Module: Pharmacy Professional Skills Coordinator: Dr. Arwa M. Amin Mostafa Academic Level: Undergraduate, B.Pharmacy School: Dubai Pharmacy College Year of first presented in Class: 2018 This Presentation is for Educational Purpose. It has no commercial value associated with it.

1. Proper use of Diabetes Mellitus
Management Devices
Arwa M. Amin Mostafa
PhD & M.Pharm Clinical Pharm, DipMgt, B.Pharm.

2. Outlines
•Types of Insulins
•Insulin Regimens
•Insulin Devices
•Proper injection of insulin using insulin Devices
•Glucagon Injection
•Proper use of GLP-1 Agonist Injection (Dulaglutide)
(Trulicity®)
•Measurement of Blood Glucose Level using
Glucometer

3. Insulin Devices
• Insulin is used to control blood glucose (BG) level in T1DM
patients and T2DM patients with BG that can’t be controlled by
oral hypoglycemic Drugs, diet and exercise.
• Insulin Devices are devices which are used to deliver insulin to
patient’s body.

4. Physiological Insulin secretion
Insulin is secreted by the Pancreas in a
glucose-dependent Manner continuously
throughout the day and in response to
oral carbohydrates dose
Figure source: American Family physician: Insulin Management of Type 2 Diabetes Mellitus (https://www.aafp.org/afp/2011/0715/p183.html) as adapted from Diabetes Education Online.
University of California, San Francisco. http://www.deo.ucsf.edu. Accessed December 10, 2010.

5. Source: Medinterest Group http://www.medinterestgroup.com/portfolio-items/diabetes-insulin-types/
NPH: Isophane Insulin
Types of Insulin

6. Activity of DifferentTypes of Insulins
Figure source: TMedWeb; http://tmedweb.tulane.edu/pharmwiki/lib/exe/detail.php/insulins.png?id=insulin_regimens

7. Insulin Regimens
• Basal-Bolus Regimen:
• Separate doses of short or rapid acting insulin 20–30 min
before main meals and intermediate or long-acting insulin
once or twice daily.
• Long acting insulin stabilizes blood glucose (BG) during
fasting (background insulin) and short acting insulin prevent
rises of BG after meals.
• Premixed-Insulin Regimen:
• 2- 3 injections-times daily of Insulin Mixture of specified
portions of short acting and intermediate acting insulins.
• Should be administered before Breakfast and evening meal.
• Examples: Humulin 70/30, Novolin 70/30, Novolog 70/30,
Humulin 50/50.

8. Insulin Regimens
Basal-Bolus Regimen
Premixed Regular/NPH
70/30 Regimen
Which Regimen is similar to physiological insulin secretion?
Figure source: American Diabetes Association: Practical Insulin

9. Insulin Regimens
Basal-Bolus Regimen Physiological Insulin Secretion
Basal-Bolus Regimen is similar to physiological insulin secretion

10. Basal-bolus OR Pre-mixed Insulin Regimens
Pre-mixed InsulinBasal-Bolus Insulin
• Simple Regimen
• Lower number of
injections
• Both basal and
short acting insulins
are in the same
mixture
• Flexibility in adjusting bolus dose based
on the content of every meal (mainly
carbohydrates and a percentage of the protein)
• Doesn’t require consistent lifestyle
pattern (meals and exercise is flexible)
• Similar to Physiological insulin
secretion.
• Low chances of developing
Hypoglycemia
• Low weight gain
• Better efficacy in glycemic control:
• Short term efficacy: FG, PPG
• Long term efficacy: HbA1C
Advantages
FG: Fasting glucose, PPG: Post-prandial glucose

11. Pre-mixed InsulinBasal-Bolus Insulin
• Requires consistent meals
content, meals timing and
exercise pattern
• Treatment doesn’t offer flexible
lifestyle
• High chances of developing
Hypoglycemia.
• Weight gain
• If basal insulin didn’t last long,
there will be high chances of high
FG
• Difficult to achieve glycemic
targets
• Requires carbohydrates
counting and insulin
dose calculation for
every meal
• Requires Patients
Education for insulin
dose calculation (Insulin-
to-Carb ratio)
• Requires more times of
injections
Disadvantages
Basal-bolus OR Premixed Insulin Regimens

12. Insulin Devices
Injectable:
• Insulin Syringe
• Insulin Pen
• Insulin Pump
Non-Injectable
• Inhaled Insulin

13. Layers of the Skin and Insulin Injection
• For Insulin to be absorbed properly, it should be injected in the
Subcutaneous fat.
• For slow and sustained rate of absorption

14. Insulin Injection sites

15. Insulin Syringe
•Not Commonly used Nowadays
•If patient is slim, use 45 ◦ angle to give the injection
•If the needle is long, pinch up skin folding is
required to increase the chance of SC injection

16. Pinch-upTechnique

17. Insulin Syringe
How to Inject Insulin Using a Syringe | Nucleus Health
https://www.youtube.com/watch?v=bBZXkNbpOGQ

18. Storage of InsulinVials
•Refrigerate Insulin vials Not in use BUT DO NOT FREEZE
•Opened Insulin vial is stable at RoomTemp from 28 - 42 days
• Avoid extreme temp
• Discard after the specified stability days

19. Insulin Pen
Insulin Pen: a pen like injecting device to deliver insulin
Advantages of Insulin Pen:
• Easy to use
• Precise dose adjustment
• More Convenient
• Patient can carry with him every where
Disadvantages:
• Expensive compared to syringes

20. Main Parts of Insulin Pen
Main Parts of Insulin Needle
Main Parts of Insulin Pen

21. Storage of Prefilled Insulin Pens

22. How to use Insulin Pen
How to do an Insulin Injection
https://www.youtube.com/watch?v=Pl28IILPDTU
How to use your Insulin Pen (UPDATED )
https://www.youtube.com/watch?v=hue_HkIpxKU&list=WL&in
dex=16

23. Insulin Pump
•Continuous Subcutaneous insulin infusion therapy device.
•Insulin is injected into the subcutaneous tissue by the pump.

24. Insulin Pump
Main Parts of Insulin Pump

25. Advantages of Insulin Pump:
• Fewer Injections (Cannula has to be changed every 7 days)
• Lifestyle flexibility
• Lower frequency of Hypoglycemia (Particularly in Pediatrics)
• Can store history of previous doses (Bolus and Basal)
Disadvantages of Insulin Pump:
• Expensive
• Superficial Infection
• Pump failure which may cause hyperglycemia
• Inconvenience of wearing External Pump
Advantages and Disadvantages of Insulin Pump

26. Insulin Pump
How the insulin Pump work?
How Does An Insulin PumpWork?
https://www.youtube.com/watch?v=t7ajHnpaLpk

27. Insulin Inhaler
• Afrezza is an Inhaled Human Insulin Powder
• Fast absorption through the lung
• Super-rapid inhalable meal-time insulin (Peak action in 15 minutes)
and action will finish within 90 minutes.
• Pulmonary function has to be assessed before initiation and every 6
months

28. Advantages of Afrezza:
• No Injections
• Small size
• Lifestyle flexibility
• Fast action in lowering Blood glucose
Disadvantages of Afrezza:
• Contraindicated in chronic lung diseases (Asthma and COPD)
• Can cause Bronchospasm
• May reduce lung function over-time
• Some patients reported having cough after using Afrezza
• Severe Allergic Reaction
Advantages and Disadvantages of Afrezza

29. Afrezza
Main Parts of Insulin Inhaler

30. Afrezza
How to use Afrezza?
https://www.youtube.com/watch?v=rVECn4BqtBs

31. Hypoglycaemia
• The most serious side effect of insulin is Hypoglycaemia.
• Hypoglycaemia is life threatening and should be treated quickly.

32. Severity of Hypoglycaemia

33. Medications for Hypoglycaemia
• Chewable GlucoseTablets
• Only for conscious and cooperative patients
• 25 g to 100 g
• Glucagon Injection
• For Unconscious patients
• 0.5 – 1 mg IM and SC injection
• Dextrose IV bolus - slowly
• 25 g/dose
IM: Intramuscular, SC: Subcutaneous

34. Glucagon Injection
• Glucagon Injection is used to treat:
• Severe Hypoglycemia due to high insulin Dose.
• Insulin Coma or insulin reaction resulting from severe low blood glucose.
• Glucagon Injection can be life saving for patients suffering from hypoglycemic
Coma.
• Care givers should be trained how to administer it to the patient
• Contraindicated in patients suffering from Pheochromocytoma OR
Glucagon Allergy

35. Glucagon Injection
Storing Glucagon Injection:
• Before dissolving: Store the kit at room temperature between 20° to 25°C .
• After dissolving: Use immediately.
• Discard any unused portion.

37. Glucagon Injection
Important Notes:
• Make sure that the patient is NOT in Hyperglycemic Coma
before use.
• Do Not prepareGlucagon Injection until you are ready to use it.
• The contents of the syringe are inactive and must be mixed with
the Glucagon in the bottle immediately before giving injection.
• After preparation, solution should be clear and of a water-like
consistency at the time of use.

38. Glucagon Injection
Important Notes.. Cont.:
•If the patient is unconscious, turn him on his/her side to
prevent choking.
• Feed the patient as soon as he/she awakens and is able to
swallow.
• If the patient does not awaken within 15 minutes, give another
dose of glucagon and INFORM EMERGENCY SERVICES
IMMEDIATELY.

39. Glucagon Injection
Glucagon Dose:
•The usual adult dose is 1 mg (1 unit).
•For children weighing less than 20 kg, give 1/2 adult dose (0.5
mg).
• Withdraw 1/2 of the solution from the bottle (0.5 mg mark on
syringe).

40. Glucagon Injection
How to use Glucagon Injection?
How to do a glucagen injection
https://www.youtube.com/watch?v=CfrBjojzlqQ

41. Dulaglutide Injection (Trulicity®)
• Dulaglutide is Glucagon-Like peptide-1 receptor agonist
• To be used Once weekly as adjuvant to diet and exercise
forT2DM.
• Should NOT be used by:
• T 1 DM
• Diabetic ketoacidosis (DKA)
• People with a history of severe GI disease.
• Children < 18 years old.
• Patients or if their family members had medullary thyroid
carcinoma (MTC).

42. Safety Information forTrulicity®
ThyroidTumors Risk
•Dulaglutide caused thyroid
tumors in rats and mice studies.
•Not yet known if it can cause
thyroid tumors in Humans.

43. Main Parts of Dulaglutide Injection (Trulicity®)

44. Dulaglutide Injection (Trulicity®)
Side Effects:
• Serious side effects:
• Acute pancreatitis
• Hypoglycemia
• Renal impairment.
• Common side effects:
• Dyspepsia
• Nausea
• Vomiting
• Diarrhea
• Decreased appetite

45. Proper use of Dulaglutide Injection (Trulicity®)
•How to useTrulicity?
https://www.trulicity.com/how-to-use/non-insulin-pen/
•Trulicity Pen demo
https://www.youtube.com/watch?v=bn50cC3kuto

46. Blood Glucose Measurement Device (Glucometer)
• Glucometer is a device which measure glucose in the blood .
• I t helps patients with DM to monitor their blood glucose level
and keep a record of it to get the best clinical advice based on
the measured glucose record.

47. Blood Glucose Measurement Device (Glucometer)
How glucometer works?
• The test strips contain glucose oxidase (GLO) and an
electrical terminal
• GLO will react with glucose in the blood producing gluconic
acid
• The strip contains electrical terminal that can measure the
amount of gluconic acid based on the current changes
between the 2 terminals of the strip.

48. Glucometer: Main Parts

49. Blood Glucose Measurement Device (Glucometer)
Proper StoringTest strips
• Test strips should be stored in their original vial away from
humidity, heat and refrigerating.
• Vial should be closed tightly after taking out the test strip.
• Strips should not be used after the expiration date.
Medical Information : How Does a Glucose Monitor MeterWork?
https://www.youtube.com/watch?v=Tzc5QYHxfdU
Diabetes Education: How are diabetes blood glucose meter test
strips made?
https://www.youtube.com/watch?v=72IgXDMOE60https://www.you
tube.com/watch?v=72IgXDMOE60

50. Blood Glucose Measurement Device (Glucometer)
• How to measure Blood Glucose using a
Glucometer?
Blood glucose measurement - OSCE Guide
https://www.youtube.com/watch?v=AyDH
P9puCag
CheckingYour Blood Glucose | Diabetes
Discharge | Nucleus Health
https://www.youtube.com/watch?v=28oR
B1LWWEw