insulin, human inhalation

ROUTE	ONSET	PEAK	DURATION
Inhaln	within 30 min	30–60 min	160 min

Contraindicated in:

Hypersensitivity to regular insulin or any other components of the formulation;
Hypoglycemia;
Smokers or those who have recently stopped smoking;
Lung disease, including asthma, COPD, and active lung cancer;
Lactation: Lactation.

Use Cautiously in:

Stress and infection (may temporarily ↑ insulin requirements);
Renal impairment (may ↓ insulin requirements);
Hepatic impairment (may ↓ insulin requirements);
OB: Pregnancy may temporarily insulin requirements; should not be used during pregnancy unless potential benefit justifies potential risk to the fetus;
Pedi: Safety and effectiveness not established in children;
Geri: Appears on Beers list. risk of hypoglycemia in older adults. Avoid use of regimens containing only short- or rapid-acting insulin without concurrent use of basal or long-acting insulin.

Adv. Reactions/Side Effects ⬆ ⬇

Endo: HYPOGLYCEMIA

F and E: hypokalemia

GI: diarrhea, nausea

Metab: weight gain

Neuro: fatigue

Resp: cough, BRONCHOSPASM, ↓lung function, throat pain/irritation

Misc: HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS)

Interactions ⬆ ⬇

Drug-drug:

Concurrent use of other antidiabetics, ACE inhibitors, angiotensin II receptor blockers, disopyramide, fibrates, fluoxetine, MAO inhibitors, pentoxifylline, pramlintide, salicylates, somastatin analogs including octreotide, and sulfonamide anti-infectives↑ risk of hypoglycemia, dose modifications may be necessary.
Glucose lowering effects may be ↓ by atypical antipsychotics including clozapine, and olanzapine, corticosteroids, danazol, diuretics, estrogens, glucagon, isonazid, niacin, oral (hormonal contraceptives), phenothiazines, progestins (in hormonal contraceptives), protease inhibitors, somatropin, sympathomimetic agents including albuterol, epinephrine and terbutaline and thyroid hormones.
Concurrent use of anti-adrenergics including beta-blockers, clonidine may ↓ signs any symptoms of hypoglycemia.
Concomitant use with pioglitazone may ↑ risk of fluid retention and worsening HF.
Concurrent use of inhaled albuterol may ↑ absorption.

Drug-Natural Products:

Glucosamine may worsen blood glucose control.
Fenugreek, chromium, and coenzyme Q-10 may produce additive hypoglycemic effects.

Route/Dosage ⬆ ⬇

Inhaln
(Adults ): 4 or 8 units inhaled at the beginning of a meal; dose depends on a variety of patient factors.

Availability ⬆ ⬇

Powder for inhalation: 4 units/cartridge; 8 units/cartridge; 12 units/cartridge

Assessment ⬆ ⬇

Before starting therapy perform a detailed medical history, physical examination, and spirometry (FEV₁) to determine potential lung disease. Assess pulmonary function via spirometry at baseline, after 6 mo and annually thereafter; more frequently if patient has pulmonary symptoms such as wheezing, bronchospasm, breathing difficulties, or persistent, recurring cough. May require discontinuation of inhalation therapy.
Assess patient periodically for symptoms of hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait) and hyperglycemia (confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; unusual thirst) during therapy.
Monitor for bronchospasm. Occurs rarely, but if bronchospasm occurs, discontinue therapy and notify health care professional immediately. Readministration should be attempted during close monitoring.
Assess for respiratory illness. Monitor blood glucose concentrations closely; may require dose adjustments.
Monitor body weight periodically. May cause weight gain. Changes in weight may necessitate changes in insulin dose.

Lab Test Considerations:

Monitor blood glucose every 6 hr during therapy, more frequently in ketoacidosis and times of stress. A1C may be monitored every 3–6 mo to determine effectiveness.
- Monitor serum potassium in patients at risk for hypokalemia (those using potassium-lowering agents, those receiving IV insulin) periodically during therapy.

Toxicity and Overdose:

Overdose is manifested by symptoms of hypoglycemia. Mild hypoglycemia may be treated by ingestion of oral glucose. Severe hypoglycemia is a life-threatening emergency; treatment consists of IV glucose, glucagon, or epinephrine.

Implementation ⬆ ⬇

Inhalation insulin must be used in combination with long-acting SUBQ insulin.
- Afrezza should only be used with Afrezza inhaler.
Inhaln: Administer at beginning of meal. Keep inhaler level; white mouthpiece on top and purple base on the bottom after inserting cartridge. Loss of drug effect occurs if inhaler is upside down, held with mouthpiece pointing down, shaken, or dropped after cartridge is inserted but before dose given. If these occur, replace cartridge before use.
- Dosing: Insulin naive patients: Start with 4 units before each meal. Patients using SUBQ mealtime (prandial) Insulin: Determine appropriate dose for each meal by converting from injected dose using dose conversion. Patients using SUBQ premixed insulin: Estimate mealtime injected dose by dividing half total daily injected premixed insulin dose equally among three meals. Convert each estimated injected mealtime dose to appropriate inhalation dose using dose conversion. Administer half of total daily injected premixed dose as an injected basal insulin dose.
- Dose conversion: If injected mealtime insulin dose is up to 4 units: Administer one 4-unit inhalation dose. If injected mealtime insulin dose is 5–8 units: Administer one 8-unit inhalation dose. If injected mealtime insulin dose is 9–12 units: Administer one 12-unit inhalation dose. If injected mealtime insulin dose is 13–16 units: Administer one 4-unit inhalation dose and one 12-unit inhalation dose (16 units). If injected mealtime insulin dose is 17–20 units: Administer one 8-unit inhalation dose and one 12-unit inhalation doses (20 units). If injected mealtime insulin dose is 21–24 units: Administer two 12-unit inhalation doses (24 units).
- Adjust dose based on metabolic needs, blood glucose–monitoring results, and glycemic control goal. Dose may need to be adjusted with changes in physical activity, meal patterns, renal and hepatic function, or during acute illness.
- Monitor blood glucose carefully in patients receiving high doses of inhalation insulin. If blood glucose control is not achieved with increased inhalation doses, consider use of SUBQ mealtime insulin.

Patient/Family Teaching ⬆ ⬇

Instruct patient on proper technique for administration. Advise patient to read Medication Guide before starting therapy and with each Rx refill in case of changes.
Advise patient to notify health care professional immediately of signs and symptoms of allergic reaction (rash, trouble breathing, fast heartbeat, sweating) occur.
Explain to patient that this medication controls hyperglycemia but does not cure diabetes. Therapy is long term.
Instruct patient in proper testing of serum glucose and ketones. Monitor closely during periods of stress or illness and health care professional notified of significant changes.
May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
Caution patient to avoid smoking while taking inhaled insulin.
Emphasize the importance of compliance with nutritional guidelines and regular exercise as directed by health care professional.
Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other Rx, OTC, or herbal products, especially inhaled medications.
Advise patient to notify health care professional of medication regimen prior to treatment or surgery.
Advise patient to notify health care professional if nausea, vomiting, or fever develops; if unable to eat regular diet; or if blood glucose levels are not controlled.
Instruct patient on signs and symptoms of hypoglycemia and hyperglycemia and what to do if they occur.
Rep: Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding.
Patients with diabetes mellitus should carry a source of sugar (candy, glucose gel) and identification describing their disease and treatment regimen at all times.
Emphasize the importance of regular follow-up, especially during first few wk of therapy.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇