dr. IVAN insulin_recording material

Types of Insulin for the Treatment of Diabetes Mellitus.

History of Insulin Development Insulin Structure and Chemistry Rapid Acting Insulin Basal Insulin Premixed Insulin T2DM Treatment Guidelines Therapy Initiation & Intensification with Insulin.

History of Insulin Development.

Moss J and Galloway J. JAMA 1977;238:1823-4 Owens DR et al. Diabetes Metab Res Rev 2014;30:104-19 Humalog ® [Prescribing Information]. Eli Lilly and Company, 2015 Humulin ® R U-500 [Prescribing Information]. Eli Lilly and Company, 2015 Tresiba ® [Prescribing Information]. Novo Nordisk A/S, 2015.

Progressive Decline in  -Cell Function in T2DM: Therapeutic Implications.

Insulin Structure and Chemistry.

Human insulin is a small peptide of 51 amino acids It consists of two chains of amino acids; chain A has 21 amino acids, and chain B has 30 amino acids Two disulfide bridges (from A7 to B7, and from A20 to B19) join the chains, and chain A also contains an internal disulfide bridge.

Insulin Monomers This is the active form of Insulin that circulates in blood and binds to the insulin receptor Insulin Hexamers Composed of 6 monomers These are the storage form of insulin both in the β-cell and in insulin vials.

What Happens When We Inject Human Insulin in the Subcutaneous Space? 1,2.

Time-action Profile of Human Regular Insulin U-100.

Limitations of Human Regular Insulin. Slow onset of activity1.

Rapid Acting Insulin.

Rapid-acting Insulin Analogs. Insulin analogs are insulin molecules whose structure has been altered to improve pharmacokinetic and pharmacodynamic properties compared with human regular insulin, but preserving biological effects and safety profile1.

Structure of Rapid-acting Insulin Analogs. unnsul zuedse u!lnsul LOJdS!l unnsul u!eqo-8 •eeccecccc•ccccccccccccccccecc uleqo-V.

Absorption Profile of Rapid-acting Insulin: Humalog.

Humalog Restores Early Insulin Peak in Patients With T2DM.

Time-action Profiles of Available Rapid-acting Insulin Analogs.

Use of Rapid-acting Insulin Analogs. Rapid-acting insulin analogs are administered close to meals.

Prandial (Mealtime) Insulin Analogs: Features, Benefits, and Limitations 1,2.

Basal Insulin.

What Is Basal Insulin? 1,2. Basal insulin is the amount of insulin secreted constantly, that is needed to maintain stable blood glucose levels between meals and overnight.

Classes of Basal Insulin 1. Initiating insulin therapy with basal insulin may be considered a convenient starting point, as it may require only 1 or 2 injections/day 2.

Characteristics of Basal Insulins 1-4. Indication Improve glycemic control in adult and pediatric patients a with diabetes Dosage and administration Subcutaneous administration b Individualize and adjust dosage based on metabolic needs, blood glucose monitoring results, and glycemic control goal Mechanism of action Stimulates peripheral glucose uptake by skeletal muscle and fat Inhibits hepatic glucose production Inhibits lipolysis and proteolysis Enhances protein synthesis Adverse reactions Hypoglycemia Hypokalemia Allergic reactions (including injection site reactions such as erythema, local edema, and pruritus ) Peripheral edema Lipodystrophy Weight gain.

Insulin Glargine: Mechanism of Sustained Release and PK/PD 1.

Insulin Detemir: Mechanism of Sustained Release and PK/PD 1.

Comparison of Time-Action Profile of Single Doses of Insulin Degludec and Insulin Glargine 3.

Basal Insulin: Features, Benefits, and Limitations.

Premixed Insulin.

What are Premix Insulins?. Premix human insulins1.

Mixtures Address Both Basal and Mealtime Hyperglycemia.

Premix Analogs Have Stronger Early Glucose Lowering Activity and Faster Onset Than Human Premixes.

PK Profiles: Insulin Lispro 100 units/ml vs. Insulin Lispro Premixes in Healthy Subjects.

Who May Benefit from Insulin Mixtures?. Patients:.

Favors basal-bolus. Comfortable with more frequent injections Comfortable with more frequent monitoring Good.

Question. Sesuaikan jenis gula darah yang dikontrol dengan kerja masing-masing jenis insulin berikut.

T2DM Treatment Guidelines.

ADA: Individualizing HbA1c Goals for T2D Treatment.

DM Treatment Algorithm from PERKENI, 2021. MODIFIKASI GAYA HIDUP SEHAT saet HI-AIC MONOTERAPI dengan sa.lah dibawah ini 27.5% BINASI 2 Obat dengan mekanisme yang berbeda KOMBINASI 3 Obat klinis 2 Obat atau Gejala klini$ (4) Insulin ± obat lain Metformin SulfoniIurea/Glinid Penghambat Glukosidase Alfa Tiazo"nedion Penghambat DPP- Agonis GLP-I belum mencapa• •-1% dalam 3 bulan, rambahan obatke 2 obat) Sulfonilurea/Glinie PenghanOat • 'azolidinedOn PengnænbatSGL I -2 InsulinBasaI Apni$ GLP- I BlaHbA1( belum mencapai dalam bulan. tambohan cbatke 3 (kombinasi 3 "bat) Su ttoni•urea/GliftId Per•ambat Alfa riazolidin«3ion pen#vambat DPP-lv penghambat SOL T -z Insulin Basal Agonis GLP- 1 aaa bclum mencapai dabm bulan. tambahan obat insuln atau Intensifikcsi terap Insu In Tambahkan Insulin atau intensifikasi insulin L 2. 3. 4. Gambar 3. Algoritma Pengobatan DM Tipe 2 Pemilihan dan pcnggunaan obat mempcrtimbangkan faktor pcmbiayaan, ketcrscdiaan obat, efektifitas, manfaat kardiorenal, cfck samping, efek terhadap berat badan, serta pilihan pasien Pengelolaan bukan hanya meliputi gula darah, tetapi juga penanganan faktor-faktor risiko kardiorenal yang lain secara terintegrasi Obat Agonis GIT-I dan penghambat SGLT-2 tcrtcntu menunjukkan manfaat untuk pasien dcngan komorbid pcnyakit kardiovaskulcr atcrosklcrotik. gagal iantung dan gagal ginial, Kedua golongan obat ini disarankan meniadi pilihan untuk pasien dengan komorbid/komplikasi penyakit tersebut. Bila HbAlC tidak bisa dipcriksa maka scbagai pedoman dipakai glukosa darah rerata yang dikonvcrsikan kc HbAlC (poin 7 pcnjclasan algoritma).

Therapy Initiation & Intensification with Insulin.

PERKENI Consensus , 2021 on Insulin Management. INSULIN BASAL Biasanya dengan metformin +/- non-insulin Iainnya Awal : S 10 unit/ha•i (referensi BB = SO k:) Penyesuaian : atau 2 4 unit. 1+2 sam" te•capai sas.æan GD : dan atasi tu-ulkan dosis 4 20% lika setelah GDP tercapai, HbA1c 7% (atau jika dosis unit/kgBB/hari), atasi GDPP dengan insulin sut makan rneRimhAn*An nntuk mømhøm&.n GI .P- R 2.'SUL11 SEBZLVU Awal : 4 unit. 0.1 dosis basal. Ji}a AIC <8% pertimbangkan untuk menurunkan basal dalam jumlah yang sama. Penyeataian : dosis i 2 unit atau 10 — dalam 1-2 kali senungga hinga sanran SMBG terapai. Hipoglikemia : tentukan dan atasi pnyebab, dosis 2 4 unit atau - 2 'ALI SEHÄRI Awal : Dosis insulin basal dibag menjadi 2 dosis/hari yaitu 2/3 pagi dan 1/3 malam atau % dan % Penyesuaian : dosis i 2 unit atau 10 — dalam 1-2 kali semirzgu sasaran SMBG Hip%likemia : dan atasi penyebab, turun}an doäs 2 4 unit atau - 20% 22 INJEK.SI INSULIN CEPAT (BASAL BOLUS) • Aval : 4 unit, atau dosis basal. AIC uxtuk menurunkan basal dalam junlah yang sama • Peuyesuaian : dosis i 2 ulit Rau 10 — dalam 1-2 seminggu hinga sasaran SMEG tercapai. • : dan atasi penyebab, 2 4 unit atau - FIEKSIBILITAS LEBIH FLEKSIBEL FLEKSIBEL.

Insulin Therapy Initiatio n and Intensification, PERKENI 2021.

Insulin Therapy Initiatio n and Intensification, PERKENI 2021.

Question. Urutkan tahapan terapi insulin sesuai dengan pedoman yang berlaku.