Transcript Insulin Initiation In Primary Care

Insulin Initiation In
Primary Care
Dr Arla Ogilvie Endocrinologist Watford General Hospital
West Herts Hospitals NHS Trust
Does the Patient Need Insulin?
?Is it appropriate for the patient to be
managed in Primary Care?
?Sufficient
Knowledge
Skills
Support
Time
Confidence
? Have all other factors relating to control
been addressed
Insulin Resistance….3Types
Liver
Muscle
Patient
Metabolic
Doctor
Before you start……
Understand the patient Understand the insulin
• Is insulin necessary?
• Factors in poor control
– Diet and ex
– Compliance with Rx
– Health beliefs
– Fears
• Hypoglycaemia
• Weight gain
• Occupation
• Type and regime
– Once daily + oral agents
– Twice daily premix
– (Basal bolus???)
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Starting dose
Patient EDUCATION
TIME for follow up
Dose titration
Regular review and support
Setting Individual Goals
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Optimise blood glucose control
Keep patient asymptomatic
Prevent long term complications
Avoid hypoglycaemia
Preserve Quality of Life
Safety is paramount!
Self-monitoring of blood glucose
• Monitoring glucose is essential for safe and
successful insulin treatment:
– It guides dose adjustment
– It allows patients to see the impact of behaviours and
diet on glucose
• Patients MUST know how to monitor glucose
• The most important aspect of self-monitoring is
that the patients DO something with the results
Diabetes UK. http://www.diabetes.org.uk/hcpreports/primary_recs.pdf, 2005
National Diabetes Support Team.
http://www.cgsupport.nhs.uk/downloads/NDST/Factsheet_Glucose_Self_Monitoring.pdf, 2005
NICE. http://www.nice.org.uk/page.aspx?o=36882, 2005. Owens D et al. Diabetes and Primary Care 2004;6:8–16
Insulin activity
Once-daily basal insulin
Insulin
• Duration depends on the insulin
• Insulin analogues may provide 24-hour cover
• Intermediate isophane preparations (Insulatard
and Humulin I) may only be active for
8 – 18 hours and have a more pronounced
peak activity
Time (8–24 hours)
Schematic representation
Benefits of a once-daily basal
insulin regimen
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One injection per day
Useful for patients reluctant to start insulin treatment
Works best for morning hyperglycaemia
Useful where someone else has to administer insulin
May help overcome fear of starting insulin
Some basal insulin injections may provide a weight
benefit1
1.Philis-Tsimikas A et al. Clin Ther 2006;28:1569–
81
Limitations of once-daily basal
insulin regimen
• Does not provide insulin for post-meal glucose
surges:
– Assumes patient can produce sufficient insulin
to cover these mealtime requirements
• Requires a fairly strict, predictable diet:
– Dosing during the day is inflexible and so
patients need to intake similar calories
each day
How Much?
TYPE 2
Nocte Isophane insulin
Insulatard or Humulin I
Start 10units + Metfomin
and Sulphonylurea
(Glitazone)
Titrate once or twice
weekly
Newer agents
•Gliptins
•GLP1 Analogues
Are NOT licensed
To be given with
insulin
Easy Dose Adjustment for
Once Daily Basal Insulin
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The 3 – 0 – 3 Rule
After Initiation
Adjust insulin every 3 days
Based on fasting glucose
If average glu > 7 – increase by 3 units
If glu < 4mmol/l decrease by 3 units
Premixed insulin
Insulin activity
Basal + Rapid acting
component
Brkfast Lunch
Dinner Bedtime
Mixtard 30 – may need snacks
Wait 30 mins between injecting and eating
Possible regimens:
• Once daily with largest
daily meal (usually
dinner)
• Twice daily with
dinner and breakfast
• Three times daily, with
each meal
Novomix 30 No snacks needed
Inject and eat immediately
Benefits of a premixed insulin
regimen
• Targets mealtime glucose
• Can be initiated as one injection per day to
familiarise patient with injecting (Most need
twice daily)
• Second or third injections of same insulin can be
added if necessary to optimise control
• Need fairly regular lifestyles, Eat similar
amounts at similar times
1. Garber AJ et al. Diabetes Obes Metab 2006;8:58–66
Analogue basal-bolus therapy
Rapid
insulin
Rapid
insulin
Rapid
insulin
Rapid-acting insulin
Long-acting insulin
Insulin activity
Long-acting
insulin
Breakfast Lunch
Dinner Bedtime
Benefits of a basal-bolus
insulin regimen
• Closest to natural insulin production by the body
• Not necessary for majority of Type 2
• May be needed for those who have erratic
mealtimes, work variable shifts
• Gives more flexibility over type of food and
when it can be eaten
• Suited to those who are highly motivated
• Need to monitor 4 times daily to optimise doses
Insulin with or without oral
agents?
• Oral agents can be continued when once daily
basal insulin is initiated
• It is recommended that metformin is continued
where possible in T2 DM
• Stop Sulphonylurea with premixed insulin
• Glitazones can be used with insulin – usually
where intolerant to metformin. Oedema may be a
problem
Commencing Insulin Therapy
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Ensure patient can blood glucose monitor and understands
BG targets
Assess patient for suitable device
Educate patient regarding :
Storage, timing and action of insulin.
Device use and safety
Injection technique, sites and rotation.
Hypoglycaemia
Driving safety and legal Implications
Sick day Rules –
Dose Adjustment and exercise ( if suitable)
After education full assessment carried out to ensure
patient competence and safety.
POOR CONTROL Troubleshooting!
 Compliance - Rx, lifestyle, acceptance
 Unable to use Pen - check technique
 Withdrawing needle too soon - ‘count to 10’
 Site problems -random rotation/hypertrophy
 Wrong timing of injections
 Eating to avoid hypos
 Rebound hyperglycaemia- check Sx of hypo