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Transcript of INSULINA
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MEDICATIA MEDICATIA ANTIDIABETICANTIDIABETIC
AADZ = boala metabolica cr. – DZ = boala metabolica cr. –
tulburarea majora estetulburarea majora este hiperglicemia hiperglicemia care are la baza care are la baza
deficitul absolut /relativ de deficitul absolut /relativ de InsulinaInsulina
Prof. Dr. Rodica Prof. Dr. Rodica CincaCinca
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!!! !!! PericolPericol
DZ – complicatii severe:DZ – complicatii severe: afectarea vaselor mici (capilare)afectarea vaselor mici (capilare)
- encefal – AVC- encefal – AVC
- retina – retinopatie diabetica- retina – retinopatie diabetica
- gl. ren. – nefropatie diabetica- gl. ren. – nefropatie diabetica
afectarea vaselor mari afectarea vaselor mari
- inima – IMA- inima – IMA
- m. inf. – arteriopatie diabetica- m. inf. – arteriopatie diabetica
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DZ tip I InsulinodependentDZ tip I InsulinodependentDebutDebut =>=> 40 ani40 ani
DZ tip II DZ tip II NoninsulinodependentNoninsulinodependent
DebutDebut 4040 aniani =>=>
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INSULINAINSULINA
Hormon sintetizat de celulele din pancreas
M utilizat in DZ tip I
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ACTIUNE FARMACODINAMICAACTIUNE FARMACODINAMICA::Efectele biologice ale InsulineiEfectele biologice ale Insulinei
a. metabolism a. metabolism GLUCIDICGLUCIDIC::
↓ ↓ glicemia: glicemia: - ↓ GLICOGENOLIZA- ↓ GLICOGENOLIZA
- ↓ GLICONEOGENEZA- ↓ GLICONEOGENEZA
- ↑ GLICOGENOGENEZA- ↑ GLICOGENOGENEZA
- ↑ TRANSPORTUL - ↑ TRANSPORTUL TRANSMEMBRANAR DE GTRANSMEMBRANAR DE G
b. metabolism b. metabolism LIPIDICLIPIDIC: : - ↓ LIPOLIZA- ↓ LIPOLIZA
- ↑ SINTEZA AGL- ↑ SINTEZA AGL
- ↑ SINTEZA TG- ↑ SINTEZA TG
- ↑ CONSUMUL CC (MUSCULAR)- ↑ CONSUMUL CC (MUSCULAR)
c. metabolism c. metabolism PROTEICPROTEIC: :
- - ↑ ANABOLISMUL PROTEIC HEPATIC SI ↑ ANABOLISMUL PROTEIC HEPATIC SI MUSCULARMUSCULAR
- ↓ CATABOLISMUL PROTEIC (↓ UREEA)- ↓ CATABOLISMUL PROTEIC (↓ UREEA)
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UTILIZARI TERAPEUTICE:UTILIZARI TERAPEUTICE:
DZ tip IDZ tip I (tratament de substitutie) (tratament de substitutie) TOATA TOATA VIATAVIATA::
- mentine glicemia la valori N (120-150mg- mentine glicemia la valori N (120-150mg%);%);
- scad simptomele secundare hiperglicemiei;- scad simptomele secundare hiperglicemiei;
- evita complicatiile cr.- evita complicatiile cr.
DZ complicatDZ complicat cu neuropatie, retinopatie, cu neuropatie, retinopatie, nefropatie.nefropatie.
DZ la gravideDZ la gravide
DZ recent depistatDZ recent depistat
DZ tip II in suprasolicitare metabolicaDZ tip II in suprasolicitare metabolica
(interventii CH, infectii (interventii CH, infectii grave)grave)
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EFECTE ADVERSE:EFECTE ADVERSE:
a.a. HIPOGLICEMIA HIPOGLICEMIA (EA frecvent intalnit): (EA frecvent intalnit): transpiratii, paloare, foame, anxietate, transpiratii, paloare, foame, anxietate, tremortremor
b.b. ALERGIA LA INSULINAALERGIA LA INSULINA – EA rar; – EA rar;
c.c. LIPODISTROFIALIPODISTROFIA dupa administrarea I dupa administrarea I in acelasi loc mult timpin acelasi loc mult timp
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TIPURI DE INSULINATIPURI DE INSULINA
I. ORIGINEI. ORIGINE
a. a. I. ANIMALAI. ANIMALA: porc si bovine: porc si bovine
b. b. I. MONOCOMPONENTAI. MONOCOMPONENTA (MC)(MC): I : I animale cu purificare cromatograficaanimale cu purificare cromatografica
c. c. I. UMANAI. UMANA (HM)(HM) obtinuta prin inginerie obtinuta prin inginerie genetica cu toleranta superioara, fara genetica cu toleranta superioara, fara impuritatiimpuritati
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II. DUPA INSTALAREA SI DURATA II. DUPA INSTALAREA SI DURATA EFECTULUI HIPOGLICEMIANTEFECTULUI HIPOGLICEMIANT
a. I. cu a. I. cu ACTIUNE RAPIDAACTIUNE RAPIDA, de , de SCURTA SCURTA DURATADURATA
!!!!!! s.c..; debut 30’; durata 6-8 ore; s.c..; debut 30’; durata 6-8 ore;
ACTRAPID; HUMULIN RACTRAPID; HUMULIN R
b. I. cu b. I. cu ACTIUNE INTERMEDIARAACTIUNE INTERMEDIARA
!!!!!! s.c.; debut 1 – 2 ore; durata 12 – 16 s.c.; debut 1 – 2 ore; durata 12 – 16 oreore
INSULINA NOVO SEMILENTA; INSULINA NOVO SEMILENTA;
HUMULIN NHUMULIN N
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REGULI DE REGULI DE
ADMINISTRARE:ADMINISTRARE:
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A. CALEA DE INJECTAREA. CALEA DE INJECTARE
a) a) s.c.s.c. profund in regiunea : - profund in regiunea : - deltoidianadeltoidiana
- coapse- coapse
- peretele - peretele abdominalabdominal
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- cu siringa gradata (clasic)- cu siringa gradata (clasic)
- cu stiloul injector portabil- cu stiloul injector portabil
- cu cateter subcutanat (modern, - cu cateter subcutanat (modern, pompe de pompe de
insulina)insulina)
b) b) i.v.i.v. in coma ceto-acidoza in coma ceto-acidoza
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B. MODUL DE ADMINISTRAREB. MODUL DE ADMINISTRARE
I. TRATAMENTUL CLASICI. TRATAMENTUL CLASIC
a) a) 3 doze /24 h3 doze /24 h
- dimineata (D1) – - dimineata (D1) – cea mai marecea mai mare
- pranz (D2) – mai mica decat D1- pranz (D2) – mai mica decat D1
- seara – comparabila cu D1- seara – comparabila cu D1
b) b) 2 doze/24 h2 doze/24 h
- dimineata – - dimineata – 2/3 din D/242/3 din D/24
- seara 1/3 din D/24- seara 1/3 din D/24
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II. TRATAMENTUL INTENSIFICATII. TRATAMENTUL INTENSIFICAT
(FIZIOLOGIC)(FIZIOLOGIC)• Individualizarea necesarului de I in Individualizarea necesarului de I in
functie de valorile glicemiei si/sau functie de valorile glicemiei si/sau glicozurieiglicozuriei
• FOARTE EFICIENTFOARTE EFICIENT !!! !!!• Dezavantaje: Dezavantaje: - frecventa ↑ a - frecventa ↑ a
hipoglicemiilorhipoglicemiilor
- tendinta de ↑ in - tendinta de ↑ in greutategreutate
- cost ↑ - cost ↑
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ANTIDIABETICE ANTIDIABETICE ORALEORALE
in DZ tip II normo/supraponderali
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A.A. SULFAMIDE HIPOGLICEMIANTESULFAMIDE HIPOGLICEMIANTE
Generatia I - TOLBUTAMID
Generatia II - GLIBENCLAMID
- GLICLAZID
- GLIPIZID
AFD:
HIPOGLICEMIANTA
- intrapancreatice → stimuleaza secretia de I
- extrapancreatice → ↓ productia de G
↑ utilizarea G
UT: DZ tip II normoponderali
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B. BIGUANIDELEBIGUANIDELE
METFORMIN
AFD:
HIPOGLICEMIANTA pentru ca:
- ↓ absorbtia intestinala de G si AA
- ↓ productia hepatica de G
- ↓ TGL
UT: DZ tip II cu obezitate care nu raspunde
favorabil la regim alimentar
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CONDUITA PRACTICĂ ÎN DZ TIP II
Regim hipoglucidic + hipocaloric ESEC
In cazul
G. normale obezitatii SULFAMIDE SULFAMIDE BIGUIANIDE BIGUIANIDEHIPOGLICEMIANTEHIPOGLICEMIANTE
ESEC ESEC
INSULINOTERAPIEINSULINOTERAPIE
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GLUCOCORTICOIZIIGLUCOCORTICOIZII
Hormoni steroidieni sintetizati din colesterol.Hormoni steroidieni sintetizati din colesterol.
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ACTIUNE FARMACODINAMICA:ACTIUNE FARMACODINAMICA:
1.1. Actiune Actiune ANTIINFLAMATOARE ANTIINFLAMATOARE ↑↑↑↑↑↑
– – ↓↓ vasodilatatia + edemul (vasodilatatia + edemul (↓ His, Bdk).↓ His, Bdk).
Acidul arahidonic, Pg, LT au rol important in Acidul arahidonic, Pg, LT au rol important in reactiile inflamatoriireactiile inflamatorii
FOSFOLIPAZA A2FOSFOLIPAZA A2 AC.ARAHIDONICAC.ARAHIDONIC
GCGC CICLOOXIGENAZACICLOOXIGENAZA PG; LTPG; LT
REACTIAREACTIA
INFLAMATOAREINFLAMATOARE
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2.2. Actiune Actiune ANTIALERGICAANTIALERGICA
3.3. Actiune Actiune IMUNOSUPRESOAREIMUNOSUPRESOARE
– – blocheaza productia de Ilk1 (Mf), de Ilk2 (Lc) blocheaza productia de Ilk1 (Mf), de Ilk2 (Lc) si de Ifn (Lc T activate)si de Ifn (Lc T activate)
4.4. Efectele Efectele METABOLICEMETABOLICE ale GC ale GC
a. a. ↑↑ GLICEMIA GLICEMIA: :
- ↓ captarea glucozei- ↓ captarea glucozei
- ↑ gluconeogeneza si glucogenogeneza - ↑ gluconeogeneza si glucogenogeneza hepaticcahepaticca
b. b. ↑↑ AGL AGL: - ↑ lipoliza: - ↑ lipoliza
c. c. INHIBA SINTEZA PROTEICAINHIBA SINTEZA PROTEICA
d. d. ↑↑ RETENTIA DE Na RETENTIA DE Na++ SI H SI H22OO
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ICS ICS ac.,cr.ac.,cr.
(tt de substitutie)(tt de substitutie)
COLAGENOZECOLAGENOZE PCE, LEDPCE, LED
INF. POSTSTREPT.INF. POSTSTREPT. (in asociere cu PG), RAA; GNA(in asociere cu PG), RAA; GNA
R. ALERGICER. ALERGICE soc anafilacticsoc anafilactic
edem angioneuroticedem angioneurotic
LEUCEMII AC.; LEUCEMII AC.; LIMFOAME MG.; LIMFOAME MG.; ANEMII HEMOL.ANEMII HEMOL.
AB AB PERSISTENTPERSISTENT
ENCEFALITE, ENCEFALITE, MIELITE, MIELITE,
POLIRADICULONEVRITE POLIRADICULONEVRITE POSTINF.POSTINF.
UTILIZARI TERAPEUTICEUTILIZARI TERAPEUTICE
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EFECTE ADVERSE:EFECTE ADVERSE:
GRAVEGRAVE – sunt considerate “ – sunt considerate “arme cu doua taisuriarme cu doua taisuri””
a.a. PRECOCEPRECOCE tulburari DIGESTIVE – hiperaciditate tulburari DIGESTIVE – hiperaciditate
(epigastralgii, pirozis etc.);(epigastralgii, pirozis etc.); tulburari NEUROPSIHICE (pe teren tulburari NEUROPSIHICE (pe teren
predispus): euforie, depresie, confuzie;predispus): euforie, depresie, confuzie; ““RISC INFECTIOS”RISC INFECTIOS”
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b. b. TARDIVETARDIVE:: OBEZITATE de tip “cushingoid”OBEZITATE de tip “cushingoid” TULBURARI OSOASE: osteoporoza; tasari; TULBURARI OSOASE: osteoporoza; tasari;
fracturi;fracturi; HTA (secundare retentiei hidrosaline);HTA (secundare retentiei hidrosaline); HIPERGLICEMIE;HIPERGLICEMIE; TULBURARI SEXUALE.TULBURARI SEXUALE.
c. c. TULBURARI DE SEVRAJTULBURARI DE SEVRAJ:: ASTENIE, DEPENDENTA PSIHICA;ASTENIE, DEPENDENTA PSIHICA; ““REBOUND”REBOUND”
!!! !!! NU oprirea brusca a GC NU oprirea brusca a GC !!!!!!
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PRINCIPII DE ADMINISTRAREPRINCIPII DE ADMINISTRARE GC se administreaza doar in afectiuni a caror GC se administreaza doar in afectiuni a caror
gravitate justifica riscul terapeutic;gravitate justifica riscul terapeutic; GC se administreaza numai dupa o schema GC se administreaza numai dupa o schema
optima (doza de atac apoi doza se reduce cu 1 optima (doza de atac apoi doza se reduce cu 1 mg la 2 – 3 saptamani)mg la 2 – 3 saptamani)
DADA
Administrarea pe “Administrarea pe “palierepaliere”” dieta normocalorica, dieta normocalorica, hiposodatahiposodata, , hipoglucidicahipoglucidica, ,
hiperproteicahiperproteica
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D.C.I.D.C.I. DENUMIRIDENUMIRI PREZ.PREZ. ADM.ADM.CORTIZONCORTIZON CORTIZON ACETATCORTIZON ACETAT f.25mg/1 mlf.25mg/1 ml i.m. 10-800 mgi.m. 10-800 mg
HIDROCORTIZONHIDROCORTIZON HHCHHC
HIDROCORTIZON HIDROCORTIZON ACETATACETAT
RAPICORTRAPICORT
f.25mg/5mlf.25mg/5ml
f.25 mg/1mlf.25 mg/1ml
fl. 100 mgfl. 100 mg
i.v.100-200mg o datai.v.100-200mg o data
PREDNISONPREDNISON PREDNISONPREDNISON cp.1 mg/5 mgcp.1 mg/5 mg oral 10-70 mg/zioral 10-70 mg/zi
PREDNISOLONPREDNISOLON SUPERCORTIZOLSUPERCORTIZOL cp. 5 mgcp. 5 mg
f. 25 mg/1 mlf. 25 mg/1 ml
oral 30-50 mg/zioral 30-50 mg/zi
i.v. 1-3 g/zii.v. 1-3 g/zi
TRIAMCINOLONTRIAMCINOLON VOLON A 10;VOLON A 10;
VOLON A 40;VOLON A 40;
BERLICORTBERLICORT
f.10 mg/mlf.10 mg/ml
f. 40mg/mlf. 40mg/ml
cp.4 mgcp.4 mg
i.m. 20-40 mg/zii.m. 20-40 mg/zi
o data la 2-4 sapt.o data la 2-4 sapt.
i.m. 2-40 mg/zii.m. 2-40 mg/zi
BETAMETASONABETAMETASONA DIPROPHOSDIPROPHOS cp. 0,5 mgcp. 0,5 mg
f. 4mg/mlf. 4mg/ml
i.m. 2 -4 mgi.m. 2 -4 mg
DEXAMETASONADEXAMETASONA SUPERPREDNOLSUPERPREDNOL cp 0,5 mgcp 0,5 mg oral 0,5 – 10 mg/zioral 0,5 – 10 mg/zi
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Un ilustru carturar spunea ca:Un ilustru carturar spunea ca:
Geniul uman a dat multiple capodopere ca Geniul uman a dat multiple capodopere ca Odiseea, Divina Comedie, Don Quijote, Faust, Odiseea, Divina Comedie, Don Quijote, Faust, despre care lumea vorbeste, dar putini le despre care lumea vorbeste, dar putini le citesc.citesc.
Medicina moderna - Farmacologia ofera mii de Medicina moderna - Farmacologia ofera mii de pagini despre utilizarea rationala a pagini despre utilizarea rationala a medicamentelor. Numai ca daca in literatura medicamentelor. Numai ca daca in literatura lectura este o problema de gust, in medicina ea lectura este o problema de gust, in medicina ea este o problema deeste o problema de VIATAVIATA..