Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. Narrator - ? 00:11 This podcast is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk. Episode 86 I'm your co host, Dr. Kane. Dr. Khyati Patel 00:34 I'm Dr. Schuman, and I'm Dr. Patel. In today's episode, we're going to talk everything you need to know about insulin in one shot. Dr. Sean Kane 00:42 So we'll start off basically talking about the kinds of insulin that are out there on the market. And then later on, we'll talk about some dosing and some clinical pearls and kind of major counseling points for a variety of different kinds of insulin. Dr. Khyati Patel 00:53 We'll throw in some aspects of insulin administration techniques, storage requirements, and then I hear from students all the time they still cannot get their head around the sliding scale. So we'll talk a little bit about sliding scale insulin especially you being here. Dr. Kane, what are you seeing from the hospital inpatient side? Dr. Sean Kane 01:12 So? Dr. Patel, where should we start with the insulins here? Dr. Khyati Patel 01:15 Let's divide up the insulins based on their duration of action, or when do we inject them? Right? So the two major categories are your basal insulins that are your almost one a day insulin that lasts for 24 hours, or give you that overall control of blood sugar throughout the day. And then we have bolus insulins that are usually there to cover hyperglycemia that emerges from meals. So talking about basal insulins, the first and foremost is the intermediate acting insulin, and that's your NPH. Novolin, remember, N is, you know, N for NPH, and the Humulin N and Novolin N are the brand names for it. So again, the n in those products stand for NPH. And at Dr. Sean Kane 02:01 least when I was in pharmacy school, before I was in a retail pharmacy, I really got confused about the N and the R, because they still share Humulin or Novolin but that letter at the end is actually really important to describe the kind of insulin that you're talking about Dr. Khyati Patel 02:16 absolutely and just to, you know, reiterate the it too that the NPH is considered a human insulin. So you're right. It's a good way to remember, if it's N It's NPH, if it's R, it's the regular insulin. Speaker 1 02:29 So one thing to look at this one comparatively again, versus of the other of the basal types we talk about later, is these do have pronounced peaks, and so because of that, there is some some risk of nocturnal hypoglycemia. These are twice a day types of insulin, generally. So if you're given morning and evening, you do have a little bit of that concern, then that as it rolls in evening and into night, that you're gonna have some of that hypoglycemic effect. And so again, that needs to be a piece of the counseling and your overall decision as you compare this to other forms of insulin. Dr. Khyati Patel 02:56 Yeah. And when it comes to stability of insulin too, you know, we always teach patient, Hey, pick up your pen or pick up your vial, put it against the light to make sure there is no floaty particle. But when it comes to NPH, it is a cloudy insulin to begin with. So when we are educating patient on how to properly use it, we have to tell them to kind of re suspend, the suspension, make it cloudy all over before they inject it. Dr. Sean Kane 03:20 In terms of how this is available, many insulins, historically were available as a vial that you had to get needles in a syringe with and you pulled it out of a vial. This has a pen now as well. Is that correct? Dr. Khyati Patel 03:32 That is correct the Humulin and Novolin. And have U-100 pen and vials both available. Speaker 1 03:39 And one other thing to notice that the vial here is available over the counter behind the pharmacy without a prescription. I know in school, you know, that's something I don't think I'd learned about the first time I saw it. Happens if somebody comes up to the window and says, I'm gonna pick up some insulin, I'm like, good for you. Where's your prescription? And as I kind of realized that, again, this is something that can be done as convenience factor for individuals who are pretty well Dr. Khyati Patel 03:59 versed in their insulin management. And it becomes very useful for pet medicine too. You know, I remember seeing some pet owners come in and picking up the needles as well as the insulin vials. And for those who don't have good insurance coverage, they can obtain their insulin over the counter behind the pharmacy, just paying out of pocket Dr. Sean Kane 04:16 and well beyond the scope of today's talk. But it's so ironic to me that you could potentially get insulin NPH without a prescription, but we don't have over the counter statins, for example, or other medications that I would absolutely consider to have a safer side effect profile that require, you know, much less counseling than insulin NPH. But I think for historical reasons, that's one of the nuances of insulin NPH, is that for historical reasons, it was and is still over the counter. Dr. Khyati Patel 04:45 Yeah, and if you think about it, insulin is a high risk medication, according to the institution of Safe Medication Practices, so just anybody and everyone walking to your counter asking for insulin, you should still be careful and find out what is the purpose for you. And, you know, dispense the allowed amount of syringes and needles, and not more than that. And so rounding up. NPH, you know, we talked about how it's cloudy in appearance, but this insulin can easily be physically mixed with other insulins if you wanted to reduce the number of injection but nowadays, with the mixed insulins being already available, we don't have to quite have patients do this physical mixing. Dr. Sean Kane 05:24 So I don't see as much NPH, at least in my clinical practice, I see a ton of the long acting insulins. Is that kind of your experience as well? Dr. Khyati Patel 05:31 Dr. Patel, that's correct. I usually reserve NPH type of intermediate acting insulins for those who don't have coverage for the long acting insulin. So those long acting ones are once a day for the most part, have a little bit longer coverage. And first one we can start off with is glargine. So the brand name is Lantus. That's U-100 we have another brand name Toujeo, which is a little bit concentrated. That's U-300 and then we have a follow on, not technically biosimilar, but the follow on insulin product called Basaglar. And everything you need to know about Basaglar is covered in Episode 56 Dr. Sean Kane 06:07 so in terms of the onset of these guys, we typically don't see a dramatic peak effect. And we see this like prolonged duration of effect of this particular insulin category. Speaker 1 06:17 And then the other thing with this one again, is, because of that peak effect, about a 20 to 24 hour duration of effect. We can do this one as a pretty nice once a day dosing of it, although, as a general rule, or kind of a practice, Pearl would be, you know, if you get above 50 units or so wanting to consider splitting it up, and a lot of that is less of a robust thou shalt do it. But as the idea that, as you get higher doses of insulin, the ability of the body to absorb it from that single site can be limited, and so you may not be getting the full amount that you're dumping into the arm there. And so because of that, splitting it up or arm or abdomen, so splitting it up so that you're getting a dose in the morning, dose and evening may be worthwhile. And those getting more than 50 units a day. Dr. Sean Kane 06:58 In terms of appearance, this is clear, but this should not be mixed with other insulins. This is kind of its own injection on its own. You can't mix it with, you know, a short acting insulin, for example, yeah. Dr. Khyati Patel 07:08 And when we talk about mixing here, we're talking about, like, physically mixing two different insulin liquids together. So obviously they can be on, you know, longer, acting glargine along with the bolus insulins as a therapy mixing, but not as a physical mixing, Dr. Sean Kane 07:22 not in the same syringe, correct? So one other thing just to mention, with Toujeo, and we did talk about Toujeo In episode 34 especially on my side of the woods in the inpatient setting, there are some nuances to converting between Toujeo and Lantus, for example, and we won't get into it today, but just be aware that it's not always a one to one conversion. Depends on the direction and things like that, correct. Dr. Khyati Patel 07:45 And we do have a resource that we will be posting in terms of, like, when it comes to converting patient from one type of insulin to another type of insulin. So what's Dr. Sean Kane 07:53 the other kind of long acting insulin that's available? So Speaker 1 07:56 kind of, comparing to the glargine we've also got detemir brand name, Levemir. So again, those sound a little bit more rimy, a little easier to remember. The two slight peak of it with differentiated system, the has a little bit of a peak and a little bit of a shorter duration compared to glargine. So I think in general, it is a once a day. But technically, you probably want to consider twice daily dosing to really get that full 24 hour coverage, because it's not that perfect 2024 hour quite like like glargine. Dr. Sean Kane 08:25 So Dr. Schuman, again, in my experience, I see a lot more glargine than I see detemir. Is there a reason, given the kind of less favorable kinetic profile of detemir that someone might be on detemir. Speaker 1 08:36 So honestly, at my facility, a lot of it is formulary considerations. We have a few individuals who were kind of grandfathered in from previously when our preferred was glargine, and are still on that one. But then there was a switch, and so we kind of now the preferred is, is detemir. But if we do have individuals where we are noticing that kind of drop off, we do sometimes switch back to glargine to try to still get as close to that 24 hour as we can, while minimizing the number of shots we give per day. Dr. Khyati Patel 09:02 Pens and vials are available for this insulin and U-100 strength, and it's also clear. So again, just like glargine, it shouldn't be mixed with any other type of insulins. And then Speaker 1 09:12 just one thing to add when we say things like U-100, U-300, what we're talking about here, just as a refresher, is the number of units per milliliter. So again, that's an important thing when you're Dr. Khyati Patel 09:20 looking at conversions. So the important thing about the detemir as well as glargine, is that, you know, we tell patients there are 24 hour insulin. So if you're on a once daily dose and twice daily dose with detemir, it has to be taken the same time every day. But then we had ultra long acting insulin came in the market called degludec or Tresiba. Again, we discussed this in Episode 34 this one has a duration of action of 42 hours. This is completely a peakless insulin. So again, this is once daily dosing. But we don't have to marry a patient to a particular time of the day. As long as they don't inject two doses within eight hours of each other, they can space it out. So. One day they want to take it in the morning, but the next day, they want to take it in the evening, because they have a, you know, flexible travel schedule. That's that's okay to do with Tresiba. Dr. Sean Kane 10:08 And just to clarify, because these are peak lists where there's not a definite onset, and they last so long a patient isn't really taking these with respect to a particular meal, right? Correct? Dr. Khyati Patel 10:19 Yeah, these are longer acting insulin so it has no consideration for meal. But that said, because they're on insulin therapy and they have diabetes to begin with, they should be eating meals consistently and not skipping meals, right? Speaker 1 10:33 And I think that's a good segue into we talk about shorter acting, because we have to be very careful with patients that sometimes get confused. I think, as far as which is which, or, well, gosh, if this one doesn't need to be taken with meals, then I guess I don't need to take any of my insulins with meals. So I think it's really important, as we look at some of the shorter act thing that we have the distinction, and we're very clear on that for our patients, absolutely. Dr. Khyati Patel 10:55 And another thing I like about degludec is that, you know, like we talked about Dr. Schuman, we should just kind of do this out of practice the higher doses of glargine. We split them in two. We don't have to do that with degludec. So if somebody wants to not take so many injections per day, degludec would be a good one, especially with their U-200 pen dialing up to 160 units per one dial per one pen injection, you can actually have a patient taking 150 units of Tresiba all in just one push. Dr. Sean Kane 11:25 So then I think that's a good transition point from our intermediate and our long acting to more of our meal time or shorter acting insulin. Dr. Khyati Patel 11:33 That's correct. And these bolus insulins, or mealtime insulins, are technically injected around the time of the meal, like Dr. Schuman just mentioned. So again, important thing to remind patient, you're not supposed to skip meals, as you have diabetes. But if you know a fire alarm goes off, or you were just on the road and couldn't find a good food, and you know you had to skip your meal, that's the time we ask patients to not take these insulin so the very first category of bolus insulin is your short acting insulin. And there's only one product in this category is the regular insulin. Again, this is just like NPH. It's a human insulin, but the brand names are Humulin R and Novolin R, where R signifies it's a regular insulin. Dr. Sean Kane 12:19 And I believe this is also the other insulin product that's available over the counter as well. Is that correct? Dr. Khyati Patel 12:24 That's correct. So over the counter, behind the pharmacy, patients can pay out of pocket and take it without prescriptions. Speaker 1 12:30 And so this is one that, again, as we mentioned, is a short acting insulin, not the fastest we have, but a shorter acting so a peak of two and a half to five hours, total duration of about four to 12 hours. So you're still getting, again, a good peak. But you can, you can get a fair amount of duration of response here, and the wide range is probably because of this hexamer formulation that it's made with correct Dr. Khyati Patel 12:51 and so basically, hexamer is three different insulin molecules come together to form this hexamer, and then when injected, it kind of releases, depending on the patient's body and physiology, releases those insulin molecules into the bloodstream, and that's why the duration of action can be very wide. And if you Dr. Sean Kane 13:09 think about it like if you're taking this with food, you kind of want your mealtime insulin to work fairly quickly, to cover whatever you eat, right? So kinetically, I could see value in having an even shorter acting insulin. But it's important as pharmacists and other healthcare providers to know, like, how quick does this kick in and how long does it last? Because pretty soon we'll talk about other categories that are even faster on set with a shorter duration, Dr. Khyati Patel 13:32 correct and so for regular insulin, we usually tell patient to take the insulin, wait 30 minutes and have the meal. So it's usually 30, about 30 minutes before having a meal, and Dr. Sean Kane 13:42 again, for convenience reasons, as you mentioned, Dr. Patel, you know, if you inject think you're going to eat, and for whatever reason you don't, you're kind of in trouble, right? Fire alarm goes off, or the kid is screaming, and you have to take him to the doctor and you couldn't eat your meal. You've already given yourself the Dr. Khyati Patel 13:57 insulin, and that is where regular insulin comes with the higher risk of hypoglycemia is because that time difference between eating a meal and injecting that insulin is a little longer. Anything can happen in that half an hour. The other Speaker 1 14:10 interesting thing about this one, again, it can be mixed with an NPH so that you can utilize it a little bit of a flexible dosing, where you can get multiple different types of peaks there. The other thing to note is it is. It comes in U-100 and U-500 vial and pen. And I know at our facility we have to be really, you know, we've been had careful about education, about how we educate patients on what they're doing with a U-500, because you definitely have that risk of accidentally giving yourself too much if you're assuming that I've been drawing up one mill before, I'm drawing up one mill again, or I'm drawing up, you know, point two mils. And so that's definitely been a big sticking point at our facility. Dr. Khyati Patel 14:43 Yeah, it takes a while before somebody, a patient, needs to advance to a U-500 insulin. It's still a regular insulin, but it is highly concentrated, so the kinetic profile is a little bit different. It's a slow on peak, but the duration for action could be almost 24 hours. So if you have a type two diabetes patient who has very high insulin resistance, requiring higher doses of insulins, at one point, we can convert them for all the basal bolus to just the U-500 regimen that could be injected either twice daily or three times a day. Speaker 1 15:17 I know a nice thing too is we do have the pen. So again, I think that helps with the comfort, as far as you're less worried about the milliliters there, and again, in terms of units. So that makes, I think the U-500 a little bit of a safer option, because you're getting the advantage and that it's concentrated, but, but I think the risk of our errors is somewhat mitigated. Dr. Khyati Patel 15:35 I mean, pens definitely have made the life easier. They became available about a couple years ago before we had to do some conversion using the BD needles from unit to milliliters to inject the U-500, and that led to a lot of dosing errors. So pens are unit based, and it's an easier conversion. Dr. Sean Kane 15:55 And I might as well mention here, you know regular insulin is very commonly used on the inpatient side, because that's the kind of insulin we use for IV therapy, whether it's for hyperkalemia, where you're giving an IV push, or if we need to give a patient a continuous infusion of insulin and titrate that every single hour, regular Insulin is the type of insulin we use for that. All of the other insulins that we've talked about and we'll talk about today, those are only for subcutaneous use. You never give those IV, whereas with regular insulin, you can give it IV or you can give it sub q, yep. Dr. Khyati Patel 16:26 And so fair use of regular insulin in the hospital side, but we don't get to just like NPH. Don't get to see whole lot of regular insulin being used on the outpatient side unless patient has insurance related issues. So what bolus insulins are more prevalently used are the rapid acting kind insulin. So overall, these rapid acting insulins are bolus insulins. However, they mimic the prandial release of insulin, close to the physiologic release, and the PK profile is designed so accordingly, so their onset of action is within 15 to 20 minutes, and total duration of action is three to five hours. So perfect, right? It starts working fast, and it kind of dies faster too, so patients don't have any delayed hypoglycemic reactions if they didn't eat enough meal or larger meal. Speaker 1 17:15 And so this is a, you know, this is a clear insulin. So that's another point we generally talk about, with the exception of an NPH. You look for, you look for the clarity of it to determine if there's any concern with with storage or beyond use, Dating can be mixed with NPH, again, noting that it's gonna look cloudy, something like, I think, a 50/50 mix, or a 75/25 no doctor tell I don't think I've ever seen a 50/50 mix, have you? Dr. Khyati Patel 17:37 Um, rarely. There was a few mixes out back in the day. But now we have the 75/25 as well as the 70/30 mixes available. Dr. Sean Kane 17:47 So in terms of the products that we have on the market, we have lispro, which is brand name, Humalog without any letters after it. So just Humalog, we have aspart, which is Novolog without an N or an R. And then we also have glulisine, brand name Apidra. So they didn't kind of go with the same log in terms of an insulin analog. But we have three main products on the market, and now we have a couple more as well, correct? Dr. Khyati Patel 18:10 So when we look at the lispro, you know, we talked about the U-200 concentrated lispro in the previous episode, but Admelog is one of the follow on product for the lispro, and that became recently available in the market. So again, just like Basaglar is a follow on for Lantus. Admelog is a follow on for the Humalog. We're not going to cover again the whole follow on and you know product and what category or what kind of FDA approval it goes through. If you're interested, we will refer you to Episode 56 that covered this type of follow on product, another product for lispro that's available. It's the junior version of the pen. It's called Humalog Jr. And the difference here is that the pen looks like a Sharpie. So if you have a type one patient who's young in school, they may carry it along, fashionably, looking like a marker, and it increases insulin in half unit increments, which most insulin pens do, one unit increment, because this is Junior and smaller doses are needed for your younger patients, the half unit increment can be more attractive. Speaker 1 19:17 I think some of the nomenclature becomes tricky, because it's essentially, I believe, a biosimilar, but because insulins are not considered biologic drugs, they really can't be called Bio equivalent here. And so I think that's something we discuss in Episode 56 Dr. Sean Kane 19:30 then, as I understand it, and I was actually unaware of this product before we started our episode, there's another new product on the market that is not a follow along, because it actually does have a different kinetic profile. And that's a new insulin as part on the market, correct? Dr. Khyati Patel 19:46 And so this is ultra rapid acting insulin category, and that's the fast acting aspart. So basically, they took the fast it faster insulin and then aspart, and then came up with this very innovative. A brand name called Fiasp. So it's basically fast insulin aspart. And if you compare its kinetic profile to your regular Novolog, which is your regular insulin aspart, the onset or peak action occurs within one 1.5 to about two hours. As compared to with Novolog, it's anywhere between one to three hours. Dr. Sean Kane 20:22 So on average, not that different. But if you look at the manufacturer website, it's a couple minutes earlier in terms of its onset Dr. Khyati Patel 20:29 correct, the duration of action is still the same. It's just that it starts acting sooner, and in order for it to be bioavailable or absorbed faster, they basically added a niacinamide molecule to improve the stability as well. Dr. Sean Kane 20:44 So that's basically all of the insulins that we have on the market. And probably by the time that this episode is published, we may even have other insulins on the market. And we really haven't even discussed something like a Freeza, the inhaled insulin, which is another kind of insulin on the market as well. If you want to learn more about that, we did discuss it in Episode 16. But again, this is a very complex topic for most healthcare providers. I think it's just important to know, you know, what are the differences in these different kinds of insulin, and when would you be using one or the other and things like that? Dr. Khyati Patel 21:12 And so inhale insulin is one way to deliver the insulin. Let's talk a little bit about the delivery options that we have available. So not only they're, you know, varying the strengths of the insulin, the how fast the pens do, the increments one unit versus half a unit. But then we have to talk about all the other delivery options as well. So the traditional delivery option is the vial syringe method. I know United States adhere to that archaic method for very long time was kind of late in adapting the pen technology. But something to keep in mind with the vial syringe type of delivery is that we prescribe the right size of syringe to complete the entire injection or dose at once and again. Various different types of sizes are available depending on the volume of insulin. Another size related thing to keep in mind is, you know, what are what? What is your patient's body habitat? Are they obese? They have a larger layer of subcutaneous tissue for them. Maybe consider a larger needle gauge size. Different gauge sizes are available as well. And just like any injection technique, you know, we have to teach the patient to inject equivalent amount of air in the vial in order to for them to easily draw the insulin into the syringe. And what Dr. Sean Kane 22:32 would happen if a patient didn't do that, where they did not inject the proper amount of air into the vial? Dr. Khyati Patel 22:38 I think the vial will fight them, you know, they will have a really hard time drawing that insulin into the syringe itself. Speaker 1 22:43 Student is trying to reconstitute pretty much anything. Knows that that positive and negative pressure can be a beast to tame. Dr. Sean Kane 22:49 I still remember when I was in the IV hood as a student, and I didn't do that, and it was during my practical where you get graded, and I'm fighting this darn syringe to get the proper volume out, and I couldn't do it because it kept popping back in and for sure, and I would assume that at some point patients will kind of figure that out, but that is a very important counseling point. Dr. Khyati Patel 23:07 Yep. So pens make our lives so much easier, right? Again, they need to be prescribed at pen needles. Again, needles are available with different length and gauge sizes as well, and with the nowadays, two main brand name manufacturers for the pen needles are available, but we have tons of generic ones too, and most pen needles fit most available insulin pen. So thank God we haven't gone to that proprietary level just yet. Yeah, because I Speaker 1 23:33 was actually just finding a new type of pen needle for a patient. Unfortunately, the report on the website, these are, like the 14 different kinds of pens, our insulin, our needles work on wonderful Let's go. Dr. Sean Kane 23:44 You know, I've seen a couple more patients at my institution on insulin pumps, more than I saw maybe five or 10 years ago. Is that something new in diabetes world in terms of having these pumps, or is it just kind of luck of the draw that I've kind of seen these patients? Dr. Khyati Patel 23:58 No, you must have seen those patients, because they are on a very continuous basal, bolus continuous delivery, especially type one patient, pump use is very common because the coverage of pump technology is pretty good. You have to consider insurance coverage at the end of the day. These are very expensive devices. Another common population, patient population that may use pump is gestational diabetes patients, or if you have a type two patients who's on a very rigorous basal and bolus insulin regimen, coverage is not as great as type one patients, but you can do prior authorizations in order to get the pump device approved. So the way the pump delivers insulin, it takes a short or rapid acting insulin and delivers it in a basal or bolus type of fashion. So again, only one type of insulin that goes into the pump, which is either basically your bolus insulin, so they're short or rapid acting but the way the pump delivers this insulin may deliver it in two different fashion, basal or bolus, and then something else to keep in mind, you know, there is a little canister that fits inside the pump that patient will have to still fill the insulin with. So they're going to use the vial, syringe method to withdraw the insulin from the vial, fill in this canister. It holds anywhere between two to three days of insulin, depending on, again, the patient's insulin needs. Another thing that patient have to take care of with the pump technology is changing the infusions that making sure that you know they're not getting at higher risk of infection, maintaining the hygiene this infusion status change every two to three days. So pumps are not very easy, even though you know they can help patients greatly and reduce the insulin doses as much as by 20% because it delivers insulin so efficiently. But at the same time, it takes a little bit of learning on the patient's part in order to learn this technology and titrations in the pump carefully. Pump technology has also constantly been upgraded to the newest type of pumps we have available are hybrid closed loop pumps. But the ultimate goal of these companies, who are working lot of R and D hours into advancing this technology, is to make a closed loop pump, which will basically be an artificial pancreas. So one day, we hope that we have that where patients don't have to do anything besides just snapping the pump on along with the continuous glucose monitor and the two devices on them will just do all the job that their pancreas would normally do. Dr. Sean Kane 26:32 So in terms of administration, you know, anything that you're injecting into the skin, even with the insulin pump, this is given as a subcutaneous injection. It's not an intramuscular injection, so the needle length isn't as long, and hopefully it's not as painful as an intramuscular injection, correct? Dr. Khyati Patel 26:47 When I'm teaching my patients, you know, the first dose they take in front of me in my clinic, and they're like, oh, this wasn't so bad, right? So again, once, once they actually do the injection in front of you, they remove all their fear and anxiety about that injection method. The subsequent injections become a little bit easier. The first thing I actually teach them is to avoid any scar tissues, because the absorption can be different in those areas. The major sites for subcutaneous injection is abdomen, thighs or back of the upper arm. I can imagine back of the upper arm being really hard to reach. So the most common ones used are abdomen and thigh. The navel region around the abdomen could be specifically very tender and full of nerve endings, so usually I advise two hinges around that area. Dr. Sean Kane 27:32 So speaking of navels, are you suggesting that you don't use an orange, for example, in terms of practicing that injection technique? Absolutely. Dr. Khyati Patel 27:41 There had been lot of documented cases where patients were taught how to inject insulin on oranges, and so they went home and they literally injected insulins into oranges, and then they ate the oranges. So my biggest fear is that a patient would do that, just like, you know, pouring amoxicillin in the ear to treat the ear infection. So first injection always make sure that they're following all the right steps and injecting in their own body. Dr. Sean Kane 28:10 And I think also, if you do it in front of them, where they have to do it themselves, I think that probably overcomes a lot of that needle phobia. Where not that you're pressuring them, but you're there to kind of support them, as opposed to their first injection, is at home, with no one around them to kind of help them, or even hold them accountable for that injection, right? Speaker 1 28:27 So there's always that, well, what if the what if x happens, we're right there to to go through it, as you said, A, C, and everything went well, and therefore we can reassure for the future. Dr. Khyati Patel 28:35 And these are subcutaneous injections, so patients don't have to, like, inject at a 45 degree or a 60 degree angle, it's just straight in 90 degrees perpendicular, and then straight out thereafter Dr. Sean Kane 28:46 and again. Just to mention one more time, IV administration is an option, but that's really with regular insulin, as opposed to any of the other insulin products. Dr. Khyati Patel 28:55 Another very important piece of advice or education for a patient is storage of the insulin. Every manufacturer has different requirements for storage, but in general, when the product is unopened, so whether it be vial or pen, if it's unopened, it can stay in the refrigerator until the expiration date on the carton or the container. But once the product is open and in use, it could be stored at room temperature up until certain days. So most ranges are anywhere between 14 days to as long as 56 days. Just have to follow the manufacturer's directions on that Dr. Sean Kane 29:30 and it doesn't improve the duration if you put it back in the fridge after opening it. So once it's open, it's open, you can't extend it by putting it back in that refrigerator. Correct. Dr. Khyati Patel 29:40 It's very important to teach patients how to store insulins properly, because if there is any breakage into this cold chain, we lose the active insulin, the degradation of insulin, which is a protein product so unstable temperatures, will definitely degrade it, and that will lead to variable blood glucose control. Or maybe not optimal blood glucose. Speaker 1 30:01 Yeah, we had a patient just a couple of weeks Who asked you to Dr. Patel that we had been dialoguing with you, my student had about and that's one of the things we realized. Part of the difficulty with controlling some of the variability was due to variability from the patient and his caregivers report about some of the storage requirements. So definitely something that I think we maybe forget about at times. We need to always be aware of Dr. Khyati Patel 30:21 another reason to emphasize the proper storage of insulin is this study, and that was really shocking study University of Missouri, Kansas professors did where they found out that usually FDA requirement for insulin products is 95% of the product when it goes to the patient should be actual insulin, active insulin. They collected different vials of insulin from various pharmacies and found that the amount of actual insulin in this vial varied very greatly, as low as 40% to as high as 80% but they were never to the FDA mark of 95% insulin. And I think that Dr. Sean Kane 31:02 really emphasizes what you mentioned about the cold chain, where, you know, you can start with 95 in the pharmacy, but then if the patient puts it in their car and leaves it in the car, and it's a hotter day, you know, you're probably knocking out some of the potency of that insulin on its own, let alone if that potency was lost in the pharmacy to begin with, right? Yeah. Dr. Khyati Patel 31:20 And if you think about it, how do these drugs come to pharmacy? They come from the second hand distributors or wholesalers. Where do the wholesalers get the products? Right? They get it from the manufacturer. So these products are shipped from one entity to another entity to all the way to the patient. It's really hard to deliver 95% of insulin, and that requires utmost storage conditions. Dr. Sean Kane 31:45 So I think that we've done a good job reviewing the different kinds of insulins, their kinetic profiles, how it's given and how it's stored. We're actually going to stop here for ending part one of this episode, for episode 86 and in Episode 87 we're going to pick back up and talk about how these insulins are dosed, how it's titrated, and get to this sliding scale concept that we use more on the inpatient side as well. Yeah. Dr. Khyati Patel 32:09 So not everything in this episode, not in one shot. Maybe we'll do two shots, but stay tuned for the second shot. Dr. Sean Kane 32:15 So with that, I just wanted to mention that currently our website is available, but we can't update it for the next month or two, so we have kind of a technical issue for that. So you won't be able to see the show notes until about November, where we'll kind of put all of the episodes up at one time. In the meantime, we love the five star reviews. We've just received a couple, and they're amazing. So keep those coming so that we can kind of climb the ranks in iTunes. We're also available at Twitter, at HelixTalk. So with that, I'm Dr Dr. Khyati Patel 32:42 King and I'm Dr. Patel, and as usual, study hard. Thank you. Narrator - Dr. Abel 32:47 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 32:58 to suggest an episode or contact us or online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.