Transcript HRCT ABNORMALITIES AND CHANGES IN LUNG FUNCTION

Management of Type 2
Diabetes with Basal Bolus
Treatment Strategies
Bruce W. Bode, MD, FACE
Atlanta Diabetes Associates
Atlanta, Georgia
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Goals of Intensive Insulin
Therapy
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Maintain near-normal glycemia
Avoid short-term crisis
Minimize long-term complications
Improve quality of life
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12
Hours
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ACE/AACE Targets for Glycemic
Control
Fasting/preprandial glucose
<110 mg/dL
Postprandial glucose
<140 mg/dL
A1C
ACE/AACE Consensus Conference; August 2001; Washington, DC.
<6.5 %
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Type 2 Diabetes:
A Progressive Disease
Over time,
most patients will need insulin
to control glucose
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Mimicking Nature with
Insulin Therapy
Over time,
most patients will need
both basal and mealtime insulin
to control glucose
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The Basal/Bolus Insulin Concept
• Basal insulin
— Suppresses glucose production between
meals and overnight
— 40% to 50% of daily needs
• Bolus insulin (mealtime)
— Limits hyperglycemia after meals
— Immediate rise and sharp peak at 1 hour
— 10% to 20% of total daily insulin
requirement at each meal
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Physiological Serum Insulin
Secretion Profile
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Plasma insulin (U/mL)
Breakfast Lunch
Dinner
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25
4:00
8:00
12:00
16:00
20:00
24:00
4:00
8:00
Time
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Basal/Bolus Treatment Program with
Rapid-acting and Long-acting Analogs
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Plasma insulin (U/mL)
Breakfast Lunch
Aspart
or
Lispro
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Dinner
Aspart
or
Lispro
Aspart
or
Lispro
Glargine
or
Detemir
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4:00
8:00
12:00
16:00
20:00
24:00
4:00
8:00
Time
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Novo Nordisk Devices in
Diabetes Care
• First pen (NovoPen® 1) launched in 1985
— Committed to developing 1 new insulin
administration system per year
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Lilly Insulin Pens
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Novo FlexPen®
• 3-mL prefilled disposable pen offers
precise dosing
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®
NovoLog FlexPen
®
82% of DNEs Preferred FlexPen®
16%
2%
Prefer FlexPen
®
Prefer Humalog pen
No preference
82%
Source: Diabetes Nurse Educators In-Depth Study—Reactions to FlexPen.
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InDuo™—Integration
Feature:
• Combined insulin
doser and blood
glucose monitor
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InDuo™—Doser Memory
Feature:
• Remembers
amount of insulin
delivered and time
since last dose
Benefit:
• Helps people inject
the right amount
of insulin at the
right time
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Starting MDI
• Starting insulin dose is based on
weight
— 0.2 x wt in lb or 0.45 x wt in kg
• Bolus dose (aspart/lispro)
— 20% of starting dose at each meal
• Basal dose (glargine/NPH)
— 40% of starting dose at bedtime
MDI=multiple dosage insulin.
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Starting MDI in 180-lb Person
• Starting dose = 0.2 x wt in lb
— 0.2 x 180 lb = 36 U
• Bolus dose = 20% of starting dose at
each meal
— 20% of 36 U = 7 U ac (TID)
• Basal dose = 40% of starting dose at
bedtime
— 40% of 36 U = 14 U HS
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Correction Bolus
• Must determine how much glucose is
lowered by 1 unit of short- or rapid-acting
insulin
• This number is known as the correction
factor (CF)
• Use the 1700 rule to estimate the CF
• CF = 1700 divided by the total daily dose
(TDD)
— Ex: if TDD = 36 U, then CF = 1700/36 = 50,
meaning 1 U will lower the blood glucose (BG)
50 mg/dL
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Correction Bolus Formula
Current BG - Ideal BG
Glucose CF
Example:
— Current BG:
— Ideal BG:
— Glucose CF:
220 mg/dL
100 mg/dL
50 mg/dL
220 - 100
= 2.4 U
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Case 1: DM 2 on SU with
Infection
• 49-year-old white man
• DM 2 onset age 43, ht 70", wt 173 lb
• On glimepiride (Amaryl®) 4 mg/d,
A1C 7.3% (intolerant to metformin)
• Infection in colostomy pouch
(ulcerative colitis) glucose up to
300 mg/dL plus
• SBGM 3 times per day
SU=sulfonylurea; DM=diabetes mellitus; SBGM=self blood-glucose monitoring.
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Case 1: DM 2 on SU with
Infection (cont’d)
• Started on MDI
• Did well, average BG 138 mg/dL at
1 month and 117 mg/dL at 2 months
post episode with A1C 6.1%
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Case 2: DM 2 on 70/30
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60-year-old African American man
DM 2 age 56, ht 69", wt 180 lb
Failed oral agents
On 70/30 BID: 10 U AM and PM
A1C 8.4%,
SMBG 144 on 0.8 tests/d
Increased 70/30, tried 3x/d, still not at
goal
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Case 2: DM 2 on 70/30 (cont’d)
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Finally agrees to MDI
Starting dose: 0.2 x wt in lb (36 U)
Bolus: 20% pre-meal (7 U ac TID)
Basal: 40% bedtime or anytime (14 U HS)
CF: 1700 divided by TDD (50 mg/dL)
Does great—A1C 6.4%
Current dose:
— 4 U AM, 4 U noon, 10 U PM, 16 U Lantus® HS
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Options to MDI
• Simpler regimen
• Insulin pump
• Premixed BID (DM 2 only)
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Variable Basal Rate:
CSII Program
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Plasma insulin (U/mL)
Breakfast
Lunch
Dinner
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Bolus
Bolus
Bolus
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Basal infusion
4:00
8:00
12:00
16:00
20:00
24:00
4:00
8:00
Time
CSII=continuous subcutaneous insulin infusion.
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History of Pumps
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Pump Infusion Sets
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Metabolic Advantages with CSII
• Improved glycemic control
• Better pharmacokinetic delivery of
insulin
— Less hypoglycemia
— Less insulin required
• Improved quality of life
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CSII: Factors Affecting A1C
• Monitoring
— A1C = 8.3 - (0.21 x BG/d)
• Recording 7.4 vs 7.8
• Diet practiced
— CHO: 7.2
— Fixed: 7.5
— WAG: 8.0
• Insulin type (Aspart)
Bode et al. Diabetes. 1999;48(suppl 1):264.
Bode et al. Diabetes Care. 2002;25:439.
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Self-Monitored Blood Glucose
in CSII
Blood Glucose (mg/dl)
220
NovoLog®
Buffered Regular
Humalog®
200
180
160
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140
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120
Type 1 Diabetes
100
80
Before and
90 min. after
breakfast
Before and
90 min. after
lunch
Bode, Diabetes 2001 ; 50(S2):A106
Before and
90 min. after
dinner
Bedtime 2 AM
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Symptomatic or Confirmed
Hypoglycemia
P<0.05
P<0.05
Episodes/month/patient
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30% relative reduction
10
8
6
4
2
0
Insulin aspart
Human insulin
Bode et al. Diabetes Care. March 2002.
Insulin lispro
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DM 1 CSII Patient:
Lispro to Aspart
700
Lispro
Average = 140
SD = 118
Glucose (mg/dL)
600
500
Aspart
Average = 118
SD = 73
400
300
200
100
0
5/9/2001
5/29/2001
6/18/2001
7/8/2001
7/28/2001
8/17/2001
9/6/2001
9/26/2001
10/16/2001
11/5/2001
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Glycemic Control in Type 2 DM:
CSII vs MDI in 127 Patients
A1C
Baseline
End of study (24 wk)
8.4
8.2
8.0
7.8
7.6
7.4
7.2
7.0
CSII
Raskin et al. Diabetes. 2001;50(suppl 2):A128.
MDI
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CSII vs MDI in DM 2 Patients
CSII
MDI
Less Pain
Less Social Limitations
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Preference
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Advocacy
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Less Hassle
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Less Life Interference
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General Satisfaction
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Flexibility
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Convenience
Less Burden
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-5
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5
10
15
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Change in Scores (Raw Units) From Baseline to Endpoint
Raskin et al. Diabetes 2001;50 Suppl 2:A128
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DM 2 Study: CSII vs MDI
• 93% in the CSII group preferred
the pump to their prior regimen
(insulin ± OHA)
• CSII group had fewer hyperglycemic
episodes (3 subjects, 6 episodes vs
11 subjects, 26 episodes in the
MDI group)
Raskin et al. Diabetes. 2001;50(suppl 2):A128.
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Case 3: DM 2 Poorly Controlled
• 58-year-old woman presented with a
12-year history of poorly controlled, insulin
treated diabetes
• Ht 66", wt 174 lb, BMI 28, C-peptide 2.1
• A1C 10.4% on 165 U/d (70/30 BID)
• Added troglitazone, metformin, glimepiride
to MDI insulin
• A1C range 7.7% to 12.6% over 3 years
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Case 3: DM 2 Poorly Controlled
(cont’d)
• Admitted twice for IV insulin and
fasting with short-lived success (A1C
to 7.6% but back up to 12.6%)
• Tried WeightWatchers® and appetite
suppressants—no help
• Decided to try CSII
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Case 3: DM 2 on CSII—
A1C Results
%
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11
10
9
8
7
6
5
4
A1C
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Case 3: DM 2 Poorly Controlled
• Patient loves the pump
• A1C remains normal as of 3/03
on 110 U/d consuming 2 meals/d
(1.4 U/kg or 0.6 U/lb)
• Also on rosiglitazone 4 mg/d
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Normalization of Lifestyle
• Liberalization of diet—timing and
amount
• Increased control with exercise
• Able to work shifts and through lunch
• Less hassle with travel—time zones
• Weight control
• Less anxiety in trying to keep on
schedule
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Current Continuation Rate: CSII
Continued 97%
Discontinued 3%
N=165.
Average duration=3.6 y.
Average discontinuation <1%/y.
Bode BW, et al. Diabetes. 1998;47(suppl 1):392.
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US Pump Usage: Total Patients
Using Insulin Pumps
250,000
Total no. of patients
200,000
200,000
157,000
150,000
120,000
100,000
81,000
50,000
6600
15,000
11,400
8700
'90
'91
60,000
35,000
26,500
43,000
20,000
0
'92
'93
'94
'95
'96
'97
'98
'99
'00
'01
'02
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Current Pump Therapy
Indications
• Diagnosed with diabetes
(even new onset DM 1)
• Need to normalize BG
— A1C > 6.5%
— Glycemic excursions
• Hypoglycemia
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Pump Therapy
Basal Rate
• Continuous flow of insulin
• Takes the place of NPH or
glargine insulin
Meal Boluses
• Insulin needed premeal
— Premeal BG
— Carbohydrates in meal
— Activity level
Units
• Correction bolus for high BG
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5
4
3
2
1
12 AM
Meal bolus
Basal rate
12 PM
Time of day
12 AM
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If A1C Is Not at Goal
Must look at:
• SMBG frequency
and recording
• Diet practiced
— Do they know
what they are
eating?
— Do they bolus for
all food and
snacks?
• Infusion-site areas
— Are they in areas
of lipohypertrophy?
• Other factors:
— Fear of low BG
— Overtreatment of
low BG
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If A1C Not at Goal and
No Reason Identified
• Place on a continuous glucose
monitoring system (CGMS by
Medtronic MiniMed, GlucoWatch® by
Cygnus) to determine the cause
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Summary
• Insulin remains the most powerful
agent we have to control diabetes
• When used appropriately in a
basal/bolus format, near-normal
glycemia can be achieved
• Newer insulins and insulin delivery
devices along with glucose sensors
will revolutionize our care of diabetes
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Conclusion
• Intensive therapy is the best way to
treat patients with diabetes
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Billing
• Get paid for what you do
• Use your codes and negotiate for
coverage
• Detailed visit: 99214
• Prolonged visit with contact plus
above: 99354 or 99355 (insulin start
or pump start)
• Prolonged visit w/o contact plus
above: 99358 or 99359 (faxes, phone
calls, e-mails)
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Billing (cont’d)
• Bill faxes as prolonged visits without
contact or negotiate a separate
charge
• Bill meter download: 99091
• Bill CGMS: 95250
• Bill immediate A1C: 83036
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Questions
• For a copy or viewing of these slides,
contact: www.adaendo.com
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