Injection Perfection: Insulin 101

Emma Keating

Pharmacy Intern

Insulin is the hormone that your pancreas makes in order to help your body use the glucose (sugar) you ingest for energy. Without insulin, your body’s blood sugar levels can get too high and can lead to long term complications over time. In diabetic patients, insulin injections may be prescribed by your doctor as a part of an individualized treatment plan. While it sounds simple enough there are a lot of things come with insulin injections, so welcome to Insulin 101! 

Self-Monitoring 1,2

When taking insulin, it is very important to check your blood sugar regularly as directed by your doctor. While having high blood sugar the problem we are trying to treat, injecting too much insulin can make your blood sugar too low. Low blood sugar, or hypoglycemia, can actually cause its own set of issues indicated by shaking, anxiety/confusion, sweating and chills, along with feeling dizzy.  Usually, you will check your blood sugar before your first meal of the day. This is called a “fasting blood sugar” and the average goal is <100 mg/dL but can vary. Your blood sugar goal and the number of times you need to check it may change, so it’s very important to talk to your healthcare provider regularly! 

Types of Insulin 3

There are several types of insulin based on how long it will work in your body or how quick it starts to work in your body. When you are first starting, it may take some time along with trial and error to find the dose that works for you.

  • Ultra-Rapid Acting – begins to work within 12-20 minutes and lasts 1-3 hours4
    • Insulin lispro-aabc (Lyumjev)
    •  
  • Rapid Acting – begins to work 15-30 minutes after injection and lasts 2-4 hours
    • Insulin lispro (Admelog, Humalog)
    • Insulin aspart (Fiasp, Novolog)
    • Insulin glulisine (Apidra)
    •  
  • Short Acting – begins to work 30 minutes after injection and lasts 3-6 hours
    • Regular insulin (Humulin R, Novolin R)
    •  
  • Intermediate Acting – begins to work 2-4 hours after injection and lasts 12-18 hours
    • Insulin NPH (Humulin N)
    •  
  • Long Acting – takes several hours to start working, but lasts about 24 hours
    • Insulin glargine (Basaglar, Lantus, Semglee)
    • Insulin detemir (Levemir)
    • Insulin degludec (Tresiba)
    •  
  • Very Long Acting – starts working in 6 hours, lasts about 36 hours
    • Insulin glargine, 300u/mL (Toujeo)

Injection Technique 1,2

Needle and Syringe – Using a needle and syringe means that you will have to draw up insulin from the vial. It is important to know your dose and how much you need prior to drawing up the medication. Afterwards, the insulin is injected under the skin (subcutaneously).

  • Wash your hands prior to injecting medication.
  • Choose the site to inject: back of the arms, the belly (except for 2 inches around the navel), front and outer side of the thighs, upper hip and upper outer area of the buttocks. Clean the area with an alcohol wipe.
  • Pinch up a fold of the skin and quickly inject at a 90 degree angle (unless otherwise directed). Continue to pinch the skin and push the plunger down to inject the insulin. Do not inject medication through clothing.
  • Hold in place for 5-10 seconds.
  • Release the skin fold and remove the needle from the skin. If you can see insulin (clear fluid) or blood leaking from the injection site then press on the area for several seconds.

Pen Injectors – generally, insulin pens are easier to use as well as easier to bring places if you are on the go! The pen has a container that stores the insulin within it and a dial to preset the exact amount of insulin that you need. You will have to attach a new needle each time and it is very important to never share a pen or needle. The injection is given subcutaneously, using a similar technique to a regular syringe and needle. Instead of pushing down the plunger of the syringe, all you will have to do is push the button on the pen injector. Instructions for use can vary depending on the type of pen, so it is important to talk to your doctor, nurse or pharmacist about proper technique!

Storage 3

Keep your insulin in the fridge until you open it. Unopened vials and pens are good until the expiration date on the device. Once you open a vial or use a pen, keep them at room temperature in a safe, dry place. Avoid extreme temperatures – never store your insulin in the freezer, direct sunlight or in the car. Opened vials expire 1 month after they are opened. Usually pens expire 1 month after they are used, but this date can vary based on the type of device you have so be sure to read the label!  

Tips & Tricks 1,2,3

Keep a notebook with all of your medicines and doses, including over the counter items, vitamins and supplements. Also keep track of your blood sugar readings and the amount of insulin you are injecting each day.

Having all of your medications sent to one pharmacy helps cut down on the risk for drug interactions or duplicate medications. This makes it easier for your pharmacist to ensure your medication safety! 

It is very important to follow your insulin regimen as directed by your doctor and to not miss any insulin doses. Follow up with your healthcare provider if you have any questions or concerns regarding your treatment plan. Remember, be disciplined with your insulin!

SOURCES

  1. Weinstock RS, Nathan DM, Mulder JE. Patient Education: Type 1 Diabetes: Insulin Treatment Beyond the Basics [Internet]. 2020 [cited 2020 Aug 27]. Available from: https://www.uptodate.com/contents/type-1-diabetes-insulin-treatment-beyond-the-basics/print
  2. Wexler DJ, Nathan DM, Mulder JE. Patient Education: Type 2 Diabetes: Insulin Treatment Beyond the Basics [Internet]. 2020 [cited 2020 Aug 27]. Available from: https://www.uptodate.com/contents/type-2-diabetes-insulin-treatment-beyond-the-basics
  3. Medication Management: Insulin Basics [Internet]. 2020 [cited 2020 Aug 27]. Available from: https://www.diabetes.org/diabetes/medication-management/insulin-other-injectables/insulin-basics
  4. Introducing Lyumjev [Internet]. 2020 [cited 2020 Sept 1]. Available from: https://www.lyumjev.com/hcp/formulation
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So I Have Diabetes... What Now?

Emma Keating

Pharmacy Intern

1.5 million Americans are newly diagnosed with diabetes every year.1 Diabetes is a disorder that disrupts the way your body processes and uses sugar. Insulin is the most important part of regulating your body’s blood sugar – when you intake sugar (or glucose), the pancreas releases insulin in order to move sugar out of the blood  and use it for energy in the cells. There are two types of diabetes: type 1 and type 2. In Type 1, the body doesn’t make enough insulin by itself. In Type 2, the body makes insulin but doesn’t react to it the way it should. Either way, a new diagnosis of diabetes can be difficult and intimidating and you may be asking yourself “What now?”

While there is no cure for diabetes, there are several ways that you can control your condition:

Balanced Meals 2,5

While changing your eating habits may be daunting, nutrition is a powerful tool in the management of diabetes. The same nutritional action plan won’t work for everyone – but there are a few general rules that you can start with. Low carb, vegetarian and Mediterranean meal plans have been shown to lower blood pressure, encourage weight loss and lower A1C (a test that measures your average blood sugar). Choose whole and unprocessed foods over processed foods and limit foods with added sugars or refined grain. Eat fresh, frozen or canned non starchy vegetables such as corn, beans, beets, brussels sprouts, broccoli, cauliflower, mushrooms, kale, salad greens, peppers, and tomatoes.  Stay hydrated and try drink water instead of sugary drinks such as soda. Know that just because you are changing your eating habits does not mean you won’t have any choices! There isn’t a “magic” regimen that will work for everyone, so find what works best for you to help manage your blood sugar levels.

Active Lifestyle 3,5

Exercising and being active can actually make your body’s cells more responsive to insulin. Making an exercise plan can be frustrating, but the most difficult part about getting into an exercise routine is starting! It does not matter what your baseline is – as long as you start, you are miles ahead of where you were. Start slowly with lighter activities such as walking and set goals for yourself to build along the way.

Staying motivated to keep moving can also be a challenge, but having a long lasting healthy habit is the best way to gain back some control over your diabetes. Having a friend or group to exercise with can be a huge inspiration – they keep you accountable and vice versa.  Don’t be afraid to add some variety into your exercise routine, this can help you work more muscles and add a change of pace.

Medications 4,5

There are many types of medication available to help you manage your diabetes! Like changing your diet, there isn’t a “magic” medication regimen that will work for everyone – diabetes treatment is individualized and sometimes it takes a few trials to find what works best for you. Generally, your medication depends on what type of diabetes you have. Some treatment plans include oral medications while others are injectable. For type 2 diabetes, many doctors start by initially prescribing a medication called metformin and then reassessing your blood sugar levels after 2-3 months to see if you would benefit from a higher dose or another medication. For type 1 diabetes, treatment typically starts with insulin right away instead of other types of oral or injectable medication. Self monitoring of your blood sugar may be suggested by your doctor. Be sure to work closely with your doctor and your pharmacist to make sure you are getting the most from your medications!

Some of the medications that your doctor might prescribe may include:

  • Metformin – this medication is generally the first treatment option and is prescribed to most people who are newly diagnosed with type 2 diabetes to reduce high blood sugar levels. This is an oral medication that makes your body more responsive to insulin and can be taken once or twice daily.
    • Common side effects can include nausea, diarrhea and gas but this can be reduced by taking metformin with food.
    • People with serious kidney, liver or heart disease or those that have high alcohol intake should not take metformin.
  • Sulfonylureas (glipizide, glyburide, glimepiride) – these medications are some of the first that were developed to treat diabetes! They are the most inexpensive medication for diabetes. They increase the amount of insulin your body makes and work really well at first, but the effects gradually fade.
    • These medications can cause low blood sugar or “hypoglycemia” which can present as sweating, shaking, or feeling anxious / confused. If this occurs, quickly eat 10-15 grams of glucose (can be a glucose tablet, or something you have on hand such as fruit juice)
    • People with kidney failure should not take these medications.
  • DPP-4 Inhibitors (Januvia, Tradjenta, Nesina, Onglyza) – these medications increase the insulin release from the pancreas after a meal. They will help lower A1c, but tend to lower it less than other medications. Usually these medications are taken orally once daily.
    • Common side effects can vary depending on the medication, but can include headache and low blood sugar, especially if you are taking it in combination with another medication.
  • SGLT2 inhibitors (Invokana, Jardiance and Farxiga) – these medications lower your blood sugar by increasing the amount of sugar your body excretes in the urine. They are typically taken orally once a day. Jardiance and Invokana have been shown to have some benefit in patients with heart or kidney disease.
    • Common side effects include urinary tract infections and dehydration.
  • GLP-1 Receptor Agonists (Byettam Bydureon, Victoza, Trulicity, Ozempic) – these are injectable medications that increase insulin release after a meal and have a lower risk for low blood sugar. The dosing schedule varies depending on the medication, some are injected weekly while others are daily. They can also assist with weight loss as they tend to make people have the sense of feeling full after eating less.
    • Common side effects include nausea, vomiting and diarrhea but tend to improve over time
  • Insulin (Novolog, Humalog, Lantus, Basaglar, etc…) – injectable insulin can be added to oral medications or used by itself. When using insulin, it is very important to self-monitor your blood sugar to make sure you don’t inject more than what your body needs as this could cause low blood sugar. Insulin may need to be injected several times daily depending on your blood sugar the type of insulin your doctor prescribes.

Living with diabetes can be very stressful but by keeping up with your medications and developing healthy eating and exercising habits it can be managed. If you have questions or concerns about your treatment plan, don’t be afraid to reach out to your healthcare provider or your local pharmacist at Price Chopper/Market 32! 

SOURCES

  1. American Diabetes Association: Newly Diagnosed [Internet]. 2020 [cited 2020 Aug 27]. Available from: https://www.diabetes.org/diabetes/newly-diagnosed
  2. American Diabetes Association: Nutrition [Internet]. 2020 [cited 2020 Aug 27]. Available from: https://www.diabetes.org/nutrition
  3. American Diabetes Association: Get Fit and Stay Fit [Internet]. 2020 [cited 2020 Aug 27]. Available from: https://www.diabetes.org/fitness/get-and-stay-fit
  4. Wexler DJ, Nathan DM, Mulder JE. Patient Education: Type 2 Diabetes: Overview Beyond the Basics [Internet]. 2020 [cited 2020 Aug 27]. Available from: https://www.uptodate.com/contents/type-2-diabetes-overview-beyond-the-basics?topicRef=1737&source=see_link
  5. Wexler DJ, Nathan DM, Mulder JE. Patient Education: Type 2 Diabetes: Treatment Beyond the Basics [Internet]. 2020 [cited 2020 Aug 27]. Available from: https://www.uptodate.com/contents/type-2-diabetes-treatment-beyond-the-basics
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Diabetes Control with Medication and Blood Glucose Monitoring to Prevent Complications

Julianna Lombardo

Pharmacy Intern

Diabetes is a condition that affects the way the body uses sugar. Normally, when sugar enters the bloodstream, insulin is released and helps aid sugar into the cells for use. In patients with diabetes, the body either does not respond to insulin or the body doesn’t make enough insulin to properly move sugar from the bloodstream into the cells.

Keeping blood sugar levels under control can take a lot of time and practice. Luckily there are many different types of medications, both oral and injectable, and many ways to test blood sugar to stay healthy while living with this condition. Maintaining a pre-prandial (before meal) blood glucose level of 80-130 mg/dL and a glucose reading 1-2 hours after a meal of less than 180mg/dL is critical in managing blood sugar levels.1 If blood sugar levels aren’t being controlled via medications and blood glucose readings, one or more of the following complications can occur. They can be remembered by the ABC DEF’s of Diabetes control.

A is for A1C:

A1C readings are measured via a simple blood test and gives the doctor a look at an average of the patient’s blood sugar values over the past 2 to 3 months.2 Everyone’s A1C goal is individualized and should be discussed with a healthcare professional. On average, a patient with diabetes will have an A1C goal of less than 7%.2 The higher the percentage, the higher a patient’s blood sugar levels are over the past 2-3 months.2 Monitoring A1C levels regularly can allow medication regimens to be made in order to optimally control blood sugar.

B is for Blood Pressure:

2 out of 3 patients with diabetes report having high blood pressure or taking a medication that lowers their blood pressure.3 It is important to attend follow up appointments regularly to monitor blood pressure. Usually patients don’t experience symptoms when they have high blood pressure which can be very dangerous.3 Purchasing a blood pressure cuff to manage blood pressure readings at home in between doctors visits can also be helpful. Medications are just one way a patient can lower their blood pressure. Eating whole grain foods, adding herbs and spices instead of salt to flavor food and limiting alcohol consummation are all small tasks to decrease blood pressure.3

C is for Cholesterol:

Managing cholesterol levels goes hand in hand with managing blood pressure readings. Patients with diabetes are 1.5x more likely to have a stroke than a patient without diabetes.4 This makes it very important to get blood work done regularly to ensure cholesterol levels are in normal range. Cholesterol medications also work very well in lowering cholesterol levels if  too high. Managing a patient’s blood pressure and cholesterol levels lowers their  risk of having a stroke.

D is for Diabetes Mellitus Kidney Disease

The kidneys are used to filter out waste products from the body. When blood sugar levels are high, the kidneys filter too much blood and can lead to overworked kidneys that begin to malfunction.5  The filters in the kidneys begin to leak resulting in useful proteins lost in urine instead to staying in the body.5 This can be prevented by managing blood glucose and early diagnosis of kidney disease. If caught early, medications can be taken to prevent the progression of kidney disease. If caught late into the progression, patients may need a kidney transplant or blood filtration by dialysis machine. A patient’s risk of kidney disease is decreased by one third if blood glucose is consistently within range.5

E is for Eye Care

Patients with diabetes are at increased risk in developing conditions affecting the eyes. When glucose stays in the blood for too long, it can cause damage to the blood vessels in the eye leading to glaucoma, cataracts, and retinopathy which can all lead to blindness.6 Getting regular eye exams is an important in order to diagnose problems in the eye early for treatment and better results.

F is for Foot Care

Patients with diabetes often experience nerve damage in their feet. This can lead to poor blood circulation and loss of feeling in a patient’s feet. It is common for patients to not notice foot injuries since the neuropathy lessens their ability to feel pain, heat or cold.7 A patient can easily develp an infection in their foot from a minor cut and not even notice it. It is very important to go to a podiatrist often to decrease the chance of infection leading to a possible amputation.

Diabetes may be a lifelong disease, but luckily medications have come a long way to make this condition manageable to prevent the escalation of problems associated with diabetes. Managing blood glucose with testing regularly and taking medications as prescribed can help keep blood sugar under control and decrease the likelihood of advancing these conditions to impact a patient’s quality of life. If you have any questions, reach out to your healthcare provider or local Price Chopper/Market 32 Pharmacist.

Sources:

  1. “The Big Picture: Checking Your Blood Glucose.” American Diabetes Association. Accessed 8 August 2020.  www.diabetes.org/diabetes/medication-management/blood-glucose-testing-and-control/checking-your-blood-glucose.
  2. “Understanding A1C.” American Diabetes Association. Accessed 8 August 2020. www.diabetes.org/a1c.
  3. “High Blood Pressure.” American Diabetes Association. Accessed 9 August 2020. www.diabetes.org/diabetes-risk/prevention/high-blood-pressure.
  4. “Stroke.” American Diabetes Association. Accessed 7 August 2020. www.diabetes.org/diabetes/complications/stroke.
  5. “Kidney Disease (Nephropathy).” American Diabetes Association. Accessed 7 August 2020.  www.diabetes.org/diabetes/complications/kidney-disease-nephropathy.
  6. “Eye Complications.” American Diabetes Association. Accessed 8 August 2020. www.diabetes.org/diabetes/complications/eye-complications.
  7. “Foot Complications.” American Diabetes Association. Accessed 8 August 2020. www.diabetes.org/diabetes/complications/foot-complications.
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