Transcript INSULIN THERAPY - Diabetes Clinic

INTENSIVE INSULIN
THERAPY
J. Robin Conway M.D.
Diabetes Clinic, Smiths Falls, ON
1-800-717-0145
www.diabetesclinic.ca
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Objectives
• Optimize diabetes management
• Assist you in initiating insulin in your office
– When to start insulin therapy?
– Insulins, doses, delivery options
– Patient training
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Challenges in Initiating Insulin?
1. Patient attitudes
– Fear of needles
– Insulin viewed as a threat by patient & physician
– Hypoglycemia
2. Physician Attitudes
– Discomfort with insulin
• Lack of knowledge and experience
– Fear of needles
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Type 1 Diabetes:
• Impaired or absent ß cell function:
–  insulin secretion
• Normal insulin action:
–  insulin sensitivity
• The insulin deficiency results in
unacceptable blood glucose control
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Type 2 Diabetes: Double Impairment
• Impaired ß cell function:
–  insulin secretion
• Impaired insulin action:
–  insulin resistance
• Results in unacceptable blood glucose
control
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Type 1 & 2 Diabetes: Key Concepts
• Minimizing the complications of diabetes
requires:
– Early diagnosis and treatment of diabetes
– Maintaining HbA1C level < 7%
• Achieving HbA1C < 7% requires control of
post-prandial and fasting hyperglycemia
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CDA Guidelines (for glycemic control)
Normal
A1C level
Preprandial
glycemia
Optimal
(0.04-0.06) (< 0.07)
3.5-6.1
4-7
(mmol/L)
Postprandial
glycemia
4.4-7.8
7-11
(mmol/L)
Haars s et al., CMAJ 2003; 159 (Suppl.): S1-29. Gerstein, H.C. et al. CDA views on the UKPDS and revision of the
guidelines affected by the results of this study.
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Steps to Glycemic Control
• Establish glycemic objectives
– Target fasting and post-prandial glycemia
• Diet counseling with exercise component
• Diabetes education for every patient
• Pharmacological treatment; oral and insulin
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Patient Counselling Topics
A.Review symptoms and treatment of
hypoglycemia
B.Proper training and correct use of glucose
monitor
C.Target desired glycemic levels for each
patient
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A. Hypoglycemia
• Definition: Glycemia < 3.8 mmol
• Patients may experience hypoglycemia at
different glycemic levels
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Symptoms of Hypoglycemia
Mild
• < 3.3 mmol/L
• Neurovegetative
symptoms
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Sweating
Trembling
Palpitations
Anxiety
Tingling
Pallor
Hunger
Moderate to Severe
• < 2.8 mmol/L
• Symptoms of glucopenia
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Confusion
Visual disturbances
Weakness
Speech disorder
Behavioural disorder
Drowsiness
Coma
Convulsions
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Preventing Hypoglycemia
• Check BG 4-6 times per day
• Carry glucose tablets
• Have Glucagon Kit available
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Preventing Hypoglycemia
• Test before driving and ideally 1 hour later
(target: over 5.5 mmol/L)
• Perform two SMBG 30 minutes apart prior to
bedtime (confirming rising or falling BG)
• When drinking alcohol, perform SMBG hourly
• With exercise, perform SMBG pre- and postexercise
• If hypoglycemia episodes persist, raise target
glucose levels
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Hypoglycemia Treatment
Guidelines
The Rule of 15
• If BG is 4 mmol/L or below
– Treat with 15 grams of carbohydrates (glucose
tabs)
– Check BG in 15 minutes, and if not above 4
mmol/L, repeat treatment
Glucagon
• Current emergency kit readily available and
knowledgeable person trained to administer
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Preventing
Hyperglycemia and DKA
• Monitor BG 4-6 times per day
• Use Correction Boluses when appropriate
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Hyperglycemia Treatment Guidelines
The Key to Preventing DKA
1st BG over 14 mmol/L:
• Take a correction bolus, check again
in 1 hour
• Call physician immediately or go to ER if
nausea and vomiting are present
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B. Patient Training
• Training by a multidisciplinary team at DEC is
IDEAL for:
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Diet counseling
Education on the injection sites
Education on the various injection devices
Evaluation of the patient’s support network
• Other resources may exist for training, i.e. retail
pharmacy
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C. Blood Glucose Monitoring
• To adjust the insulin treatment
• To detect or confirm hypoglycemia or severe
hyperglycemia
• To adjust treatment to the circumstances of daily
life using an insulin scale prescribed by the
attending physician
• To improve patient safety and increase motivation
to comply with treatment
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Ideal Testing Frequency
• Stable type 2
– 1-2 readings/day
• Type 1 or Unstable type 2
– 3-8 readings/day
• Important to stress the need to vary testing
times
– AC, PC, h.s. and prn during the night
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Injection Tools and Options
• Durable delivery devices
– Novolin-Pen® 3
– Novolin-Pen® Junior
– InDuo®
– Innovo®
– HumaPen®
• Insulin pumps
• Syringes
• Disposable: multidose,
prefilled (3.0 mL)
– NovolinSet® (NPH,
Toronto, 30/70 )
– Humulin® N
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Advancing Insulin Therapy Through
Device Innovation
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Goal of Insulin Therapy
We are trying to duplicate
how the pancreas works in
releasing insulin for
someone who doesn’t
have diabetes
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Non-diabetic Insulin and Glucose
Profiles
Breakfast
Lunch
Supper
75
Insulin
(µU/mL)
50
Insulin
25
Basal insulin
0
9.0
Glucose
6.0
Glucose
(mmo/L) 3.0
Basal glucose
0
7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
a.m.
p.m.
Time of Day
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Insulin Preparations
Rapid-acting Aspart (NovoRapid®)
Vial and cartridge
Lispro (Humalog®)
Short-acting
(regular)
Novolin®ge Toronto
Humulin® R
Vial and cartridge
Prolonged
action
Start 30-60
min.
Peak 4 hr
Vial and cartridge
Intermediate
Start < 15
min.
Novolin®ge NPH
Humulin® N
Humulin® U
Start 1.5
hrs
Peak 7 hr
vial only
Lantus (Glargine)
vial only
Levemir www.diabetesclinic.ca
(Detemir)
cartridge
Start 3-4
hrs.
Peakless 24
Insulin PreMixes
• Regular + intermediate
– Novolin® 10/90, 20/80, 30/70, 40/60, 50/50
– Humulin® 30/70, 20/80
• Analogue Pre-Mix
– Humalog® 25/75 (insulin lispro protamine
suspension)
– NovoMix 30* (protaminated insulin aspart)
* Not available
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Normal Blood Glucose Levels
Blood Glucose (mmols)
1086420
8am
noon
6pm
2am
4am
8am
Time
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Normal Blood Glucose Levels
Blood Glucose (mmols)
1086420
8am
noon
6pm
2am
4am
8am
Time
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Blood Glucose (mmols)
Two injections/day
108642-
R or H + N in AM
R or H + N at Supper
0
8am
noon
6pm
2am
4am
8am
Time
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Blood Glucose (mmols)
10-
Three injections/day
8642-
R or H + N in
AM
R or H at
Supper
N before bed
0
8am
noon
6pm
2am
4am
8am
Time
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Blood Glucose (mmols)
Four injections/day
108642-
R or H at every meal
N or U once or twice/day
0
8am
noon
6pm
2am
4am
8am
Time
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Blood Glucose (mmols)
Continuous Infusion
108642-
0
8am
noon
6pm
2am
4am
8am
Time
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Limitations of Regular Human
Insulin
• Slow onset of activity
– Should be given 30 to 45 minutes before meal
• Inconvenient for patients
• Long duration of activity
– Lasts up to 12 hours
• Potential for late postprandial
hypoglycaemia (4-6 hours)
– Need for additional snack
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Adherence to Injection Recommendation
(Canada)
"When do you inject your insulin?"
% of Respondents
100
42%
32%
22%
4%
0
30–45 min
15–30 min
0–15 min
Before
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1998 Roper Starch Canada, Premix Insulin Using
Meal
0–15 min
After
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Dissociation of Regular Human
Insulin
Regular Human Insulin
10-3 M
10-3 M

formulation
10-5 M

hexamers
10-8 M
peak time
2-4 hr

dimers
monomers
capillary membrane
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Objectives for the Development of ShortActing Insulin Analogues
• Modify time action to address
– Postprandial hyperglycemia
– Hypoglycemia
• Improve safety and convenience
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Whats’ new in type 1 diabetes
treatment?
• Insulin analogues.
• Physiological insulin replacement
• Aggressive “intensive” management
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4 injections per day
Insulin infusion pumps
Continuous glucose monitoring systems
Integrated technologies for monitoring control
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Non-diabetic Insulin and Glucose
Profiles
Breakfast
Lunch
Supper
75
Insulin
(µU/mL)
50
Insulin
25
Basal insulin
0
9.0
Glucose
6.0
Glucose
(mmo/L) 3.0
Basal glucose
0
7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
a.m.
p.m.
Time of Day
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NovoRapid® (insulin aspart)
Time-Action Profile
0
2
4
6
8
10
12
14
16
18
20
22
24
NovoRapid®
Rapid-acting insulin analogue
Onset: 10-20 minutes
Maximum effect: 1-3 hours
Duration: 3-5 hours
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Goal of Insulin Therapy
We are trying to duplicate
how the pancreas works in
releasing insulin for
someone who doesn’t
have diabetes
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Insulin Therapy Options
• MDI therapy
– 0.5 units/kg = total daily dose
– 4x/day 40% NPH @ hs and 60% rapid acting
analogue ac meals
– For patients with significant complications (i.e.
renal failure, foot infections, CVD, etc…)
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Basal Insulin
In someone without diabetes, the
pancreas delivers a small amount of
insulin continuously to cover the body’s
non-food related insulin needs.
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Bolus Insulin
The amount of insulin required to
cover the food you eat.
Fast-acting or Short-acting
(clear) insulin works as a
Bolus Insulin
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Why count carbs?
• More precise way of measuring the
impact of a meal on blood sugar
• Lets you decide how much insulin is
needed to “cover” the meal
• Greater flexibility -eat what you want,
when you want to eat it
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Fine Tuning: Bolus Doses
• Carbohydrate counting or pre-determined
meal portion
• Individualized insulin to carbohydrate dose
or insulin to meal dose
• Adjust bolus based on post-meal BGs or
next pre-meal BG
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Fine Tuning: Basal Rate
• Monitor BG pre-meal, post-meal,
bedtime, 12am, and 2-4am
• Test fasting BG with skipped meals
• Adjust nighttime basal based on
2-4am and pre-breakfast BG
• Adjust basal by 0.1 u/hr to avoid
over-correction
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Novolin®ge 30/70
Time-Action Profile
Premixed insulin
Onset: 0.5 hour
Maximum effect: 2-12 hours
Duration: 24 hours
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30/70 - Twice/day
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30/70 Dose Calculation
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•
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Weight = 80 kg
80 kg x 0.3 U/kg = 24 U
2/3 in the AM = 16 Units
1/3 at supper = 8 Units
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Dosage Changes
• Change insulin dose so that peak of action
corresponds to most abnormal value (pre-meal)
• If all values are abnormal - start with fasting
glycemia followed by lunch, supper and bedtime
• Change the dose by increments of 1-4 U
• Not more than twice/week
• Monitor for PATTERNS in hypoglycemia
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Full Range of Novo Nordisk Insulins
0
2
4
6
8
10
12
14
16
18
20
22
24
NovoRapid® Penfill®
Rapid-acting human
insulin analogue
(insulin aspart)
Novolin®ge Toronto Penfill®
Short-acting insulin
(insulin injection, human biosynthetic)
Novolin®ge NPH Penfill®
Intermediate-acting
Insulin (insulin injection, human
biosynthetic)
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Onset: 10-20 minutes
Maximum effect: 1-3 hours
Duration: 3-5 hours
Onset: 0.5 hour
Maximum effect: 1-3 hours
Duration: 8 hours
Onset: 1.5 hours
Maximum effect: 4-12 hours
Duration: 24 hours
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Somogyi Effect
• Hyperglycemia secondary to asymptomatic
hypoglycemia (especially at night)
• If the insulin is increased in evening, the
problem worsens
• Check capillary glycemia around 3 a.m. to
eliminate hypoglycemia
• In this case, reduce the h.s. NPH
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Follow-Up: The Patient’s Role
Every Day
Every 3 months
• Check BG 4-6 times a day,
and always before bed
• Follow hypoglycemia
guidelines
• Follow hyperglycemia
guidelines
• Visit healthcare provider even if feeling well
• Review log book and pump
settings with physician
• Get an A1c test
Every month


Review DKA prevention
Check BG
-
3am (overnight)
1 and/or 2-hour post-meal BG for all meals on a given day
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Case Study #1
• Patient R.M., DM for 9 years
• BMI = 34,
• Meds: metformin 1000 mg BID and
glyburide 10 mg BID, Avandia 8 mg OD
• HbA1C is 9.5 %, FBS 11.8
What is the next step?
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Case Study #2
• Patient K.G., DM for 15 years
• BMI = 23
• Meds: Metformin 1000 mg BID and Gluconorm 2
mg TID
• HbA1C = 8.5%, FBS 7.4
• Post MI
What is the next step?
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