k). Hundreds of thousands of people of all ages throughout the world are using an insulin pump for diabetes mellitus management. First used by patients with type 1 diabetes, some persons with type 2 diabetes use them as well. (Stoppler, 2018). Insulin pumps are about the size of a small cell phone and are computerized. Insulin pumps provide a constant stream of insulin so that fewer needle sticks are required. Pumps are a good option for children or anyone else who has trouble remembering to administer their insulin injections (Cleveland Clinic, 2021). Insulin pumps may be especially useful for people who (Cleveland Clinic, 2021): ● Experience delays in the absorption of food ● Are active and may want to pause insulin doses when exercising ● Have severe reactions to hypoglycemia ● Have diabetes and are planning a pregnancy Artificial Pancreas Device System The Artificial Pancreas Device System is a system of devises that closely mimics the functioning of a healthy pancreas. Most of these systems consist of a continuous glucose monitoring system, and an insulin infusion pump. A blood glucose device is used to calibrate CGM. A computer-controlled algorithm connects the CGM and insulin pump to facilitate ongoing communication between the two devices (Food and Drug Administration (FDA), 2018). An artificial pancreas device system replaces manual blood glucose testing and the use of insulin injections. The system monitors blood glucose levels 24-hours a day. The system can be monitored remotely (e.g., by parents or healthcare professionals) (NIDDK, 2021f). There are three categories of artificial pancreas device systems. These include: 1. Threshold suspend device systems (also called low glucose suspend systems): This type of system temporarily suspends insulin delivery when the glucose level falls to or approaches a low glucose threshold. Its purpose is to reduce the severity of or reverse hypoglycemia. Insulin Typical blood glucose levels targets are to keep daytime blood glucose levels before meals between 80 and 130 mg/dL (4.44 to 7.2 mmol/L) and after meal results to no higher than 180 mg/dL (10 mmol/L), two hours after eating (Mayo Clinic, 2021f). Persons with type 1 diabetes typically need lifelong insulin therapy. There are many types of insulin therapy and include: ● Short-acting (regular) insulin ● Rapid acting insulin ● Intermediate-acting (NPH) insulin. ● Long-acting insulin (Mayo Clinic, 2021f) Examples of the various types of insulin include (Mayo Clinic, 2021f): ● Short-acting: Humulin R and Novolin R ● Rapid-acting: Glulisine (Apidra), insulin lispro (Humanlog), and insulin aspart (Novolog) ● Intermediate-acting: Insulin NPH (Novolin N, Humulin N0 ● Long-acting: Insulin glargine (Lantus, Toujeo Solostar), insulin detemir (Levemir), and insulin degludec (Tresiba) Pharmacologic therapy for type 2 diabetes The FDA (2021k) makes the following recommendations for pharmacologic therapy for type 2 diabetes. ● Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes.
Traditional insulin pumps transport insulin from a chamber within the pump via tubing to a site on the skin that is connected to a smaller flexible plastic cannula. The cannula is a few millimeters long and delivers the insulin underneath the skin (Cleveland Clinic, 2021). Insulin patch pumps also use a cannula beneath the skin. However, the insulin delivery chamber and the cannula are part of one pod that “sits” in the skin with an adhesive patch. The patch can be directly placed on the stomach or arm. There is no external tubing, and it is controlled wirelessly via a handheld controller (Cleveland, Clinic, 2021). There are both advantages and disadvantages of insulin pumps. Advantages include: ● Consistent, adjustable insulin delivery ● Fewer insulin injections ● Flexibility and privacy ● Improved blood glucose levels ● Improved lifestyle freedom and flexibility Risks or complications of insulin pumps include (Cleveland Clinic, 20210: ● Setting up the pump incorrectly ● Costing more than injections ● Problems hiding the tubing or pump with non-patch styles (Cleveland, Clinic, 2021) 2. Insulin-only system: This system “achieves a target glucose level by automatically increasing or decreasing the amount of insulin infused based on the CGM values. 3. Bi-hormonal control system: This device “achieves a target glucose level by using two algorithms to instruct an infusion pump to deliver two different hormones—one hormone (insulin) to lower glucose levels and another (such as glucagon) to increase blood glucose levels. The bi- hormonal system mimics the glucose-regulating function of a healthy pancreas more closely than an insulin-only system (FDA, 2017). Research continues regarding the development of artificial pancreas device systems. To date, the FDA has approved two systems. These are (Tenderich, 2020). ● Medtronic MiniMed 670G: This is a hybrid closed-loop system. ● Control-IQ from Tandem Diabetes Care: This system combines Tandem’s touchscreen insulin pump with the Dexcom CGM and a smart algorithm for the purpose of auto- adjusts for high and low blood glucose levels and automatic corrections for unexpected highs. Inhaled insulin is available as a rapid-acting insulin. Inhaled insulin is contraindicated in patients with chronic lung disease and is not recommended in patients who smoke or who recently stopped smoking. All patients require spirometry evaluation to identify potential lung disease before and after starting inhaled insulin therapy (ADA, 2021k). Self-Assessment Quiz Question #7 Pharmacological therapy for the treatment of diabetes includes which of the following interventions? a. Administration of inhaled insulin is contraindicated in patients who smoke. b. Administration of Lantus is the preferred initial pharmacological agent for patients with type 2 diabetes. c. Incorporating manual blood glucose testing in conjunction with an artificial pancreas system. d. Using inhaled insulin is available as a long-acting insulin.
● Once initiated, metformin should be continued as long as it is tolerated and not contraindicated; other agents, including insulin, should be added to metformin.
Book Code: ANCCUS2423
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