Insulin

(IN-suh-lin)

  Action:
Regulates proper glucose use in normal metabolic processes.

  Indications:
Management of type 1 diabetes mellitus (insulin-dependent) and type 2 diabetes mellitus (non-insulin-dependent) not properly controlled by diet, exercise, and weight reduction. In hyperkalemia, infusions of glucose and insulin lower serum potassium levels. IV or IM regular insulin may be given for rapid effect in severe ketoacidosis or diabetic coma. Highly purified (single component) and human insulins are used for treatment of local insulin allergy, immunologic insulin resistance, lipodystrophy at injection site, temporary insulin administration, and in newly diagnosed diabetic patients.

  Contraindications:
Hypersensitivity to pork or mixed beef/pork insulin unless successful desensitization has been accomplished.

  Route/Dosage:
Insulin preparations are classified into 3 groups based on promptness, duration, and intensity of action following SC administration. These classifications are rapid- (Regular or Semilente), intermediate- (Lente or NPH) or long- (Ultralente) acting. Maintenance doses are given SC and must be individualized by monitoring patients closely. Consider following dosage guidelines.

Children and Adults: 0.5 to 1 U/kg/day.

Adolescents (During Growth Spurt): 0.8 to 1.2 U/kg/day. Adjust doses to achieve premeal and bedtime blood glucose levels of 80 to 140 mg/dL (children < 5 yr 100 to 200 mg/dL). Regular insulin is given IV or IM for severe ketoacidosis or diabetic coma.

  Interactions:

Alcohol, anabolic steroids, beta blockers, clofibrate, fenfluramine, guanthidine, MAO inhibitors, phenylbutazone, salicylates, sulfinpyrazone, tetracyclines: May increase hypoglycemic effects of insulin.

Contraceptives (oral), corticosteroids, dextrothyroxine, diltiazem, dobutamine, epinephrine, smoking, thiazide diuretics, thyroid hormone: May decrease hypoglycemic effects of insulin.

  Lab Test Interferences:
None well documented.

  Adverse Reactions:

META:

Hypoglycemia.

DERM:

Lipodystrophy (from repeated insulin injection into same site).

OTHER:

Hypersensitivity reaction (eg, rash, shortness of breath, fast pulse, sweating, hypotension, anaphylaxis, angioedema); local reactions (eg, redness, swelling, itching at injection site).

  Precautions:

Pregnancy: Insulin is drug of choice for control of diabetes in pregnancy; supervise carefully.

Lactation: Not excreted in breast milk. Breastfeeding may decrease insulin requirements despite increase in necessary caloric intake.

Changing insulin: Changes in purity, strength, brand, type, or species source of insulin may necessitate dosage adjustment. Make changes cautiously under medical supervision.

Diabetic ketoacidosis: May result from stress, illness, or insulin omission and may develop slowly after long period of poor insulin control. Condition is potentially life-threatening and requires prompt diagnosis and treatment.

Hypoglycemia: May result from excessive insulin dose, increased work or exercise without eating, or from illness with vomiting, fever, or diarrhea. May also occur when insulin requirements decline.

Insulin resistance: Requirements of > 200 units/day of insulin for > 2 days in absence of ketoacidosis or acute infection may occur, especially in obese patients, patients with acanthosis nigricans, patients with insulin receptor defects, or during infection.

  Administration/Storage:

• For insulin suspension, ensure uniform dispersion by rolling vial gently between hands. Avoid vigorous shaking that may result in formation of air bubbles.
• When mixing insulins, draw regular insulin into syringe first.
• Use only insulin syringes.
• Select appropriate injection site according to patient history and needs; rotate administration sites to prevent lipodystrophy. SC insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on arms, and slowest at sites on anterior thigh.
• Administer insulin 30 min before meals.
• Store properly in accordance with patient's daily needs. Insulin remains stable for 1 mo at room temperature or 3 mo under refrigeration. Store extra bottle of insulin in refrigerator.
• Refrigerate prefilled plastic and glass syringes, which can be stored under refrigeration for up to 14 days.
• Do not freeze.
• Do not expose to extreme temperatures or sunlight.

  Assessment/Interventions:

• Obtain patient history, including drug history and any known allergies.
• Assess patient for signs of hypoglycemia (eg, anxiety, chills, confusion, cool and pale skin, drowsiness, excessive hunger, headache, irritability, nausea, rapid pulse, tremors).
• Observe patient for signs of hyperglycemia (eg, drowsiness, fruitlike breath odor, frequent urination, loss of appetite, thirst).
• Monitor blood glucose levels throughout course of therapy.
• Observe injection sites for signs of local hypersensitivity reaction, such as redness, itching, or burning.
• Notify health care provider if hypoglycemia or adverse reactions occur.
• If lipoatrophy or lipohypertrophy develops at injection site, use alternate sites or purified insulin.
• Document injection sites used.

  Patient/Family Education:

• Teach name, dose, action, and side effects of insulin.
• Tell patient not to change brand, strength, type, or dose without health care provider's knowledge.
• Dosage adjustments may be necessary when type of insulin is changed.
• Tell patient to consult health care provider for dosage changes during illness.
• Instruct patient to use same type and brand of syringe each time to prevent dosage errors.
• Explain potential long-term complications of diabetes, and encourage regular, general physical and eye examinations.
• Tell patient to report redness, swelling, or itching at injection site.
• Explain significance and importance of reporting the following side effects: visual changes; rash; infection that does not heal; increased thirst; increased urination; dry mouth; burning sensation in feet, legs, or hands; pain in legs after exercise; frequent episodes of low or high blood sugar levels.
• Show patient how to rotate injection sites to prevent scarring.
• Teach patient how to monitor blood glucose as directed.
• Identify source for obtaining medical ID (eg, Medi-Alert ) and explain importance of information.
• Teach patient and family how to draw up and administer insulin.
• Demonstrate self-care techniques for patient using insulin pump.
• Emphasize importance of compliance with diet and exchange system for meals.
• Emphasize importance of regular exercise.
• Tell patient to carry source of sugar (eg, candy, sugar packets) to counteract hypoglycemia.

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