O slideshow foi denunciado.
Utilizamos seu perfil e dados de atividades no LinkedIn para personalizar e exibir anúncios mais relevantes. Altere suas preferências de anúncios quando desejar.

Insulinoterapia, Nuevos Retos - Dra. Jenny Cepeda

1.475 visualizações

Publicada em

Exposición sobre "Insulinoterapia y Nuevos Retos" a cargo de la Dra. Deysi Hernandez, en la 1 era. Jornada de Residentes INDEN "Avanzando hacia el futuro". El evento se realizó el 21 de marzo del 2015 en instalaciones de la UNIBE.
Para ver la exposición ir a: https://www.youtube.com/watch?v=p7NC4qZLpa4

Más información en: www.inden.do

Publicada em: Saúde e medicina
  • You might get some help from ⇒ www.HelpWriting.net ⇐ Success and best regards!
       Responder 
    Tem certeza que deseja  Sim  Não
    Insira sua mensagem aqui
  • Transcript for THEIRNAME, Your transcript is expiring! (accept here) ☞☞☞ https://t.cn/A6wnCpvk
       Responder 
    Tem certeza que deseja  Sim  Não
    Insira sua mensagem aqui
  • Diabetes Has Been Cured. You'll Be Shocked What It Is! Gov't Threatens to Shut Down Site. ➤➤ https://bit.ly/2swQ6OO
       Responder 
    Tem certeza que deseja  Sim  Não
    Insira sua mensagem aqui
  • Has the "Cure" for Diabetes Been Kept from You?  http://ishbv.com/matt1a/pdf
       Responder 
    Tem certeza que deseja  Sim  Não
    Insira sua mensagem aqui
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (Unlimited) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Responder 
    Tem certeza que deseja  Sim  Não
    Insira sua mensagem aqui

Insulinoterapia, Nuevos Retos - Dra. Jenny Cepeda

  1. 1. {
  2. 2. Banting, Best, Collip y MacLeod 1921 Islotina Mc-Collip Leonard Thompson 11 enero 1922 1936 Hagedorn 1946 NPH Scott y Fisher zinc
  3. 3. Entrada glucosa Inhibe producción hepática glucosa Inhibe lipólisis, proteólisis Promueve síntesis proteica Conversión del exceso glucosa a grasa
  4. 4. Insulinas porcinas y bovinas Insulina humana Análogos de insulina Insulina inhalada
  5. 5. RAZON?
  6. 6. Insulinas Prandiales Basales Precombinadas
  7. 7. Insulina rápida humana Velocidad de absorción baja Inicia 15 a 60 mins tras inyección Pico 2 a 4 horas. Acción máx.: 5-8 hrs
  8. 8. I. Prandiales: Lispro L p Inicia 15 mins EM: 60-90 mins Actua 4-5 hrs Flexible
  9. 9. I. Prandiales: Aspart A
  10. 10. Glulisina L G
  11. 11. INSULINA INHALADA: 1. Insulina de acción rápida 2. No pctes con asma, broncoespasmos, EPOC o cualquier otra enfermedad pulmonar crónica •No en CAD
  12. 12. Insulinas basales: NPH Inicia 2.5- 3 hrs Pico 5-7 hrs Duración 13-16 hrs Reducción basal
  13. 13. I. Basales: Detemir
  14. 14. I. Basales: Glargina A A G
  15. 15. • Degludec • U300 glargina (Toujeo) • Peglispro INSULINAS MODERNAS http://www.medscape.com/viewarticle/
  16. 16. Insulinas precombinadas NPL 75/25 NPA 70/30 Insulina 70/30 Problemas autocombinación Ancianos Trastorno motricidad fina y/o visuales No fácil ajuste Inadecuadas DM 1
  17. 17. Objetivos de insulinoterapia Prevenir y retrasar complicaciones micro y macrovasculares Evitar CAD Detener catabolia y recuperar masa magra Reducir infecciones frecuentes Reducir morbimortalidad materno- fetal
  18. 18. ADA-EASD Position Statement Update: Management of Hyperglycemia in T2DM, 2015 larga (Detemir) Ultra-rápida (Lispro, Aspártica, Glulisina) Hours Larga (Glargina) 0 2 4 6 8 10 12 14 16 18 20 22 24 Rápida (Regular) Horas después injección Niveldeinsulina (Degludec) TERAPIA ANTI-HIPERGLICEMICA NPH
  19. 19. Healthy eating, weight control, increased physical activity & diabetes education Metformin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): Metformin + Metformin + Metformin + Metformin + Metformin + high low risk gain edema, HF, fxs low Thiazolidine- dione intermediate low risk neutral rare high DPP-4 inhibitor highest high risk gain hypoglycemia variable Insulin (basal) Metformin + Metformin + Metformin + Metformin + Metformin + Basal Insulin + Sulfonylurea + TZD DPP-4-i GLP-1-RA Insulin§ or or or or Thiazolidine- dione + SU DPP-4-i GLP-1-RA Insulin§ TZD DPP-4-ior or or GLP-1-RA high low risk loss GI high GLP-1 receptor agonist Sulfonylurea high moderate risk gain hypoglycemia low SGLT2 inhibitor intermediate low risk loss GU, dehydration high SU TZD Insulin§ GLP-1 receptor agonist + SGLT-2 Inhibitor + SU TZD Insulin§ Metformin + Metformin + or or or or SGLT2-i or or or SGLT2-i Mono- therapy Efficacy* Hypo risk Weight Side effects Costs Dual therapy† Efficacy* Hypo risk Weight Side effects Costs Triple therapy or or DPP-4 Inhibitor + SU TZD Insulin§ SGLT2-i or or or SGLT2-i or DPP-4-i If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i: Metformin + Combination injectable therapy‡ GLP-1-RAMealtime Insulin Insulin (basal) + Terapia antihiperglicémica: recomendaciones generales Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
  20. 20. Healthy eating, weight control, increased physical activity & diabetes education Metformin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): Metformin + Metformin + Metformin + Metformin + Metformin + high low risk gain edema, HF, fxs low Thiazolidine- dione intermediate low risk neutral rare high DPP-4 inhibitor highest high risk gain hypoglycemia variable Insulin (basal) Metformin + Metformin + Metformin + Metformin + Metformin + Basal Insulin + Sulfonylurea + TZD DPP-4-i GLP-1-RA Insulin§ or or or or Thiazolidine- dione + SU DPP-4-i GLP-1-RA Insulin§ TZD DPP-4-ior or or GLP-1-RA high low risk loss GI high GLP-1 receptor agonist Sulfonylurea high moderate risk gain hypoglycemia low SGLT2 inhibitor intermediate low risk loss GU, dehydration high SU TZD Insulin§ GLP-1 receptor agonist + SGLT-2 Inhibitor + SU TZD Insulin§ Metformin + Metformin + or or or or SGLT2-i or or or SGLT2-i Mono- therapy Efficacy* Hypo risk Weight Side effects Costs Dual therapy† Efficacy* Hypo risk Weight Side effects Costs Triple therapy or or DPP-4 Inhibitor + SU TZD Insulin§ SGLT2-i or or or SGLT2-i or DPP-4-i If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i: Metformin + Combination injectable therapy‡ GLP-1-RAMealtime Insulin Insulin (basal) + Terapia antihiperglicémica: Recomendaciones generales Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
  21. 21. Healthy eating, weight control, increased physical activity & diabetes education Metformin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): Metformin + Metformin + Metformin + Metformin + Metformin + high low risk gain edema, HF, fxs low Thiazolidine- dione intermediate low risk neutral rare high DPP-4 inhibitor highest high risk gain hypoglycemia variable Insulin (basal) Metformin + Metformin + Metformin + Metformin + Metformin + Basal Insulin + Sulfonylurea + TZD DPP-4-i GLP-1-RA Insulin§ or or or or Thiazolidine- dione + SU DPP-4-i GLP-1-RA Insulin§ TZD DPP-4-ior or or GLP-1-RA high low risk loss GI high GLP-1 receptor agonist Sulfonylurea high moderate risk gain hypoglycemia low SGLT2 inhibitor intermediate low risk loss GU, dehydration high SU TZD Insulin§ GLP-1 receptor agonist + SGLT-2 Inhibitor + SU TZD Insulin§ Metformin + Metformin + or or or or SGLT2-i or or or SGLT2-i Mono- therapy Efficacy* Hypo risk Weight Side effects Costs Dual therapy† Efficacy* Hypo risk Weight Side effects Costs Triple therapy or or DPP-4 Inhibitor + SU TZD Insulin§ SGLT2-i or or or SGLT2-i or DPP-4-i If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i: Metformin + Combination injectable therapy‡ GLP-1-RAMealtime Insulin Insulin (basal) + Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
  22. 22. Healthy eating, weight control, increased physical activity & diabetes education Metformin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): Metformin + Metformin + Metformin + Metformin + Metformin + high low risk gain edema, HF, fxs low Thiazolidine- dione intermediate low risk neutral rare high DPP-4 inhibitor highest high risk gain hypoglycemia variable Insulin (basal) Metformin + Metformin + Metformin + Metformin + Metformin + Basal Insulin + Sulfonylurea + TZD DPP-4-i GLP-1-RA Insulin§ or or or or Thiazolidine- dione + SU DPP-4-i GLP-1-RA Insulin§ TZD DPP-4-ior or or GLP-1-RA high low risk loss GI high GLP-1 receptor agonist Sulfonylurea high moderate risk gain hypoglycemia low SGLT2 inhibitor intermediate low risk loss GU, dehydration high SU TZD Insulin§ GLP-1 receptor agonist + SGLT-2 Inhibitor + SU TZD Insulin§ Metformin + Metformin + or or or or SGLT2-i or or or SGLT2-i Mono- therapy Efficacy* Hypo risk Weight Side effects Costs Dual therapy† Efficacy* Hypo risk Weight Side effects Costs Triple therapy or or DPP-4 Inhibitor + SU TZD Insulin§ SGLT2-i or or or SGLT2-i or DPP-4-i If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i: Metformin + Combination injectable therapy‡ GLP-1-RAMealtime Insulin Insulin (basal) + Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
  23. 23. Healthy eating, weight control, increased physical activity & diabetes education Metformin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): Metformin + Metformin + Metformin + Metformin + Metformin + high low risk gain edema, HF, fxs low Thiazolidine- dione intermediate low risk neutral rare high DPP-4 inhibitor highest high risk gain hypoglycemia variable Insulin (basal) Metformin + Metformin + Metformin + Metformin + Metformin + Basal Insulin + Sulfonylurea + TZD DPP-4-i GLP-1-RA Insulin§ or or or or Thiazolidine- dione + SU DPP-4-i GLP-1-RA Insulin§ TZD DPP-4-ior or or GLP-1-RA high low risk loss GI high GLP-1 receptor agonist Sulfonylurea high moderate risk gain hypoglycemia low SGLT2 inhibitor intermediate low risk loss GU, dehydration high SU TZD Insulin§ GLP-1 receptor agonist + SGLT-2 Inhibitor + SU TZD Insulin§ Metformin + Metformin + or or or or SGLT2-i or or or SGLT2-i Mono- therapy Efficacy* Hypo risk Weight Side effects Costs Dual therapy† Efficacy* Hypo risk Weight Side effects Costs Triple therapy or or DPP-4 Inhibitor + SU TZD Insulin§ SGLT2-i or or or SGLT2-i or DPP-4-i If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i: Metformin + Combination injectable therapy‡ GLP-1-RAMealtime Insulin Insulin (basal) + Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442 HbA1c ≥9% Intolerancia o contraindicación metformina Hiperglicemia incontrolada (cuadros catabólicos, Gp ≥300-350 mg/dl, HbA1c ≥10-12%)
  24. 24. A QUIEN??
  25. 25. Inicio DM 1 y DM2 con síntomas Cuadros agudos, hospitalización Diabetes gestacional sin control y pregestacional Insuficiencia renal y hepática Falla terapéutica ADO CON EL TX DE INSULINA EN RECIEN DX SE HA DEMOSTRADO UN AUMENTO DE LA SECRESION DE LA MISMA TANTO 1ERA COMO 2DA FASE ORIGIN A DOSIS 0.1 A 0.15 U DE ANALOGOS REDUCIENDO 30-35 % DE LA PROGRESION DE DIABETES
  26. 26. • Edad/expectativa de vida • Comorbilidades • Duración de la diabetes • Hipoglicemias • Consideraciones individuales • Enf. Cardiovasculares/ complicaciones microvasculares avanzadas
  27. 27. more stringent less stringent Patient attitude and expected treatment efforts highly motivated, adherent, excellent self-care capacities less motivated, non-adherent, poor self-care capacities Risks potentially associated with hypoglycemia and other drug adverse effects low high Disease duration newly diagnosed long-standing Life expectancy long short Important comorbidities absent severefew / mild Established vascular complications absent severefew / mild Readily available limited Usually not modifiable Potentially modifiable HbA1c 7% PATIENT / DISEASE FEATURES Approach to the management of hyperglycemia Resources and support system Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
  28. 28. DOSIS DE INSULINA
  29. 29. Add ≥2 rapid insulin* injections before meals ('basal-bolus’† ) Change to premixed insulin* twice daily Add 1 rapid insulin* injections before largest meal • Start: Divide current basal dose into 2/3 AM, 1/3 PM or 1/2 AM, 1/2 PM. • Adjust: é dose by 1-2 U or 10-15% once- twice weekly until SMBG target reached. • For hypo: Determine and address cause; ê corresponding dose by 2-4 U or 10-20%. • Start: 10U/day or 0.1-0.2 U/kg/day • Adjust: 10-15% or 2-4 U once-twice weekly to reach FBG target. • For hypo: Determine & address cause; ê dose by 4 units or 10-20%. Basal Insulin (usually with metformin +/- other non-insulin agent) If not controlled after FBG target is reached (or if dose > 0.5 U/kg/day), treat PPG excursions with meal-time insulin. (Consider initial GLP-1-RA trial.) If not controlled, consider basal- bolus. If not controlled, consider basal- bolus. • Start: 4U, 0.1 U/kg, or 10% basal dose. If A1c<8%, consider ê basal by same amount. • Adjust: é dose by 1-2 U or 10-15% once- twice weekly until SMBG target reached. • For hypo: Determine and address cause; ê corresponding dose by 2-4 U or 10-20%. • Start: 4U, 0.1 U/kg, or 10% basal dose/meal.‡ If A1c<8%, consider ê basal by same amount. • Adjust: é dose by 1-2 U or 10-15% once-twice weekly to achieve SMBG target. • For hypo: Determine and address cause; ê corresponding dose by 2-4 U or 10-20%. Enfoque para inicio y ajuste de tx insulínico Dm 2 Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
  30. 30. Add ≥2 rapid insulin* injections before meals ('basal-bolus’† ) Change to premixed insulin* twice daily Add 1 rapid insulin* injections before largest meal • Start: Divide current basal dose into 2/3 AM, 1/3 PM or 1/2 AM, 1/2 PM. • Adjust: é dose by 1-2 U or 10-15% once- twice weekly until SMBG target reached. • For hypo: Determine and address cause; ê corresponding dose by 2-4 U or 10-20%. • Start: 10U/day or 0.1-0.2 U/kg/day • Adjust: 10-15% or 2-4 U once-twice weekly to reach FBG target. • For hypo: Determine & address cause; ê dose by 4 units or 10-20%. Basal Insulin (usually with metformin +/- other non-insulin agent) If not controlled after FBG target is reached (or if dose > 0.5 U/kg/day), treat PPG excursions with meal-time insulin. (Consider initial GLP-1-RA trial.) low mod. high more flexible less flexible Complexity # Injections Flexibility 1 2 3+ If not controlled, consider basal- bolus. If not controlled, consider basal- bolus. • Start: 4U, 0.1 U/kg, or 10% basal dose. If A1c<8%, consider ê basal by same amount. • Adjust: é dose by 1-2 U or 10-15% once- twice weekly until SMBG target reached. • For hypo: Determine and address cause; ê corresponding dose by 2-4 U or 10-20%. • Start: 4U, 0.1 U/kg, or 10% basal dose/meal.‡ If A1c<8%, consider ê basal by same amount. • Adjust: é dose by 1-2 U or 10-15% once-twice weekly to achieve SMBG target. • For hypo: Determine and address cause; ê corresponding dose by 2-4 U or 10-20%. Enfoque para inicio y ajuste de tx insulinico Dm2 Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
  31. 31. 0.2 a 0.5 U/ kg: 50% basal (2/3 y 1/3) 50% bolus Conteo CBH: 1 U <> 15 g CBH Automonitoreo DM 1
  32. 32. Síntomas de hiperglicemia Contraindicación ADO HbA1c >9 % Cuadros agudos GA >250 mg/dl y GPP > 350 mg/dl Embarazo DM 2
  33. 33. { CenaAlmuerzoDesayuno 5am 6am 7am 8am 9 am 10am 11am 12md 1 pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12pm 1am 2am 3am 4am Horarios y tiempos de comida
  34. 34. { CenaAlmuerzoDesayuno 5am 6am 7am 8am 9 am 10am 11am 12md 1 pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12pm 1am 2am 3am 4am Horarios y tiempos de comida
  35. 35. { CenaAlmuerzoDesayuno 5am 6am 7am 8am 9 am 10am 11am 12md 1 pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12pm 1am 2am 3am 4am Horarios y tiempos de comida
  36. 36. { CenaAlmuerzoDesayuno 5am 6am 7am 8am 9 am 10am 11am 12md 1 pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12pm 1am 2am 3am 4am Horarios y tiempos de comida
  37. 37. { CenaAlmuerzoDesayuno 5am 6am 7am 8am 9 am 10am 11am 12md 1 pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12pm 1am 2am 3am 4am Horarios y tiempos de comida
  38. 38. http://es.paperblog.com/donde-se-aplica-la-insulina-2711226/
  39. 39. Hipoglicemia Ganancia de peso Alergia Lipodistrofia Edema Presbiopenia EFECTOS ADVERSOS
  40. 40. Conclusión

×