Insulina y dm

TERAPIA DE INSULINA EN LA DIABETES MELLITUS

DR. LEOPOLDO MELÉNDEZ RIVERA

MEDICINA INTERNA

INSULINA EN EL DIABÉTICO

• DIABETES TIPO 1• DIABETES TIPO 2 REFRACTARIA A

TRATAMIENTO ORAL• DIABETES GESTACIONAL• SÍNDROMES ESPECÍFICOS

DIABETES CARE 26 S1, 2003


• INSULINA– ORIGEN

• BOVINA• PORCINA• HUMANA

RECOMBINANTE• ANÁLOGOS

– TIPOS• RÁPIDA• CORTA• INTERMEDIA• LARGA


http://mx.wrs.yahoo.com/_ylt=A9FJqhqX6.pDxaQA_JjF8Qt.;_ylu=X3oDMTA2bTQ0OXZjBHNlYwNzcg--/SIG=1et3eskcd/EXP=1139555607/**http%3A/mx.search.yahoo.com/search/images/view%3Fback=http%253A%252F%252Fmx.search.yahoo.com%252Fsearch%252Fimages%253Fp%253D%252BINSULINA%2526ei%253DUTF-8%2526fr%253DFP-tab-img-t%2526b%253D101%26w=220%26h=200%26imgurl=i.esmas.com%252Fimage%252F0%252F000%252F003%252F224%252Fpi_N.jpg%26rurl=http%253A%252F%252Fwww.esmas.com%252Fnoticierostelevisa%252Fmexico%252F339047.html%26size=6.2kB%26name=pi_N.jpg%26p=INSULINA%26type=jpeg%26no=119%26tt=3.245%26ei=UTF-8


NEJM 352;2:174-183, 2005


• MARCAS

– NPH HUMULIN N (LILLY)

– RÁPIDA

HUMULIN R (LILLY)– LISPRO

HUMALOG– GLARGINA

LANTUS– ASPARTICA

NOVORPID



• TRANSPORTE Y ALMACENAJE

– REFRIGERADA 4° A 8°– NO AGITAR– MENOS DE UN MES

• MEZCLADO– PRIMERO INSULINA

RÁPIDA Y DESPUES INTERMEDIA

– GLARGINA NO SE COMBINA



• JERINGAS

– INYECCIÓN SUBCUTÁNEA

– CAPACIDAD 0.3, 0.5, 1 Y 2 ML

– NO SE COMPARTE

– SUSTITUTOS• INYECTORES JET• BOMBAS DE INFUSIÓN

CONTÍNUA



• TÉCNICA DE INYECCIÓN

– INYECTAR VOLUMEN DE AIRE EQUIVALENTE

– CARGAR Y AGITAR GENTIL

– MEZCLAR PRIMERO INSULNA RÁPIDA

– INYECTAR A 90°– NO ASPIRAR– NO BURBUJAS



• SITIO DE INYECCIÓN

– BRAZO– GLUTEOS– ABDOMEN– ESCAPULAS– MUSLOS



• DOSIS

– INSULINA RÁPIDA 15 MIN PREPRANDIAL O AL FINAL

– INSULINA INTERMEDIA 30 MIN PREPRANDIAL– INSULINA LISPRO PREPRANDIAL INMEDIATA– INSULINA GLARGINA PREPRANDIAL INMEDIATA



• DOSIS

NEJM 352;2:174-183, 2005


• DOSIS– NPH

• COLACIÓN NOCTURNA

NEJM 352;2:174-183, 2005


• DOSIS. Recommended Strategies for Initiating Insulin in Type 2 Diabetes*

A1C ThresholdTherapeutic Strategy Suggested Initial Dose† Follow-up

7.0% to 10.0% despite 2 oral medications

Initiate basal insulin

10 U every day for insulin glargine Advance insulin dose weekly until FPG is within target

Continue oral medications

10 U every day or twice daily for NPH If A1C remains > 7.0% and PPG is elevated, add prandial insulin starting with largest daily meal

Monitor A1C every 3 months until < 7.0%; every 6 months thereafter

> 10.0% despite 2 oral medications

Initiate basal-prandial insulin‡

Basal, as above Optimize prandial doses for each meal

Discontinue oral secretagogues

Prandial: 5-10 U at each meal§ (Approximately 1 U for every 10-15 g of carbohydrate to start)

Advance insulin dose weekly until PPG and FPG are within target

Premixed insulin is not usually recommended, but can consider 10 U before breakfast and dinner

Monitor A1C every 3 months until < 7.0%; every 6 months thereafter

FPG = fasting plasma glucose; NPH = neutral protamine Hagedorn; PPG = postprandial glucose*Consider adding insulin in all patients who have A1C > 7.0% despite optimal doses of 2 oral agents.†Reduced doses may be prudent in chronic renal disease.‡A basal insulin can be introduced initially; however, the need to advance within 3-5 months to a basal-prandial regimen is more likely at such baseline A1C levels.§An alternative for initial dosing of prandial insulin is 5-10 U at the main meal.

Medscape General Medicine 7(4):49, 2005


• COMPLICACIONES

– HIPOGLICEMIA


INSULINA EN EL DIABÉTICO Advantages of Basal-Prandial and Premixed Insulin Regimens[42,56]

Basal-Prandial Insulin Regimens

Premixed Insulin ProductsBasal Insulin (Insulin Glargine or NPH)

Prandial Insulin (Rapid-Acting Analog or Regular Human)

Advantages

Flexibility: allows variation in timing of meals and activities

Rapid-acting analogs allow greater flexibility/allow variation in timing of meals and activities

Convenience: longer- and shorter-acting insulins combined in 1 injection (may be given twice daily)

Easy to titrate based on FPG, A1C Easy to titrate based on PPG, A1C

Glargine has no pronounced peak and is associated with a lower incidence of hypoglycemia, especially nocturnal hypoglycemia

Can mix with other insulin products to reduce number of injections

Glargine provides ~24-hour coverage with once-daily dosing

FPG = fasting plasma glucose; NPH = neutral protamine Hagedorn; PPG = postprandial glucose


INSULINA EN EL DIABÉTICO Disadvantages of Basal-Prandial and Premixed Insulin Regimens

Basal-Prandial Insulin Regimens Premixed Insulin Products

Basal Insulin (Insulin Glargine or NPH) Prandial Insulin (Rapid-Acting Analog or Regular Human)

Glargine cannot be mixed with other insulins

Greater number of daily injections

Cannot titrate basal insulin and prandial insulin individually

NPH may require 2 injections per day for 24-hour coverage

Less mealtime flexibility with regular human insulin

Increased risk for hypoglycemia

NPH is associated with variability of absorption (ie, site of injection, inter- and intrapatient)

Lunchtime prandial dose may need to be administered separately

Less mealtime flexibility

NPH has an increased risk for midmorning and/or nocturnal hypoglycemia

Difficult to administer premeal correction doses, especially with prefilled pen cartridges

FPG = fasting plasma glucose; NPH = neutral protamine Hagedorn; PPG = postprandial glucose



• RECHAZO

– INYECCIONES– MITOS

• CEGUERA• ALERGIAS• FASE TERMINAL• AUMENTO DE PESO• RIESGO

CARDIOVASCULAR



• INSULINA RÁPIDA

– EN CETOACIDOSIS • BOLO INICIAL DE 0.15 UI/KG• INFUSIÓN DE 0.1 UI/KG/HR Y DOBLAR CADA HORA

• BOLO INICIAL 0.4 UI/KG – 50% IV, 50% SC

• BOLO SC 0.1UI/KG/HR Y 10UI SC/HR

• AL ALCANZAR 250 MG/DL…

Diabetes Care 24:131-153, 2001Diabetes Care 27:S94-S102, 2004


• INSULINA RÁPIDA– EN CETOACIDOSIS

• AL ALCANZAR 250 MG/DL (SIN CETOSIS):

– INFUSIÓN A 0.05 UI/KG/HR– 5 UI SC/HR O 5-10 UI SC/ 2 HR

• AL ALCANZAR 200 MG/DL:

– 5 UI SC C/50 MG >150 MG/DL– 20 UI SC C/150 MG>300 MG/DL

Diabetes Care 24:131-153, 2001Diabetes Care 27:S94-S102, 2004


• INSULINA RÁPIDA– EN ESTADO HIPEROSMOLAR

• BOLO INICIAL 0.15 UI/KG IV• INFUSION 0.1 UI/KG/HR• DOBLAR CADA HORA HASTA BAJAR 50-70 MG/DL INICIA 1 UI/HR DOSIS-RESPUESTA INFUSIÓN 0.02 UI/KG/HR HASTA 10 – 50 UI/HR

• SIN ESTADO HIPEROSMOLAR– 5 UI SC C/50 MG >150 MG/DL– 20 UI SC C/150 MG>300 MG/DL– 0.05-0.1 UI/KG/HR AL MANTENER 250-300MG/DL

Diabetes Care 24:131-153, 2001Diabetes Care 27:553-591, 2004


• INSULINA RÁPIDA– DEFICIT DE AGUA

• (Na/140 – 1) X 0.6 X PESO • 150 (1.07) 60 (2.5)

• MIELINOLISIS PONTINA

Diabetes Care 24:131-153, 2001Diabetes Care 27:553-591, 2004


• INSULINA RÁPIDA– OSMOLARIDAD SÉRICA

•2 Na + glucosa/18 + BUN/2.8 • 150 400 60 343• 150 100 60 327• 145 100 60 316• 145 100 15 3

•Osm Ser = 280 - 310Diabetes Care 24:131-153, 2001Diabetes Care 27:553-591, 2004


• INSULINA RÁPIDA– EN HIPERGLICEMIA AGUDA

• 1 UI DISMINUYE 30 A 50 MG/DL DE GLUCOSA SÉRICA

– ESQUEMAS SEGÚN ESCALA DE TIRA REACTIVA

• 1 UI METABOLIZA 4 GRAMOS DE GLUCOSA EXÓGENA

– 1000 CC SOL. GLUCOSADA 5% UTILIZA 12.5 UI

GOODMAN Y GILMAN, TRATADO DE FISIOLOGÍA

INSULINA EN EL DIABÉTICO • INSULINA RÁPIDA

– EN HIPERGLICEMIA AGUDA

• ESQUEMA DE INSULINA RÁPIDA

– 200-240 MG/DL = 3UI 80-120 MG/DL– 240-360 MG/DL = 5UI 120-160 MG/DL– 360-480 MG/DL = 7UI 80-200 MG/DL

• CONDICIONANTES

– OBESIDAD– FUNCIÓN RENAL– FUNCIÓN HEPÁTICA– USO PREVIO– ESTADO CATABÓLICO

VALORACIÓN PREOPERATORIA, HALABE J.


• INSULINA LISPRO– EN HIPERGLICEMIA PREPRANDIALES

• 10 - 20% DE LA DOSIS TOTAL DIARIA POR CADA EVENTO

• PREVIA GLICEMIA CAPILAR UNA HORA ANTES• APLICAR 0 – 15 MINUTOS ANTES

– EN EVENTOS QUIRÚRGICOS• 10 – 20% DE LA DOSIS TOTAL CADA 4 HRS PRN• 0.02 UI/KG CADA HORA

Diabetes Care 27:553-591, 2004:

RESISTENCIA A LA INSULINA

www.medscape.com/viewprogram/3942, ABRIL 2005

DEFINICIÓN

• REQUERIMIENTO DIARIO >100 UI• NECESIDAD DE UN MONTO MAYOR DE INSULINA

(ENDÓGENO O EXÓGENA) PARA ALCANZAR LA RESPUESTA NORMAL

SINÓNIMOS

• SÍNDROME METABÓLICO• SÍNDROME X• SÍNDROME DISMETABÓLICO

http://www.medscape.com/viewprogram/3942



1. National Cholesterol Education Program/Adult Treatment Panel III (NCEP/ATP III) Diagnostic Criteria for the Metabolic Syndrome

Diagnosis is made when 3 or more of the following are present:

Waist circumference Men > 102 cm Women> 88 cm

Fasting triglycerides >/= 150 mg/dL

Blood pressure >/= 130/85 mmHg

HDL cholesterol </= 50 mg/dL for women; </= 40 mg/dL for men

Fasting glucose* >/= 110 mg/dL

• This was changed to 100 mg/dL following the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association (ADA) conference proceedings[

The value of 110 mg/dL does not reflect the revised ADA criteria for impaired fasting glucose.




2. WHO Criteria for the Metabolic Syndrome

Insulin resistance, as identified by 1 of the following:

• Type 2 diabetes

• Impaired fasting glucose (101-125 mg/dL)

• Impaired glucose tolerance (140-199 mg/dL 2h after 75 g of glucose)

• If normal fasting glucose, glucose uptake below the lowest quartile for background population under hyperinsulinemic, euglycemic conditions

Plus 2 of the following:

• Antihypertensive medication and/or blood pressure >/= 140 mmHg systolic or >/= 90 diastolic

• Triglycerides >/= 150 mg/dL

• HDL < 35 mg/dL for men or < 39 mg/dL for women

• BMI > 30 kg/m2 and/or waist-hip ratio > 0.9 men, > 0.85 women

• Urinary albumin excretion >/= 20 mcg/min or albumin-creatinine ratio >/= 30 mg/g




3. AACE Clinical Criteria for Diagnosis of the Insulin Resistance Syndrome

Risk Factor Cutoff

Overweight/obesity BMI >/= 25 kg/m2

Elevated triglycerides >/= 150 mg/dL

HDL cholesterol Men Women

< 40 mg/dL< 50 mg/dL

Blood pressure >/= 130/85 mmHg

2h post 75 g glucose challenge

> 140 mg/dL

Fasting glucose Between 110 and 126 mg/dL

Additional risk factors -Family history of type 2 diabetes-Hypertension-Coronary heart disease (CHD)-Polycystic ovary syndrome-Sedentary lifestyle-Advanced age-Ethnic groups at high risk for type 2 diabetes or CHD




4. Major Cardiovascular Risk Factors

Hypertension (blood pressure > 140/90 mmHg or taking antihypertensive medication)

Cigarette smoking

Obesity

Physical inactivity

Dyslipidemia/low HDL cholesterol (< 40 mg/dL) or high triglycerides ( > 150 mg/dL)

Diabetes mellitus (coronary heart disease risk equivalent)

Microalbuminuria or glomerular filtration rate < 60 mL/min

Age ( > 55 years for men, > 65 for women)

Family history of premature coronary heart disease



NEJM 1999; 341:248-257

CAUSAS

• MUTACIONES EN LOS TRANSPORTADORES DE GLUCOSA• ALTERACIONES EN EL GEN GLUT 4• DEFECTOS EN LA TRANSLOCACIÓN DEL GEN GLUT 4• DEFECTOS EN LAS VÍAS DE SEÑALIZACIÓN• DISMINUCIÓN DEL TRANSPORTE DE GLUCOSA POR INSULINA

http://content.nejm.org/content/vol341/issue4/images/large/06f2.jpeg


NEJM 1999; 341:248-257

CAUSAS

• FACTORES PARACRINOS• ÁCIDOS GRASOS• GLUCOTOXICIDAD• FACTOR DE NECROSIS TUMORAL

• FACTORES NO INSULÍNICOS• EJERCICIO• BRADIQUININAS• ÓXIDO NITROSO• FACTORES DE CRECIMIENTO INSULINA-LIKE• PÉPTIDO C• HORMONAS TIROIDEAS

http://content.nejm.org/content/vol341/issue4/images/large/06f2.jpeg

Insulina y dm

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