INSULIN

Insulin is a drug that is used to control glucose in patients with diabetes

mellitus. It is the only parenteral antidiabetic agent available for exogenous
replacement of low levels of insulin.

Insulin is the hormone produced by the pancreatic beta cells of the islets of
Langerhans. It is released into circulation when the levels of glucose around
the cells arise. Insulin circulates through the body and reacts with specific
insulin receptor sites to stimulate the transport of glucose into cells to be
used for energy (facilitated diffusion).

Originally prepared from pork and beef pancreas, virtually all insulin is
prepared by recombinant DNA technology now. This is a purer form of insulin
and is not associated with sensitivity problems that many patients developed
with the animal products.

Contents [hide]
 1 Disease Spotlight: Diabetes Mellitus
o 1.1 Therapeutic Action
o 1.2 Indications
o 1.3 Pharmacokinetics
o 1.4 Contraindications and Cautions
o 1.5 Adverse Effects
o 1.6 Interactions
o 1.7 Nursing Considerations
 2 Practice Quiz: Insulin
 3 See Also
 4 Further Reading and Resources

Disease Spotlight: Diabetes Mellitus

  Diabetes Mellitus (literally, “honey urine”) is a condition wherein
there is a complex disturbance in the metabolism of carbohydrates,
proteins, and fats. This alteration results in thickening of the layer
below the endothelial lining of the blood vessels. This, in turn,
causes narrowing, vessel remodeling, and decreased blood flow
through vessels.
 Most frequent clinical signs
include hyperglycemia (fasting blood sugar of >106 mg/dL) and the
presence of sugar in the urine (glycosuria).
 Diabetes is classified into two: type 1 and type 2. Type 1 diabetes is
common in younger people and is connected with cases of viral
destruction of beta cells of the pancreas. On the other hand, type 2
is adult-onset and is associated with not enough insulin to maintain
glucose control.
 Hyperglycemia (high blood sugar) results when there is an
increase in glucose in the blood. Clinical signs and symptoms
include fatigue, lethargy, irritation, glycosuria, polyphagia,
polydipsia, and itchy skin (from the accumulation of wastes
that liver cannot clear).
 Hypoglycemia is a blood glucose concentration lower than 40
mg/dL and can occur in many clinical situations like starvation and
overtreatment of hyperglycemia. Manifestations include headache,
paresthesias, hunger, and diaphoresis.

Therapeutic Action

The desired and beneficial action of insulin is:

 Insulin replaces endogenous insulin. It is the only

parenteral antidiabetic agent available for exogenous replacement of
low levels of insulin. It reacts with the receptors of the cells to
facilitate transport of various metabolites and ions across cell
membranes and stimulates the synthesis of glycogen from glucose,
of fats from lipids, and of proteins from amino acids.

Indications
Insulin is indicated for the following medical conditions:

 Treatment of type 1 diabetes

 Treatment of type 2 diabetes when other agents have failed
 Short-term treatment of type 2 diabetes during periods of stress
 Management of diabetic ketoacidosis, hyperkalemia, and marked
insulin resistance

Pharmacokinetics

Here are the characteristic interactions of insulin and the body in terms of
absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration

Regular 30-60 min 2-4 h 6-12 h

NPH (Humulin N) 1-1.5 h 4-12 h 24 h

Ultralente
(Humulin 4-8 h 10-30 h 20-36 h
Ultralente)

Lispro (Humalog) <15 min 30-90 min 2-5 h

Aspart (Novolog) 10-20 min 1-3 h 3-5 h

Glargine (Lantus) 60-70 min None 24 h

Glulisine (Apidra) 2-5 min 30-90 min 2h

Detemir (Levemir) 1-2 h 3-6 h 5.7-23.3 h

T1/2: varies with each preparation

Metabolism: cellular level
Excretion: –

Contraindications and Cautions

The following are contraindications and cautions for the use of insulin:

 No contraindications as it is a replacement hormone. However,

close monitoring is needed among pregnant and lactating women to
adjust the dose accordingly. It is the drug of choice for management
of diabetes during pregnancy.
 Insulin does enter breast milk but it is destroyed in the GI tract
and does not affect the nursing infant.
 Insulin-dependent mothers may have inhibited milk production
because of insulin’s effects on fat and protein metabolism.

Adverse Effects

Use of insulin may result in these adverse effects:

 hypoglycemia and ketoacidosis

 local reactions at the injection site (lipodystrophy).

Interactions

The following are drug-drug interactions involved in the use of insulin:

 MAOIs, beta blockers, salicylates, alcohol. Increased glucose

reduction
 Beta blockers. Blocking the SNS also blocks many of the signs and
symptoms of hypoglycemia, hindering the patient’s ability to
recognize problems.
 Various herbal therapies (juniper berries, ginseng, garlic,
fenugreek, coriander, dandelion root, celery). Increased risk of
developing hypoglycemia.

Nursing Considerations

Here are important nursing considerations when administering insulin:

Nursing Assessment
These are the important things the nurse should include in conducting
assessment, history taking, and examination:

 Assess for contraindications or cautions (e.g. history of allergy,

pregnancy, etc.) so that appropriate monitoring and dose
adjustments can be completed.
 Perform a physical assessment to establish a baseline before
beginning therapy.
 Assess skin lesions; orientation and reflexes; blood pressure, pulse,
respiration and adventitious breath sounds which could indicate a
response to high or low glucose levels and potential risk factors in
giving insulin.
 Inspect skin areas that will be used for injection; note any areas
that are bruised, thickened, or scarred, which could interfere with
insulin absorption and alter anticipated response to insulin therapy.
 Obtain blood glucose levels as ordered to monitor response to
insulin.
 Assess activity level, including amount and degree of exercise which
can alter serum glucose levels and need for these drugs.
 Monitor the results of laboratory tests, including urinalysis, for
evidence of glucosuria.

Nursing Diagnoses and Care Planning

Here are some of the nursing diagnoses that can be formulated in the use of
this drug for therapy:

 Risk for unstable blood glucose related to ineffective dosing

of antidiabetic agents
 Imbalanced nutrition: less than body requirements related to the
use of insulin and underlying disease process
 Risk for infection related to glucose levels

Nursing Implementation with Rationale

These are vital nursing interventions done in patients who are taking insulin:
  Ensure that patient has dietary and exercise regimen and using
good hygiene practices to improve the effectiveness of the insulin
and decrease adverse effects of the disease.
 Monitor nutritional status to provide nutritional consultation as
needed.
 Gently rotate the vial containing the agent and avoid vigorous
shaking to ensure uniform suspension of insulin.
 Rotate injection sites to avoid damage to muscles and to prevent
subcutaneous atrophy.
 Monitor response carefully to avoid adverse effects.
 Always verify the name of the insulin being given because each
insulin has a different peak and duration, and the names can be
confused.
 Use caution when mixing types of insulin; administer mixtures of
regular and NPH insulins within 15 minutes after combining them to
ensure appropriate suspension and therapeutic effect.
 Store insulin in a cool place away from direct sunlight to ensure
effectiveness. Predrawn syringes are stable for 1 week if
refrigerated.
 Monitor patient’s food intake and exercise and activities to ensure
therapeutic effect and avoid hypoglycemia.
 Monitor patient’s sensory losses to incorporate his or her needs into
safety issues, as well as potential problems in drawing up and
administering insulin.
 Provide good skin care and foot care, to prevent the development of
serious infections and changes in therapeutic insulin doses.
 Provide comfort measures to help patient cope with drug effects.
 Provide patient education about drug effects and warning signs to
report to enhance patient knowledge and to promote compliance.

Evaluation

Here are aspects of care that should be evaluated to determine the

effectiveness of drug therapy:
 Monitor patient response to therapy (stabilization of blood glucose
levels).
 Monitor for adverse effects (hypoglycemia, ketoacidosis, injection-
site irritation).
 Evaluate patient understanding on drug therapy by asking the
patient to name the drug, its indication, and adverse effects to
watch for.
 Monitor patient compliance to drug therapy.