Multidose Insulin Research Articles

Impact of a therapeutic educational intervention using a gamification method aimed at adolescents with type 1 diabetes mellitus.

ntroduction : Autoimmune type 1 diabetes mellitus (T1D) is one of the most prevalent chronic diseases in the paediatric age group. Gamification in diabetes education may have the potential to change health behaviours by creating an innovative, engaging and interactive learning environment. Material and methods : A 6-month prospective quasiexperimental pilot study aimed at evaluating the impact of a gamified educational intervention (own kahoot ®, face-to-face, in 2 sessions, with immediate feedback) on diabetes knowledge, metabolic control and quality of life of adolescents with T1D. Variables recorded : knowledge using the Diabetes Knowledge Questionnaire Test (DKQ2) and own Diabethoc questionnaire, metabolic control parameters through glycosylated haemoglobin, main parameters established according to the recommendations of the Advanced Technologies & Treatments for Diabetes (for sensor use >70%) and quality of life in diabetes with the PedsQL test. Results : Twenty-one patients (61.9% boys) with a mean age of 13.8±0.81SD years on multi-dose insulin therapy 71.4% (n=15) and the insulin pump 28.6% (n=6) were included. Assessment by DKQ2 showed a 38.7% increase in knowledge post-intervention. The Diabet-hoc test showed an increase of 65.3% throughout the study. Changes in metabolic control and the quality-of-life test were not statistically significant. Conclusions : Our tool demonstrated an improvement in diabetes knowledge maintained at 6 months after the study

Refrigerated multi-dose insulin vials remain sterile through 6 months of use.

To evaluate sterility in refrigerated multi-dose insulin vials through 6 months of routine aspiration. Twelve vials of insulin, six of insulin glargine U100 (Lantus®, 10 mL multi-dose vial, Sanofi, Bridgewater, NJ) containing the preservative metacresol, and six of protamine zinc insulin U40 (ProZinc®, 10 mL multi-dose vial, Boehringer Ingelheim, Duluth, GA) containing the preservative phenol, were refrigerated and aspirated twice daily for 6 months, using a new insulin syringe each time. Three vials of each insulin type were wiped with a single-use alcohol swab before sampling. Three times weekly, aspirated samples were inoculated in Tryptic Soy Broth enrichment media and incubated for evidence of microbial growth. Positive broth was cultured and speciated. Endpoints were microbial vial contamination (defined as three consecutive positive cultures of the same organism) and completion of the six-month study period. Microbial contamination was not identified in any vial throughout the study period. A total of 454 aspirated samples were cultured, one of which exhibited non-repeatable growth of Staphylococcus epidermidis. This vial was prematurely lost to breakage after 59 culture samples (29 after the positive growth). Refrigerated phenol- and metacresol-containing multi-dose insulin products carry minimal risk for iatrogenic infection through 6 months of use, regardless of alcohol swab preparation.

Severe Abdominal Lipohypertrophy Due to Poor Insulin Management

A 58-year-old manfrom Pakistan with a long-standing history of type 2 diabetes and diabetes-related complications and comorbidities presented to an endocrinologist. The patient reported that he has been on multidose insulin regimen for the last 20 years with insulin totaling over 250 units a day. Laboratory tests showed should the following review significant findings: (1) hemoglobin A1C level, >14%; (2) fasting glucose level, 398 mg/dL; and (3) creatinine level, 1.56 mg/dL. General physical examination revealed a middle-aged male patient with a body mass index of 23 kg/m2 and a large area of rubbery, hyperpigmented, necrotic masses below the umbilical line.

Delivery of Insulin via Skin Route for the Management of Diabetes Mellitus: Approaches for Breaching the Obstacles.

Insulin is used for the treatment of diabetes mellitus, which is characterized by hyperglycemia. Subcutaneous injections are the standard mode of delivery for insulin therapy; however, this procedure is very often invasive, which hinders patient compliance, particularly for individuals requiring insulin doses four times a day. Furthermore, cases have been reported of sudden hypoglycemia occurrences following multidose insulin injections. Such an invasive and intensive approach motivates the quest for alternative, more user-friendly insulin administration approaches. For example, transdermal delivery has numerous advantages, such as prolonged drug release, low variability in the drug plasma level, and improved patient compliance. In this paper, the authors summarize different approaches used in transdermal insulin delivery, including microneedles, chemical permeation enhancers, sonophoresis, patches, electroporation, iontophoresis, vesicular formulations, microemulsions, nanoparticles, and microdermabrasion. Transdermal systems for insulin delivery are still being widely researched. The conclusions presented in this paper are extracted from the literature, notably, that the transdermal route could effectively and reliably deliver insulin into the circulatory system. Consistent progress in this area will ensure that some of the aforementioned transdermal insulin delivery systems will be introduced in clinical practice and commercially available in the near future.

Patient‐Centered Care of the Pregnant Patient with Diabetes Who Uses an Insulin Pump during Labor and Delivery

<h2>Poster Presentation</h2><h3>Purpose for the Program</h3> Continuous subcutaneous insulin infusion (CSII) pump therapy is associated with better quality of life and in some studies better glucose control than standard multidose insulin injections. A person with diabetes who uses an insulin pump for blood glucose management considers the insulin pump as a lifeline. Disconnecting from the insulin pump raises concern and triggers unnecessary anxiety. Most of our patients were told to discontinue their pumps on admission to the labor and delivery unit. Sometimes a physician would write an order to allow a patient to continue using the pump, which was problematic because no supervision of insulin delivery or assessment of the patient's ability to manage the pump was taking place by nursing staff or physicians. The obstetricians were not familiar with the intricacies of dose adjustments and the need for quick, abrupt changes in dosage during the postpartum period. <h3>Proposed Change</h3> To partner with the director of our Diabetes and Obesity Institute and initiate a pump pilot program with tools and guidelines unique to the obstetric setting. The most important component of this patient‐centric journey was use of an insulin pump agreement. Because these patients make daily insulin dose adjustments independently, it was critical to empower both the pump‐using patient and nurse to form a partnership concerning insulin dosage during hospitalization. The agreement addressed the following key points:<ul><li>•Showing the nurse bolus doses, basal rates, and changes.</li><li>•Frequency of infusion set and infusion site changes.</li><li>•Reporting symptoms of hypoglycemia and pump problems.</li><li>•Situations when the pump may need to be discontinued.</li></ul> <h3>Implementation, Outcomes, and Evaluation</h3> Standardized orders for insulin pump therapy management in the intrapartum and immediate postpartum periods were developed, along with a medication administration record that allowed for documentation of basal rates and boluses. All pump patients have an endocrine consult to assess ability to manage self‐care and determine postpartum dosage changes. Mandatory education sessions for all nurses, midlevel healthcare providers, and physician staff were provided by our diabetes nurse clinicians. The sessions addressed technical aspects of CSII pump therapy and the patient's emotional connection to the pump. The nurse clinicians were notified when a patient using an insulin pump was admitted and assisted nurses and healthcare providers with any process issues. Data collection and outcomes evaluation are ongoing with changes being made as relevant. <h3>Implications for Nursing Practice</h3> Nursing has been essential in the formation of a multidisciplinary team that partnered with other disciplines to provide safe, effective, and patient‐centered care.

Drugs for diabetes: part 9 prescribing for patients with cardiac disease

Up to one-third of patients with heart disease have diabetes. Cardiological status should be considered when deciding on treatment for diabetes. Patients with stable coronary disease can be treated with metformin, sulphonylureas or pioglitazone. Following an acute coronary syndrome, intensive insulin therapy with multi-dose insulin has been shown to reduce mortality, and longerterm treatment with pioglitazone may reduce recurrent events. There is little trial information for glycaemia control in patients with chronic heart failure, and metformin and insulin are both frequently used. Dipeptidylpeptidase-4 (DPP-4) inhibitors are new oral antidiabetic drugs, which are weight neutral, and the injected glucagon-like peptide-1 (GLP-1) receptor agonists reduce weight. Long-term outcome studies are awaited to see if they have cardiovascular advantages in any particular group of patients.

Toddlers’ choice: Yo-Yoing diabetes control or deci-unit insulin dosing?

While the incidence of toddlers' diabetes is soaring, their mainstay insulins were withdrawn, namely the weak 10% or 20% insulin mixtures (WIM), which were injected only once or twice daily. Consequently, toddlers are coerced to use an insulin pump, multi-dose insulin regime (MuDIR), mix or dilute insulins. This paper highlights the difficulties and proposes a simple solution. While an insulin pump is the best available option, it is not readily available for everyone. Mixing insulins is not sufficiently precise in small doses. Although diluting insulin would allow precise dosing and reduce the dose variability secondary to dribbling after injections, it, like insulin mixing, deprives children from using the pen and related child-friendly accessories. In MuDIR, we inject 4-5 small doses of insulin instead of 1-2 daily larger doses of WIM. Thus, on using a half unit (½unit) insulin pen, a dose of 0.5, 1, 1.5 and 2 units are adjusted in steps of 100%, 50%, 33% or 25%; unlike the advisable 5%-20%. This does not easily match the tiny erratic meals of grazing toddlers. Maternal anxiety peaks on watching yo-yoing glycemia. Carers have to accept either persistently high sugar or wild fluctuation. The risks of such poor glycemic pattern are increasingly recognized. Using insulin U20 in a ½unit disposable pen allows deci-unit dosing, with 5%-20% dose-tuning, greater accuracy on delivering small doses and reduction of dose variability from dribbling. Deci-unit dosing may help avoid wide glycemic swings and provide the affordable alternative to insulin pumps for toddlers. Deci-unit pen materializes the Human Rights of Children, a safer and effective treatment.

An Update on the DIGAMI Studies

In the Diabetes Mellitus-Glucose Infusion in Acute Myocardial Infarction [DIGAMI] study, insulin-glucose infusion, followed by multidose insulin treatment, improved long-term prognosis in diabetic patients with acute myocardial infarction (AMI) at 1 year [Malmberg K et al. J Am Coll Cardoiol 1995]. This article discusses recent data from the extended follow-up (maximum 8.3 years; median 4.1 years) for 1145 subjects in the DIGAMI 2 study.

Glycaemic control after myocardial infarction: The DIGAMI protocol

The diabetes mellitus, insulin glucose infusion in acute myocardial infarction (DIGAMI) study (Malmberg et al, 1994; 1995; 1996; 1997) assessed the effects of intravenous insulin and glucose, followed by multi-dose subcutaneous insulin, on mortality after acute myocardial infarction (AMI) in patients with hyperglycaemia. The study suggested improved survival rates in those patients who had received insulin and glucose. These results prompted many clinicians to question and alter their practice. However, the study did cause some controversy. The suggested regimen was not without problems and the trial raised questions about the importance of chronic versus acute metabolic control. The subsequent DIGAMI 2 study (Malmberg et al, 2005) sought to answer queries raised by the original study but was also controversial. It is important to note, however, that the DIGAMI study did identify the benefit of strict glycaemic control in patients with AMI. It is essential that nurses are aware of this to enable them to improve patient outcomes.

Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity

Patients with diabetes have an unfavourable prognosis after an acute myocardial infarction. In the first DIGAMI study, an insulin-based glucose management improved survival. In DIGAMI 2, three treatment strategies were compared: group 1, acute insulin-glucose infusion followed by insulin-based long-term glucose control; group 2, insulin-glucose infusion followed by standard glucose control; and group 3, routine metabolic management according to local practice. DIGAMI 2 recruited 1253 patients (mean age 68 years; 67% males) with type 2 diabetes and suspected acute myocardial infarction randomly assigned to groups 1 (n=474), 2 (n=473), and 3 (n=306). The primary endpoint was all-cause mortality between groups 1 and 2, and a difference was hypothesized as the primary objective. The secondary objective was to compare total mortality between groups 2 and 3, whereas morbidity differences served as tertiary objectives. The median study duration was 2.1 (interquartile range 1.03-3.00) years. At randomization, HbA1c was 7.2, 7.3, and 7.3% in groups 1, 2, and 3, respectively, whereas blood glucose was 12.8, 12.5, and 12.9 mmol/L, respectively. Blood glucose was significantly reduced after 24 h in all groups, more in groups 1 and 2 (9.1 and 9.1 mmol/L) receiving insulin-glucose infusion than in group 3 (10.0 mmol/L). Long-term glucose-lowering treatment differed between groups with multidose insulin (> or =3 doses/day) given to 15 and 13% of patients in groups 2 and 3, respectively compared with 42% in group 1 at hospital discharge. By the end of follow-up, HbA1c did not differ significantly among groups 1-3 ( approximately 6.8%). The corresponding values for fasting blood glucose were 8.0, 8.3, and 8.6 mmol/L. Hence, the target fasting blood glucose for patients in group 1 of 5-7 mmol/L was never reached. The study mortality (groups 1-3 combined) was 18.4%. Mortality between groups 1 (23.4%) and 2 (22.6%; primary endpoint) did not differ significantly (HR 1.03; 95% CI 0.79-1.34; P=0.831), nor did mortality between groups 2 (22.6%) and 3 (19.3%; secondary endpoint) (HR 1.23; CI 0.89-1.69; P=0.203). There were no significant differences in morbidity expressed as non-fatal reinfarctions and strokes among the three groups. DIGAMI 2 did not support the fact that an acutely introduced, long-term insulin treatment improves survival in type 2 diabetic patients following myocardial infarction when compared with a conventional management at similar levels of glucose control or that insulin-based treatment lowers the number of non-fatal myocardial reinfarctions and strokes. However, an epidemiological analysis confirms that the glucose level is a strong, independent predictor of long-term mortality in this patient category, underlining that glucose control seems to be an important part of their management.

Education and multidisciplinary team care concepts for pediatric and adolescent diabetes mellitus.

The DCCT scientifically established the basis for optimizing blood glucose control in type 1 diabetes mellitus around the world using a multidisciplinary team approach and patient-centered adjustments of food and insulin based upon blood glucose data generated by the patient. Pediatric diabetologists no longer believe that it is prudent to allow higher blood glucose levels in prepubertal children but much educational emphasis must be placed upon minimizing serious episodes of hypoglycemia. Individualized treatment should be determined by a close working relationship between highly trained diabetes nurses, educators and dieticians with the patient as the focus of self-care decisions, and a pediatric diabetologist ideally setting the philosophical and medical goals. Rather than the diabetes health care team being the only ones to initiate treatment, patient and parents should be empowered to analyze their own data, identify patterns, solve problems with food and activity, and do so based upon actual blood glucose results. This empowerment paradigm helps decrease care frustrations and improve treatment outcomes. Survival education followed by in-depth problem solving education and organized follow-up education are all needed steps for successful diabetes management. Identification of psychosocial barriers and energy diverting behavioral and family issues just as knowledge about learning styles play key roles in this process. Dogma should be avoided. More physiological utilization of insulin analogs, greater insulin dosing flexibility with a multidose insulin regimen coupled with adaptation of insulin to food and activity, should allow maximum benefit. Four major types of learning styles are reviewed: concrete sequential learners, abstract sequential learners, abstract random learners and concrete random learners. Health Belief Models, Locus of Control constructs, and Self-Efficacy models all provide sophisticated ways to help identify and overcome learning and self-care barriers. Parental, child, adolescent and young adult responsibility for care also needs to be addressed and placed in the context of family functioning and glycemic goals. Age and developmental stages as well as parental and societal roles play important roles in the care needed to live well with a chronic illness. The role of the health care professionals who are part of the diabetes care team involves not only setting the stage and providing guidance but also supervising appropriate short- as well as long-term complications monitoring for early detection and treatment of microangiopathy. Applying not only telephone but also fax, e-mail and computers in modern diabetes care should facilitate applications of these psychological, educational and medical models to improve short-term and long-term diabetes treatment outcomes.

Basal Insulin Replacement And Use Of Rapid-Acting Insulin Analogues In Patients With Type 1 Diabetes

ObjectiveTo analyze various treatment strategies for replacement of basal insulin in patients with type 1 diabetes who are receiving rapid-acting insulin with meals. MethodsRecently published studies are reviewed, and the available information on basal insulin adjustment is summarized. ResultsIn a comparison of presupper insulin lispro versus regular human insulin in adolescent patients, post-prandial blood glucose excursion was much lower with insulin lispro. Patients who were given regular insulin at supper and no bedtime snack had a significantly higher occurrence of nocturnal hypoglycemia than did those given insulin lispro at supper and no snack at bedtime. In another study that attempted to identify the optimal basal insulin in the context of multidose therapy with insulin lispro, NPH insulin yielded lower blood glucose levels and a trend toward better glycosylated hemoglobin levels than did Ultralente insulin. For improvement of glycemic control during insulin lispro therapy, adjustments in the ratio of bolus to basal insulin and the number of basal insulin injections have been shown to be useful. In addition, use of insulin lispro in continuous subcutaneous insulin infusion therapy significantly reduced the rate of occurrence of hypoglycemic episodes in comparison with regular insulin. ConclusionRapid-acting insulin analogues improve postprandial blood glucose control and decrease the frequency of hypoglycemia in patients with type 1 diabetes whether insulin pump therapy or a multidose insulin injection regimen is being used. For full benefit of short-acting insulin analogues, adjustments must be made in basal insulin replacement. (Endocr Pract. 2000;6:88-92)

Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus

Objectives: To test the hypothesis that intensive metabolic treatment with insulin-glucose infusion followed by multidose insulin treatment in patients with diabetes mellitus and acute myocardial infarction improves the prognosis.Design: Patients...

How to Apply the Experience from the Diabetes Control and Complications Trial to Children and Adolescents?

The Diabetes Control and Complications Trial (DCCT) taught us to set target blood glucose (BG) and glycohaemoglobin (GHb) goals, to ensure safety regarding hypogly-caemia, to be flexible with insulin and meal planning and to offer frequent contact with diabetes educators, dieticians, psychologists and social workers as well as with diabe-tologists skilled in intensified management. Insulin dosage should be individualized based upon frequent BG monitoring results. Co-ordinated multidisciplinary health care teams provide optimum problem-solving rather than disaster control working with children, adolescents and their families. The patient and the family should form the central core of the diabetes team with outpatient follow-up every month and frequent telephone contact between visits. GHb should be obtained at least every 1–2 months to provide feedback as based on the DCCT intensified treatment cohort. Insulin lispro helps minimize hypoglycaemia and makes insulin administration more convenient and timely. Barriers to improvement should be identified: learning problems, concomitant significant illnesses (epilepsy, coeliac and thyroid disease, asthma) and family problems. Ensure age-appropriate transfer of self-care but continue adult supervision. Educate, motivate and re-educate. Meal planning includes not only carbohydrate counting but also maintaining normal lipids and energy needs for growth and development as well as strategies for activity compensation and hypoglycaemia prevention. Consideration of protein restriction may be required in adolescents with microalbuminuria. Individualized multidose insulin algorithms allow reactive (corrective) decisions based upon capillary BG results plus proactive (anticipatory) decisions to compensate for expected BG changes from changes in activity, food and/or illness using a multidose insulin schedule. The number of insulin injections does not define an intensified insulin treatment programme but rather the ability to target and achieve near-normal BG values as often as possible - without severe episodes of hypoglycaemia. Self BG monitoring is a key to success. Long-term monitoring should include not only frequent GHb but also at least annual fasting lipids, thyroid functions and microalbuminuria as well as dilated retinal exams, blood pressure, growth charting and Tanner staging.

Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): Effects on mortality at 1 year

We tested how insulin-glucose infusion followed by multidose insulin treatment in diabetic patients with acute myocardial infarction affected mortality during the subsequent 12 months of follow-up. Despite significant improvements in acute coronary care, diabetic patients with acute myocardial infarction still have a high mortality rate. A total of 620 patients were studied: 306 randomized to treatment with insulin-glucose infusion followed by multidose subcutaneous insulin for > or = 3 months and 314 to conventional therapy. The two groups were well matched for baseline characteristics. Blood glucose decreased from 15.4 +/- 4.1 to 9.6 +/- 3.3 mmol/liter (mean +/- SD) in the infusion group during the 1st 24 h, and from 15.7 +/- 4.2 to 11.7 +/- 4.1 among control patients (p < 0.0001). After 1 year 57 subjects (18.6%) in the infusion group and 82 (26.1%) in the control group had died (relative mortality reduction 29%, p = 0.027). The mortality reduction was particularly evident in patients who had a low cardiovascular risk profile and no previous insulin treatment (3-month mortality rate 6.5% in the infusion group vs. 13.5% in the control group [relative reduction 52%, p = 0.046]; 1-year mortality rate 8.6% in the infusion group vs. 18.0% in the control group [relative reduction 52%, p = 0.020]). Insulin-glucose infusion followed by a multidose insulin regimen improved long-term prognosis in diabetic patients with acute myocardial infarction.

Evaluation of the sterility and stability of insulin from multidose vials used for prolonged periods.

Diabetic patients frequently use their insulin vials for prolonged periods, even though antibacterial preservatives used in multidose insulin vials are not required to be effective beyond 28 days. For this reason, we evaluated the antibacterial activity present in multidose insulin vials for up to 50 days. Multidose lente insulin vials were inoculated with S. aureus and P. aeruginosa. Vials incubated at room temperature (21 degrees C) were sterile by 48 hours, whereas when they were incubated at refrigerator temperatures (4 degrees C), S. aureus contamination persisted up to the 17th day and P. aeruginosa were killed after 10 days. The same vials were serially contaminated on days 17, 30, and 50, and a similar antibacterial effect was maintained. Sixty-nine multidose insulin vials used for an average of 53 days were cultured. Eight vials demonstrated bacterial contamination with 1 cfu/ml of S. epidermidis or Propionibacterium acnes. No endotoxin was detected in the multidose vials used for more than 28 days. Insulin assays on 40 multidose insulin vials used for more than 28 days showed an average insulin content of 101.6 +/- 1.9 units/ml. This study did not demonstrate significant bacterial contamination, endotoxin activity, or insulin degradation of multidose insulin in vials used for periods longer than 28 days. In addition, antibacterial preservatives were more effective at room temperature than at refrigerator temperature; thus, the practice of patients not refrigerating insulin vials is sensible.

Use of the nursing process in infection control

s 133 antibacterial effect was maintained. Sixty-nine multi-dose insulin vials used for an average of 53 days (range: 6-212) were cultured. Eight vials demonstrated bacterial contamination with 1 cfu/ml of Staph. epidermidis or Propionibacterium acnes. No endotoxin (limulus lysate assay) was detected in five multi-dose vials used for more than 28 days. This study did not demonstrate significant bacterial contamination or endotoxin activity of multi-dose insulin in vials used for periods longer than 28 days. In addition, antibacterial preservatives were more effective at room temperature than at refrigerator temperature; thus, the practice of patients not refrigerating insulin vials is sensible.

The antibacterial activity of preservatives in multidose insulin vials used for prolonged periods

The antibacterial activity of preservatives in multidose insulin vials used for prolonged periods

Effects of insulin on wound healing in diabetic mice.

In the present study wound healing was examined in normal C57B1/6 male mice, diabetic mice, non-treated; and in diabetic mice treated with insulin. Small dermal wounds were made in the ears of the mice 40 h after the initial injection of insulin or vehicle alone. All animals were biopsied 8 h later. The wounds were examined by light and electron microscopy and wound components (capillaries, fibroblasts, PMN's oedema, collagen) were quantitated by lineal point analysis. The non-treated, diabetic mice demonstrated in inability to heal wounds when compared to controls; whereas, diabetic mice given a multidose insulin regimen demonstrated a response similar to controls. Insulin treatment of diabetic mice reduced the mean level of hyperglycaemia when compared to the non-treated diabetic mice. There was no detectable difference in the healing response with duration of diabetes in either the insulin-treated or non-treated diabetic mice. Although there was a mild reduction in hyperglycaemia, these data support the hypotheses that insulin is a necessary component of an adequate wound healing response.