module ii insulin therapy
TRANSCRIPT
SDM: Focus on Insulin Therapy
Major microvascular and macrovascularcomplications of diabetes
Sexual dysfunction
Peripheral sensorydysfunction
Coronary heart disease
Skin infection
Atherosclerosis
Gastro-intestinal andbladder dysfunction
Diabetic foot
Diabetic retinopathy
Diabetic nephropathy
Diabetic neuropathy
Cerebrovascular disease
Peripheral vasculardisease
Coronary disease
Cognitive impairment3
Cardiac autonomicneuropathy
Microvascular1,2Microvascular1,2 Macrovascular1,2Macrovascular1,2
Adapted from: 1. International Diabetes Foundation. Time to Act: Type 2 diabetes, the metabolic syndrome and cardiovascular disease in Europe. 2006. 2. International Diabetes Federation. Time to Act. 2001. 3. Seaguist ER. Diabetes. 2010;59:4-6.
HbA1c
Microvascular complications e.g. kidney disease and blindness *
Heart attack *
UKPDS: Tight Glycaemic Control Reduces UKPDS: Tight Glycaemic Control Reduces ComplicationsComplications
Deaths related to diabetes *
21%
Stratton IM et al. UKPDS 35. BMJ 2000; 321: 405–412
Amputation or fatal peripheral blood vessel disease *
37%
14%
12%
43%
Stroke **
1%
Epidemiological extrapolation showing benefit of a 1% reduction in mean HbA1c
* p<0.0001
** p=0.035
Scientific Foundation for Insulin Therapy in Type 2 Diabetes
Why is insulin needed?
When is insulin needed?
Is insulin therapy effective?
Is insulin therapy safe?
The first step is to set a glycemic target (agreed to by the patient)
Achieving Glycemic Control
HbA1c target (%)ADA/EASD <7
IDF ≤6.5
NICE <6.5
AACE ≤6.5
France <6.5*
Canada ≤7
Australia ≤7
Latin America <6.5
Are these HbA1c targets still appropriate in light of recent clinical trials?
Scientific Foundation for Insulin Therapy in Type 2 Diabetes
Why is insulin needed?
When is insulin needed?
Is insulin therapy effective?
Is insulin therapy safe?
To achieve glycemic targets
Clinical Inertia: “Failure to Advance Therapy When Recommended”
Mea
n A
1C a
t La
st V
isit*
(%
)
8.2 Years8.2 Years
ADA GoalADA Goal
Diet and ExerciseDiet and Exercise
Years Elapsed Since Initial Diagnosis
Initiation of
insulin therapy
Initiation of
insulin therapy
SU or metformin
SU or metformin
Combination oral agents
Combination oral agents
8.6%8.9%
9.6%
7
8
9
10
2.5 Years 2.9 Years 2.8 Years
*Adapted from: Brown JB et al. Diabetes Care. 2004;27:1535-1540.
Mazze, Strock, Simonson, Kendall, Cuddihy, Bergenstal. SDM Quick Guide 5th Edition, International Diabetes Center, 2009
Staged DiabetesManagement
* Liraglutide approved in EU
*
ADA/EASD Revised Algorithm for T2DM Nathan DM, et al. Diabetes Care & Diabetologia January 2009.
At diagnosis:Lifestyle + Metformin
Lifestyle + Metformin+ Basal insulin
Lifestyle + Metformin+ Sulfonylureas
Lifestyle + Metformin+ Intensive insulin
Tier 1: well-validated therapies
STEP 1 STEP 2 STEP 3
Tier 2: Less well validated therapies
Lifestyle + Metformin+ Pioglitazone
No hypoglycaemiaOedema/CHF
Bone loss
Lifestyle + metformin+ GLP-1 agonist
No hypoglycaemiaWeight loss
Nausea/vomiting
Lifestyle + metformin+ Pioglitazone+ Sulfonylurea
Lifestyle + metformin+ Pioglitazone+ Basal insulin
Insulin
ADA/EASD Revised Algorithm for T2DM Nathan DM, et al. Diabetes Care & Diabetologia January 2009.
At diagnosis:Lifestyle + Metformin
Lifestyle + Metformin+ Basal insulin
Lifestyle + Metformin+ Sulfonylureas
Lifestyle + Metformin+ Intensive insulin
Tier 1: well-validated therapies
STEP 1 STEP 2 STEP 3
Tier 2: Less well validated therapies
Lifestyle + Metformin+ Pioglitazone
No hypoglycaemiaOedema/CHF
Bone loss
Lifestyle + metformin+ GLP-1 agonist
No hypoglycaemiaWeight loss
Nausea/vomiting
Lifestyle + metformin+ Pioglitazone+ Sulfonylurea
Lifestyle + metformin+ Pioglitazone+ Basal insulin
Insulin
Mazze, Strock, Simonson, Kendall, Cuddihy, Bergenstal. SDM Quick Guide 5th Edition, International Diabetes Center, 2009
* Liraglutide approved in EU
*
Scientific Foundation for Insulin Therapy in Type 2 Diabetes
Why is insulin needed?
When is insulin needed?
Is insulin therapy effective?
Is insulin therapy safe?
To achieve glycemic targets
Earlier in the treatment plan
Titrate to clinically effective dose Advance if not at target in 3 months
TWO DRUG THERAPYTWO DRUG THERAPY
THREE DRUG THERAPYTHREE DRUG THERAPY
Add Background InsulinOr TZD, SU
METFORMINMETFORMIN
Background & Mealtime (main meal) + Oral Agent(s)*
Background & Mealtime (all meals) + Sensitizers*
Premixed Insulin + Sensitizers*
MULTI-DOSE INSULIN THERAPY MULTI-DOSE INSULIN THERAPY
* Limited published data for use of insulin plus either DPP-4 inhibitor or GLP-1 agonist
A1C >11%FPG >300 mg/dL
RPG >350 mg/dL
Start Insulin (Multi-Dose
Insulin therapy preferred)
Type 2 Diabetes Master DecisionPath
Advance if not at target in 3 monthsTitrate to clinically effective dose
Add SU Add DPP4-I Add GLP-1 Agonist Add TZD
2 meals
Add Background Insulin or
TZD, DPP-4, GLP1
Add Background Insulin or
SU, DPP-4, GLP1
Mazze, Strock, Simonson, Kendall, Cuddihy, Bergenstal. SDM Quick Guide 5th Edition, International Diabetes Center, 2009
Relative contributions of postprandial glucose and FPG to A1C
20
40
60
80
100
Fasting plasma glucose Postprandial plasma glucose
Monnier L et al. Diabetes Care. 2003;26:881-5.
A1C quintiles (%)
0>10.29.3–10.28.5–9.27.3–8.4<7.3
Contribution(%)
Plasma Glucose Normally Maintained in Narrow Range
Adapted from Polonsky KS, et al. N Engl J Med. 1988;318:1231-1239.
6 AM 10 AM 2 PM 6 PM 10 PM 2 AM
Time of Day
400400
300300
200200
100100
00
Diabetes
No diabetescontrol
Fix fasting firstFix fasting first
Pla
sma
Glu
cose
(m
g/dL
)
Plasma Glucose Normally Maintained in Narrow Range
Adapted from Polonsky KS, et al. N Engl J Med. 1988;318:1231-1239.
6 AM 10 AM 2 PM 6 PM 10 PM 2 AM
Time of Day
400400
300300
200200
100100
00
Fix fasting firstFix fasting first
Diabetes
No diabetescontrol
Pla
sma
Glu
cose
(m
g/dL
)
8.5
9.0
8.0
7.5
7.0
6.5
0 4 8 12 16 20 24
HbA
1c (%
)
NPH + OADInsulin glargine + OAD
Weeks
0
2
4
6
8
10
12
14
16 21% risk reduction p <0.02
42% risk reduction p <0.01
Overall Nocturnal Hypoglycemia
Events
per
pati
ent
per
year
Insulin Glargine vs. NPH in Treat-to-Target Trial: HbA1c and Hypoglycemia
Riddle et al. Diabetes Care 2003;26:3080-6.
Randomized to NPH or Glargine + OAD with target HbA1c <7%
Insulin Detemir vs. NPH in Treat-to-Target Trial: HbA1c and Hypoglycemia
Hermansen et al. Diabetes Care 29:1269, 2006
-2 0 12 24
8.5
9.0
8.0
7.5
7.0
6.5
HbA
1c (%
)
Weeks
NPH + OADInsulin detemir + OAD 47% risk reduction
p < 0.001
Events
per
pati
ent
per
year
55% risk reduction p < 0.001
0
2
4
6
8
10
12
14
16
18
Overall Nocturnal Hypoglycaemia
Long-acting
0
10
20
30
40
50
0 2 4 6 8 10 12 14 16 18 20 22 24
Using Insulin EffectivelyPhysiologic Insulin Replacement
Insu
lin L
eve
ls
Time of DayAdapted from Polonsky. N Engl J Med. 1996;334:777-783.Kendall DM. N Engl J Med 322: 898-903, 1990.
Sensitizers
Sulfonylurea / GLP-1 A / DPP-4 I
Long-ActingLong-Acting
Long-acting
0
10
20
30
40
50
0 2 4 6 8 10 12 14 16 18 20 22 24
Using Insulin EffectivelyPhysiologic Insulin Replacement
Insu
lin L
eve
ls
Time of DayAdapted from Polonsky. N Engl J Med. 1996;334:777-783.Kendall DM. N Engl J Med 322: 898-903, 1990.
Sensitizers
Sulfonylurea / GLP-1 A / DPP-4 I
Long-ActingLong-Acting
24-Hour Plasma Glucose CurveNormal and People with Type 2 Diabetes
Time of Day
400
300
200
100
00600 06001000 1400 1800 2200 0200
Glucose(mg/dL)
Meal Meal MealNormal
Fix Fasting First
Adapted from Polonsky et al, N Engl J Med 1988.
24-Hour Plasma Glucose CurveNormal and People with Type 2 Diabetes
Time of Day
400
300
200
100
00600 06001000 1400 1800 2200 0200
Glucose(mg/dL)
Meal Meal MealNormal
Fix Fasting First
Adapted from Polonsky et al, N Engl J Med 1988.
Premixed: 75/25 with lispro, 70/30 with aspart,
50/50 with lispro
Premixed Regimen with Rapid-acting Insulin
Background / Mealtime (Basal / Bolus) Insulin Regimen
Rapid-acting insulin at meals Long-acting insulin at bed
Improvement in HbA1c with Basal – Bolus Insulin Regimen (Glargine / Glulisine) in Type 2 Diabetes
The majority of patients achieved HbA1c <7.0%
• Simple algorithm: 73.0%
• CHO counting: 69.2%p = NS
Simple algorithm
CHO counting
Bergenstal RM, Johnson M, Powers M et al. Diabetes Care 2008;31:1305–10.
Scientific Foundation for Insulin Therapy in Type 2 Diabetes
Why is insulin needed?
When is insulin needed?
Is insulin therapy effective?
Is insulin therapy safe?
To achieve glycemic targets
Earlier in the treatment plan
Yes – if regimen is matched to patient’s glucose profile and lifestyle
Scientific Foundation for Insulin Therapy in Type 2 Diabetes
Why is insulin needed?
When is insulin needed?
Is insulin therapy effective?
Is insulin therapy safe?
To achieve glycemic targets
Earlier in the treatment plan
Yes – if regimen matched to patient’s glucose profile and lifestyle
Used effectively – the benefits of glycemic control out weight risks
Weight Gain
Hypoglycemia
Cancer
Minimize by lifestyle advice & matching glycemic profile Minimize by lifestyle advice & matching glycemic profile
Not clear risk of exogenous insulin and cancer established – likely some increased risk of cancer with diabetes
Starting and Adjusting Insulin in Type 2 Diabetes
Steps for Starting Insulin Therapy in Type 2 Diabetes
1. Set a target or goal for glucose control• HbA1c and self-monitored blood glucose
2. Use an algorithm to advance therapy
Apply a consistent approach with timelines to reach goal
3. Determine the appropriate insulin regimen
4. Calculate the starting insulin dose
5. Educate patient and family
Steps for Starting Insulin Therapy in Type 2 Diabetes
1. Set a target or goal for glucose control• HbA1c and self-monitored blood glucose
2. Use an algorithm to advance therapy
Apply a consistent approach with timelines to reach goal
3. Determine the appropriate insulin regimen
4. Calculate the starting insulin dose
5. Educate patient and family
IDF ADA IDC/SDM
HbA1c <6.5% <7% <7%
Fasting and
Premeal
<100 mg/dL
5.5 mmol/l
90 -130 mg/dL
6.0-7.2 mmol/l
70-120 mg/dL
3.9-6.7 mmol/l
2 hour Postmeal
<140 mg/dL
7.8 mmol/l
<180 mg/dL
<10 mmol/l
<160 mg/dL
8.9 mmol/l
Glycemic Targets for Type 2 Diabetes*
Diabetes Care 33 Supp1, Jan 2010Insulin BASICS 2nd ed 2008:p25, International Diabetes Center
* non-pregnant adults
Steps for Starting Insulin Therapy in Type 2 Diabetes
1. Set a target or goal for glucose control• HbA1c and self-monitored blood glucose
2. Use an algorithm to advance therapy
Apply a consistent approach with timelines to reach goal
3. Determine the appropriate insulin regimen
4. Calculate the starting insulin dose
5. Educate patient and family
Mazze, Strock, Simonson, Kendall, Cuddihy, Bergenstal. SDM Quick Guide 5th Edition, International Diabetes Center, 2009
Staged DiabetesManagement at IDC
*
Steps for Starting Insulin Therapy in Type 2 Diabetes
1. Set a target or goal for glucose control• HbA1c and self-monitored blood glucose
2. Use an algorithm to advance therapy
Apply a consistent approach with timelines to reach goal
3. Determine the appropriate insulin regimen
4. Calculate the starting insulin dose
5. Educate patient and family
Preparing for Insulin in Type 2 DiabetesClinical Indicators
Initiate insulin if:
HbA1c above target for >3 months and on maximum effective dose of 2 or more glucose-lowering agents
HbA1c >11% and/or symptomatic and blood glucose >300 mg/dL
– If clinically stable and high intake of sweetened beverages (>36 oz or 3 cans/day), eliminate sweetened beverages and re-evaluate need for insulin in 1-2 weeks
SDM Quick Guide 5th Edition, 2009 International Diabetes Center, Park Nicollet Institute
0
10
20
30
40
50
0 2 4 6 8 10 12 14 16 18 20 22 24
Using Insulin EffectivelyPhysiologic Insulin Replacement
Insu
lin L
eve
ls
Time of Day
Meal Meal Meal
Basal (background) insulin needs = 50%
Mealtime (bolus) insulin needs = 50%
Adapted from Polonsky. N Engl J Med. 1996;334:777-783.Kendall DM. N Engl J Med 322: 898-903, 1990.
Re
lati
ve
Ins
ulin
Eff
ec
tR
ela
tiv
e In
su
lin E
ffe
ct
Time (Hours)
0 2 4 6 8 10 12 14 16
Long-Acting: Glargine (Lantus®)Detemir (Levemir®)
18 20
Intermediate: NPH (Humulin® N, Novolin® N)
Short-Acting: Regular (Humulin® R, Novolin® R)
Rapid-Acting: Lispro (Humalog®), Aspart (NovoLog®),Glulisine (Apidra®)
Insulin Time Action Curves
Bergenstal, “Effective insulin therapy,” International Textbook of Diabetes Mellitus vol 1. 3rd ed, Chichester NY, John Wiley and Sons, Inc., 2004:995-1015.
Background (Basal) Insulin
+ 2 Drugs
Elevated FPG
Stable daytime BG
Overwhelmed
Desire single injection
Premixed Insulin Sensitizer(s)
Elevated PPG
Increasing daytime BG
HbA1c >11%
Decreased dexterity
or visual acuity
Regular schedule
Background andMealtime Insulin
Sensitizer(s)
Elevated fasting
and/or post-meal
HbA1c >11%
Intensive control
More flexibility
Erratic schedule
Selecting an Insulin Regimen
Glycemic Factors
Patient Factors
Case Study: Khalida
73 year-old woman
Glycemic factors
Diabetes for 7 years
Taking metformin 1000 BID; and 10 mg glyburide BID
Current HbA1c 7.9%
SMBG in morning and evening are high
Patient factors
Very Fearful of injections
Background (Basal) Insulin Options
Glargine (Lantus®) and Detemir (Levemir®)– No significant peak; lasts up to 24 hours
– Twice daily dosing may be required
– Decreases risk of nocturnal hypoglycemia
NPH (Humulin® N and Novolin® N)– Less expensive
– Twice daily dosing required
Riddle et al. Diabetes Care. 26:3080-3086; 2003Raskin et al Diabetes Care. 28:260-265; 2005
Starting Background (Basal) Insulin
HbA1c <9% HbA1c ≥9%
Background Insulin Dose
0.1 units/kg 0.2 units/kg
Start with single dose of long-acting insulin (glargine or detemir) or intermediate-acting insulin (NPH) at bedtime if cost is a concern.
Maintain oral agents: 1-2 of them - SU, Metformin, (maybe TZD), NOTE: DPP-4 Inhibitors and/or GLP-1 mimetic with insulin is “off-label”
Starting Background (Basal) Insulin
Example: Khalida with HbA1c of 7.9%
Determine weight in kg
Weight in lbs _____ ÷ 2.2 = _____ kg
Calculate initial dose of background insulin
Weight in kg ______ x units/kg _____ = _____units
100 0.1 10
Plan
BedPMNoonAM
10-LA
100222
Background (Basal) Insulin
+ 2 Drugs
Elevated FPG Stable daytime BG
Overwhelmed Desire single injection
Premixed Insulin Sensitizer(s)
Elevated PPG Increasing daytime BG HbA1c >11%
Decreased dexterity or visual acuity Regular schedule
Background andMealtime Insulin
Sensitizer(s)
Elevated fasting and/or post-meal HbA1c >11% Intensive control
More flexibility Erratic schedule
Selecting an Insulin Regimen
Glycemic Factors
Patient Factors
Premixed Insulin
Human Insulin Begins to Work
Works Hardest
Stops Working
75/25 with Lispro Humalog Mix 75/25
50/50 with Lispro Humalog Mix 50/50
70/30 with Aspart NovoLog Mix 70/30
5-15 min 1-2 hrs 10-16 hrs
70/30 with Reg Humulin 70/30 Novolin 70/30
30-45 min 4-8 / 2-3 hrs 10-16 hrs
Based on package insert data
Case Study: Saleem Ahmad
63-year-old
Glycemic factorsCame to the Emergency Room with a foot infection
HbA1c 11.8%
Patient factorsFatigued, thirsty, dehydrated, +family history of diabetes but surprised he got diabetes and he is scared
Starting Premixed Insulin
HbA1c < 9% HbA1c ≥ 9%
Premixed Insulin Dose
0.1 units/kg
(2 times/day)
0.2 units/kg total
0.2 units/kg
(2 times/day)
0.4 units/kg total
Start with two doses; before breakfast and dinner
Consider adding insulin sensitizer (metformin)
Guide to Starting and Adjusting Insulin for Types 2 Diabetes © 2008 International Diabetes Center, Park Nicollet
Premixed regimen with rapid-acting insulin
Premixed: 75/25 with lispro, 70/30 with aspart,
50/50 with lispro
© 2007 International Diabetes Center, Minneapolis, MN All rights reserved..
Background (Basal) Insulin
+ 2 Drugs
Elevated FPG Stable daytime BG
Premixed Insulin Sensitizer(s)
Elevated PPG Increasing daytime BG HbA1c >11%
Background andMealtime Insulin
Sensitizer(s)
Elevated fasting and/or post-meal HbA1c >11% Intensive control
More flexibility Erratic schedule
Selecting an Insulin Regimen
Glycemic Factors
Patient Factors
Overwhelmed Desire single injection
Decreased dexterity or visual acuity Regular schedule
Case Study: A Qudoos
58 year old male
Glycemic factors
Diabetes for 14 years
Sitagliptin/metformin (Janumet™) 50/1000 BID and 30 mg pioglitazone (Actos®)
Current HbA1c 9.4%, elevated fasting and post-meal glucose
Patient factors
Eats healthy diet, exercises regularly
Desire flexible schedule for work
Starting Background (Basal) and Mealtime (Bolus) Insulin
HbA1c <9% HbA1c ≥9%
Background
Insulin Dose
0.1 units/kg
(once daily)
0.2 units/kg
(once daily)
Mealtime
Insulin Dose
0.1 units/kg (divided evenly between meals)
0.2 units/kg(divided evenly between meals)
Total Insulin
Dose
0.2 units/kg 0.4 units/kg
Stop meal related therapy (Janumet™) and begin metformin 1000 mg BID.
Consider pros and cons of maintaining pioglitazone (Actos®).
Background (Basal) and Mealtime (Bolus) Insulin Regimen
RA = rapid-acting insulin: Lispro, aspart, glulisine
Rapid-acting insulin at meals Long-acting insulin at bed
Steps for Starting Insulin Therapy in Type 2 Diabetes
1. Set a target or goal for glucose control• HbA1c and self-monitored blood glucose
2. Use an algorithm to advance therapy
Apply a consistent approach with timelines to reach goal
3. Determine the appropriate insulin regimen
4. Calculate the starting insulin dose
5. Educate patient and family
Team Approach to Starting Insulin
What Gets in the Way of Starting Insulin?Patient Concerns
1. Injections (Shots)
2. Diabetes more
serious
3. Complicated
4. Inconvenient
5. Sense of failure
6. Hypoglycemia
Bergenstal Chapter 53, International Textbook of Diabetes Mellitus 3rd Edition, 2004 John Wiley & Sons and International Diabetes Center, unpublished survey data
How does diabetes change over the years?
© From Let’s Talk About Insulin 2008, © International Diabetes Center
YearsYears-10-10 -5-5 00 55 1010 1515 2020 2525 3030
Insulin Resistance
Insulin LevelPre DiabetesMetabolic Syndrome
-15-15
Impaired Incretin Action
What Gets in the Way of Starting Insulin?
1. Complexity of starting and
adjusting insulin
2. Not sure what it is like to take
an insulin injection
3. Weight gain
4. Hypoglycemia
5. Other concerns?
Bergenstal Chapter 53, International Textbook of Diabetes Mellitus 3rd Edition, 2004 John Wiley & Sons; Jeavons D et al. Postgrad Med J 2006; 82:347-350.
Doctor Concerns
Begin with a practice injection (saline)
Can help to allay apprehension about injections
Information that follows may be better heard
You try it!
Saline Injection Demonstration
1. Remove cap from the end of the syringe
2. Remove the needle cap 3. Pull back on plungerto the amount calculated(e.g. 10 units)
5. Pull back on the plunger to measure the correct amount (e.g. 10 units)
6. To remove air bubbles, push plunger back in.
4. Insert needle and push air into the vial
7. Pull back on the plunger to measure the correct amount (e.g. 10 units). Remove needle from vial
You are ready to give the injection
Saline Injection Demonstration
9. Administer the injection into the abdomen. Remove needle and cover area with your finger for a few seconds.
10. Throw away the used syringe in a sharps container (do not re-cap)
8. Hold the syringein your hand as shown (like holding a pen)
Important Education Topics for Starting Insulin Therapy
Diabetes overview
Insulin administration
Glucose monitoring
Simple eating guidelines
Hypoglycemia
FlexPen®
SoloStar® (sanofi aventis)
Examples of Insulin Pens
Pre-filled (Disposable)
Re-usable (uses insulin cartridges)
NovoPen® 4
HumaPen ®
Sites for Insulin Administration
Abdomen preferred
Insulin BASICS 2nd ed 2008:p19, International Diabetes Center
Insulin storageCheck package insert for specific instructions
Keep unopened insulin in refrigerator or cool temperature
Insulin in use can be stored at room temperature
Range is from 10 days to 42 days depending on insulin
Check package insert for specific instructions
Keep above freezing and below 86F ( 30C)
Insulin BASICS 2nd ed 2008:p110, International Diabetes Center
Important Education Topics for Starting Insulin Therapy
Diabetes overview
Insulin administration
Glucose monitoring
Simple eating guidelines
Hypoglycemia
Blood Glucose Monitoring
To improve clinical decision-making
To evaluate efficacy of the therapy
To pin point problems
To support adherence to regimen
Feedback for the patient
IDF ADA IDC
HbA1c <6.5% <7% <7.0%
Fasting and
Premeal
<100 mg/dL
5.5 mmol/l
70 -130 mg/dL
3.9-7.2 mmol/l
70-120 mg/dL
3.9-6.7 mmol/l
2 hour Postmeal
<140 mg/dL
7.8 mmol/l
<180 mg/dL
<10 mmol/l
<160 mg/dL
8.9 mmol/l
Glycemic Targets for Type 2 Diabetes*
Diabetes Care 29(8), Aug 2006Diabetes Care 32 Supp1, Jan 2009Insulin BASICS 2nd ed 2008:p25, International Diabetes Center
* non-pregnant adults
Ideal Testing FrequencyPatients Taking Insulin
Minimum four times/day recommended
Glucose testing:
– Before each meal and before bedtime
– Consider pre-meal and 30-90 minutes post meal to evaluate effect of insulin on post-meal glucose
Modify frequency of monitoring if necessary
Encourage patients to record values in a record book
Use meter with a memory for verified data
Modify based on individual patient circumstances; vary the times of testing to build a profile
Important Education Topics for Starting Insulin Therapy
Diabetes overview
Insulin administration
Glucose monitoring
Simple eating guidelines
Hypoglycemia
2009 International Diabetes Center
2. Choose a variety of foods 1. Eat 3 meals per day
Quick Start: Healthy Eating Guidelines
Eat fewer or smaller portions of sweetened foods or beverages (soft drinks, juices, desserts, candy)
Include carbohydrate at each meal
Avoid alcohol for now
Choose healthy foods when possible
Replace, reduce, restrict
Small to moderately sized portions
Similar portions from day to day at a given meal time
Consistent meal times (initially for all insulin regimens)
Include small snacks, if desired
Insulin BASICS 2nd ed 2008:p34, International Diabetes Center
Important Education Topics for Starting Insulin Therapy
Diabetes overview
Insulin administration
Glucose monitoring
Simple eating guidelines
Hypoglycemia
Hypoglycemia
BG
Below
70 mg/dL
(3.9 mmol/L)
Insulin BASICS 2nd ed 2008:p30, International Diabetes Center
Common Symptoms
Weak, shaky, lightheaded
Sweaty, clammy
Irritability
Tingling or numb lips
Confusion
Hungry
Treatment of Hypoglycemia(Routine 15)
Test blood glucose if possible
Treat with 15 gm carbohydrate if <70 mg/dL (3.8 mol/L)
– 3-4 glucose tablets or 1/2 cup
juice or soda pop
– BG ~50-60 mg/dL (3 mmol/L)
– Have carbohydrate readily available
– Avoid high-fat carbohydrates
(slower absorption)
Wait 15 minutes
Test and treat again if glucose below target
Insulin BASICS 2nd edition 2008: p 31, © International Diabetes Center
Treatment of Severe Hypoglycemia Requires assistance to treat
Note: Severe hypoglycemia is rare in type 2 diabetes
Unable to swallow safely
Needs injection of glucagon– Hormone that releases stored glycogen (glucose)– Given intramuscular or subcutaneous– Standard dose: 1.0 mg adults; 0.5 mg for children
Precautions– May cause nausea/vomiting/headache– Increase fluids following injection
Call for emergency assistance
Insulin BASICS 2nd edition 2008: p 77, © International Diabetes Center
Hypoglycemia Prevention
Follow food/insulin plan
Test BG daily
Be prepared and carry carbohydrate
Keep records
Wear medical ID
Inform family, friends, co-workers how to recognize and treat lows
Inform doctor of low glucose patterns
Check BG before driving
Insulin BASICS 2nd edition 2008, © International Diabetes Center
Steps for Starting Insulin Therapy in Type 2 Diabetes
1. Set a target or goal for glucose control
HbA1c and self-monitored blood glucose
2. Use an algorithm to advance therapy
Apply a consistent approach with timelines to reach goal
3. Determine the appropriate insulin regimen
4. Calculate the starting insulin dose
5. Educate patient and family
Fine-Tuning Glycemic Control
Overview
Nutrition Messages
Insulin Adjustments
Glucose Data
Treating Hypoglycemia
Nutrition Messages
Insulin Regimen
Meals Snacks
Background Control carbohydrate3-4 carb choice*/meal
Not needed
Pre-Mixed Eat at consistent times with consistent carb
May be needed depending on schedule & insulin
Background and Mealtime
Start with consistent carb
Not neededif snack is eaten, add RA insulin to cover
*One carb choice = 15 grams of carbohydrate
Titrating Insulin for Background Regimen
If most AM fasting BG >120 mg/dL
Titrate until fasting glucose at target BG
If most AM fasting BG <120 mg/dL and HbA1c remains above target
Test pre dinner and bedtime (or 2-hour post dinner) and consider need for mealtime insulin
Guide to Starting and Adjusting Insulin for Types 2 Diabetes © 2008 International Diabetes Center, Park Nicollet
Titration Guide (Table 6)
SDM Quick Guide, 2009, IDCGuide to Starting and Adjusting Insulin for Types 2 Diabetes © 2008 International Diabetes Center, Park Nicollet
If most BG <200 mg/dL
<70 mg/dL Decrease by 1-3 units
70-120 mg/dL No change
121-200 mg/dL Increase by 1-3 units
>200 mg/dL Increase by 3-5 units or 10%
What adjustments would youmake for Khalida?
Pre- Bkfst
Ins-Med
Post Pre Ins-Med
Pt Pre-Din
Ins Post HS
Mon 155 Met. 1000Glyb.
10
121 Met. 1000Glyb.
10
148 10LA
Tue 163 142 199 10LA
Wed 143 112 143 10LA
Thur 133 96 116 12 LA
Started at 0.1 units/kg x 100 kg (220#) =10 units
After Insulin Adjustment
Pre- Bkfst
Ins-Med
Post Pre Ins-Med
Pt Pre-Din
Ins Post HS
Mon 137 Met. 1000Glyb.
10
111 Met. 1000Glyb.
10
147 12LA
Tue 140 125 165 12LA
Wed 122 102 137 12LA
Thur 148 114 156?
Titrating Insulin for Background Regimen
If most AM fasting BG >120 mg/dL
Titrate until fasting glucose at target BG
If dose reaches 0.5-0.7 units/kg body weight, consider adding mealtime insulin
If most AM fasting BG <120 mg/dL and HbA1c remains above target
Test pre dinner and bedtime (or 2-hour post dinner) and consider need for mealtime insulin
Guide to Starting and Adjusting Insulin for Types 2 Diabetes © 2008 International Diabetes Center, Park Nicollet
Step-wise Transition from Background to Background & Mealtime Regimen
Start with single injection rapid-acting insulin before largest meal (most carb. choices)
– 0.1 units/kg rapid-acting (RA) insulin
Subtract 0.1 units/kg from background insulin dose
Consider maintaining oral agents
Example 100 kg patient on 60 units background insulin
New dose: 100 kg x 0.1 units/kg = 10 units RA before largest meal
60 units – (0.1 units/kg) = 50 units background insulin
Staged Diabetes Management Quick Guide © 2007 International Diabetes Center, Park Nicollet
Titrating Insulin for Premixed Regimen
If most BG >200 mg/dL Increase total insulin by 0.1 units/kg
Distribute equally between doses
If most BG <200 mg/dL Use titration guide to adjust
AM FBG: adjust pre-dinner insulin dose
Pre-dinner: adjust pre-breakfast insulin
How would you adjust Saleem Ahmad dose of Mix 75/25?
Pre-
Bkfst
Ins Post Pre Ins Post Pre-
Din
Ins Post HS
Mon 265 19 201 19 236
Tue 244 19 198 19 254
Wed 254 19 205 19 215
Thur 195 206 22724 24
Started at 0.2 units/kg x 95 kg (209#) = 19 units AM and PM
0.1 units/kg x 95 kg (209#) = 9.5 units
After Insulin Adjustment
Pre-
Bkfst
Ins Post Pre Ins Post Pre-
Din
Ins Post HS
Mon 184 24 162 24 210
Tue 193 24 182 24 219
Wed 174 24 158 24 183
Thur 160 155 19426 26
Use titration guide to adjust
Titrating Insulin for Background & Mealtime Regimen
If most BG >200 mg/dL Increase total insulin by 0.1 units/kgAdd half to backgroundDistribute remaining half between mealtime doses
If most BG <200 mg/dL Use titration guide to adjustAM FBG: adjust backgroundPre-lunch/dinner: adjust previous mealtime insulinIf more than 40 mg/dL pre- to 2 hr. postmeal rise, increase RA 1-3 units
What adjustment would you make to A. Qudoos insulin doses?
Pre-
Bkfst
Ins Post Pre Ins Post Pre-
Din
Ins Post HS
Mon 133 5 RA
244 5 RA
115 6 RA
156 16
LATue 125 5
RA201 5
RA124 6
RA170 16
LA
Wed 114 5
RA
199 5
RA
117 6 RA
187 16 LA
Thur 139 7 RA
8 RA
Started at 0.2 units/kg x 80 kg (176#) = 16 units LA and 16 units RA divided between 3 meals
5 RA
16 LA
After Insulin Adjustment3 carbs for breakfast - 2 carbs for lunch 4 carbs for dinner
Pre-
Bkfst
Ins Post Pre Ins Post Pre-
Din
Ins Post HS
Mon 105 7
RA
142 5 RA 78 72 8 RA 139 16
LA
Tue 112 7 RA
151 5 RA 85 70 8 RA 125 16 LA
Wed 98 7
RA
125 5
RA
66 69 8 RA 98 16 LA
Thur 110 132 74 65 1127 RA
8 RA
5 RA
16 LA
Starting vs. Final Insulin Dose
Typical Patient
(Type 2 DM)
Regimen Starting Dose (units)
Common Final Dose
(units)Background Insulin
0.2 units/kg
(20 units)
0.5-0.7 units/kg
(50-70 units)
Premixed Insulin
0.2 units/kg BID (40 units total)
1.0-1.2 units/kg (100-120 units)
Background & Mealtime Insulin
0.2 units/kg background 0.2 units/kg mealtime (40 units total)
1.0-1.2 units/kg (100-120 units)
220 lbs
(100 kg)
HbA1c 9%
Average dose for type 1 diabetes is 0.7 units/kg
Follow-up and Summary
Recommended follow-up
– Every 1-2 weeks while adjusting dose
– Every 3 months once dose established
Have patient monitor BG more extensively 1-2 weeks prior to visit to have recent data for adjusting
Use a team approach when starting insulin
Consider enabling patients to make adjustments to their insulin regimen
Case Studies