1. Absolute lack of insulin
2. Rapid-acting insulin
   1. decrease post prandial hyperglycemia
   2. Fast onset and short DOA
      1. DOA 3-5hrs
      2. onset of <15mins
      3. peak 1-3 hrs
   3. Drugs
      1. insulin lispro (Humalog)
      2. insulin aspart (Novolog)
      3. Insulin Glulisine (Apidre)
   4. preferred in use for cont. SubQ insulin infusion devices
   5. can be "acutely" mixed NPH w/o effecting rapid abs.
3. Short Acting insulin
   1. Rapid onset
      1. 30min- 1hr
      2. pk- 2-3hrs
      3. DOA 5-8hrs
   2. Formulations
      1. SubQ
      2. IV
         1. only insulin used IV
            1. IV for diabetic ketoacidosis
   3. short acting zinc crystalline
   4. Drugs
      1. Regular Novolin R
      2. regular Humulin R
      3. Humulog
      4. Novolog
      5. injected 30-45min before meal
   5. the DOA/Onset/ pk increase with size of dose
      1. delayed abs, dose dependant DOA, and variability of abs.(~25%) --> makes dosing unpredictable
4. Intermediate Acting insulin
   1. dispensed as turbid susp. @ neutral pH w/ protamine and phosphate buffer
      1. NPH (neutral protamine Hagedorn)
   2. Onset 2-5hr
   3. DOA 4-12hrs
   4. Drugs
      1. Humulin N
      2. Novolin N
      3. Isophane insulin suspension
         1. uncomplex insulin +protamine
5. Long Acting insulin
   1. Slow onset of action
   2. Drugs
      1. Insulin Detemir (Levemir)
         1. DOA 24+ hrs
      2. insulin Glargine (Lantus)
         1. no pk
         2. onset 1-1.5hrs
         3. max effect after 4-6hr
         4. max activity 11-24+ hrs
         5. Dont mix w/ other insulin
6. Premixed
   1. Novolin 70 NPH/ 30 regular
   2. Humulin 70 NPH / 30 Regular
   3. 50/50 NPL, Lispro
   4. 75/25 NPL, Lispro
   5. 70/30 NPA, Aspart
   6. Short acting& intermediate acting
   7. More stable mixture than the rapid acting mixtures
      1. Isophane complexes
7. Major Concerns
   1. allergic rxns w/ NPH and protamine zinc insulin
   2. Prompt insulin (lente) not compatible w/ NPH or protamine zinc insulin
8. Goals of therapy
   1. replace the background or basal overnight, fasting, b/t meal as well as bolus or prandial insulin
   2. replicate normal physiologic insulin secretion
9. Insulin TX of special circumstances
   1. Diabetic ketoacidosis
      1. fat being broken down to ketones
      2. fruity breath
      3. SX
         1. n/v
         2. abdominal pain
         3. deap slow breathing
         4. change in mental state/status
         5. elevated blood/ urinary ketones/ glucose
         6. arterial blood pH > 7.3
         7. low Bicarbonate <15mmol/L
      4. TX
         1. IV hydration
         2. insulin therapy
         3. maintenance of K & other electrolytes
10. Emergency TX
    1. Glucagon
       1. used severe hypoglycemia
11. Insulin- medicinal
    1. 86 AA
    2. 2 polypeptide chains linked by 2 disulfide bonds
       1. Chain A most conservative in activity
    3. half life 4min
       1. proinsulin half life 30 min
    4. inhibit insulin release
       1. Alpha agonist
    5. stimulate insulin release
       1. beta agonist
       2. cholinergics
    6. effects
       1. metabolism of
          1. carbs
          2. lipids
          3. protein
       2. tissues
          1. liver
             1. increase glucose uptake
             2. increase gluokinase
             3. increase glycogen synthesis, glycolysis, acetyl CoA production
             4. decrease glycogen break down
             5. increase fatty acid synthesis
          2. adipose
             1. increase triglyceride synthesis
          3. muscle
             1. increase glucose uptake
             2. increase glucose transporter
             3. increase glycogen synthesis, glycolysis, acetyl CoA production
             4. decrease glycogen break down
          4. brain is non responsive
    7. admin
       1. formulations
          1. SubQ
          2. IV
          3. IM
          4. Inhalation
             1. exubera
       2. injection
          1. stomach>arm>thigh>butt rate of abs
    8. SE
       1. hypoglycemia
       2. cough, sore throat, dry mouth
          1. Inhalation form
12. Dispensed as clear solutions at neutral pH +zinc (increase stability & self life)