Transcript insulin Management in type 2 diabetes mellitus

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insulin Management in type 2
diabetes mellitus
PRACTICAL POINTERS FOR CLINICAL PRACTICE
What is so frightening about
diabetes???
Denial, myths, fear....
I can’t have diabetes, I feel GREAATTTT!
Only fat people get diabetes, so if I keep my
weight down, I won’t get it.
My grandmother told me that diabetes comes
from eating too much sugar.
I took my medication once or twice a week. I
really don’t think it helped, so I quit taking it.
the diabetes epidemic
MANAGE SMARTER AND
MORE AGGRESSIVELY
Indications for Insulin therapy
Adjunctive therapy - used when oral agents alone fail to achieve target glycemic goals
Basal insulin at bedtime decrease fasting blood sugars, oral agents control blood sugar during
the day.
Replacement therapy - used when both basal and meal-time insulin are needed.
Glucose Toxicity - use Intensive Insulin Therapy (IIT) for 2-4 weeks at diagnosis which may improve
endogenous insulin secretion and sensitivity.
Triggers for starting insulin:
persistent glucose > 250 mg/dl.
HbA1c > 10%
ketonuria
symptoms - polyuria, polydipsia, weight loss
IIT used early can resolve glycemic issues faster than oral agents.
Other - during hospitalization, pre-operatively, with steroid therapy, or at any time that glycemic control
deteriorates
Pregnancy
triggers
for
Contraindications to oral medications
starting
insulin
failure
Insulin Products
Insulin Regimens
How to Start and intensify
INsulin
Starting insulin
Is a process
Generally takes a few weeks
Familiarize patient with insulin administration
Build patient confidence
Gradual improvement of glycemic control while
avoiding hypoglycemic episodes
If available, consultation with CDE is invaluable
Start Simple
Long acting or immediate acting insulin
Add short acting with meals to reduce post-meal
rises
Continue to use oral agents; Metformin, TZDs,
DPP-4’s
Sulfonylureas - discontinue
May require 20-30% more insulin if oral agents
are discontinued
Commercial for Certified
Diabetes Educators
Insulin Regimens
basal regimen
Once daily injection of Glargine, Detemir, NPH
Given at bedtime to lower fasting blood glucose
Can be used alone or with oral agents
Detemir and NPH may need to be given twice
daily
NPH associated with more hypoglycemia
Raising basal only can lead to lows at night
Glargine and Detemir are more costly than
Intermediate and Short-Acting Regimen
✰ Add short-acting insulin if post-meal
blood sugars are high
Split-Mix: consider that insulin proportions are
✰
typically 2/3 in morning and 1/3 in evening.
Ratios of long-acting/NPH to rapid/Regular of
2:1
in am and 1:1 in evening.
Split-mix often leads to hypoglycemia in
✰
middle of
night related to NPH peak at 6-8 hours after
Basal-Bolus Regimen
Ideal for replacement insulin therapy
Preferred for patients who have unpredictable
mealtime and activity schedules.
Basal insulin is 40-50% of total daily dose of
insulin
Bolus
given
pre-meal
should
be
50-60%
- may be adjusted according to
carbohydrate
counting using insulin-to-carbohydrate
ratio
How to Figure Insulin to CArb
Ratio (I:CR)
To Figure I:CR divide
amount of carb person
is consuming by
amount of insulin
taken at meal
☞
Example:
60gm ÷ 10 units = 6
I:CR is 1:6
☟
If person
eats 75 gm
carbs
☞
75 mg ÷ 6
=
12 units
Sensitivity/Correction Factor
Used for patients with varying blood glucose
Corrects pre-meal highs or lows
Given only before meals
Ensures that the post-meal glucose will be in
acceptable range
More commonly used in Type1 vs. Type 2
Calculation:
Sensitivity/Correction Factor
Divide 1500 by total daily dose (TDD) insulin this determines the sensitivity ratio.
Example: 1500 ÷ 50 units/day = 30
Correction Factor: If patient blood sugar is 250
mg/dl. and target blood glucose range is 100
mg/dl. , figure 1 unit of insulin is needed for every
30 pts. above target range of 100 mg/dl.
Doing the Math
Target Glucose Range: 100 mg/dl.
I:CR 1:6
Sensitivity Factor: 1:30
Patient blood glucose is: 250 mg/dl.
Calculation:
SMBG
Target
250 mg/dl. - 100mg/dl. = 150
Sensitivity: 1:30 150÷30 = 5 units
I:CR person eats 75 gms. at lunch = 12 units
Meal Bolus =12 units PLUS 5 units correction = 17
units
IIT IMPortant tips
In Intensive Insulin Therapy
(IIT)
If person eats 3 meals/day and 3 carb
snacks they should bolus 6 times per day
Better managed with consistent carb intake at
meals rather than snacks - reduces # of
injections to 3 per day
OR teach patient about non-carb snacks
Self MOnitoring of Blood
Glucose (SMBG)
Very important component of insulin
management to assess and make appropriate
and safe changes
Recommendations for testing vary as to patient
and insulin type : 1-2 times if on basal regimen
only OR 2-4 times for combined regimen.
REMEMBER: 4-8 testings provide only 4-8
“snapshots.” Can lose alot of information in
between & at night
IMPORTANT: Evaluate fasting and 2 hour
postprandial blood glucose readings when
chosing basal insulin only, mixed insulins, or
basal-bolus regimens (IIT)
Target is a blood sugar < 180 mg/dl. or A1c of
7% or less.
Need to check postprandials at different meals to
identify a pattern that may be ocurring
CONTINUOUS GLUCOSE
MONITORING (CGMS)
Medical Nutrition Therapy
Proper nutrition is
essential to insulin
management.
ADA recommends
individualized MNT
Teaches carb
counting and is
individualized to
patient’s level of
understanding
Current Nutrition Recommendations:
3 meals / day; 30-45 gms. carbs
each
With or Without
1-2 snacks in between meals - if
each snack is < 30 gms. no
additional
rapid-acting insulin needed
Focus of MNT
Lifestyle changes
Increased physical
activity
Pt. may chose to eat
3 meals/day OR
small meals with
snacks
CArbohydrates
Greatest impact on postprandial blood sugars
Patient should understand which foods contains
carbs
Understand portion size & number of servings
per meal/snack
Total carb consumption vs. type of carb impacts
blood sugar control
No evidence to support low vs. high glycemic
Protein
Is widely misunderstood in diabetes glycemic
control
Does raise plasma glucose concentration - amt.
produced is small and does not appear in general
blood circulation
Protein has not been found to slow carbohydrate
absorption
Does not treat hypoglycemia
FAts
Intake should be limited
Saturated fat is the primary determinant of LDL
Trans fats increase LDL & lower HDL - limit as
much as possible
Initial MNT guidelines
Consume 3 meals/day, not skip meals
Meals no more than 4-6 hrs. apart
Set maximum carbohydrate intake per meal
Avoid regular soda, fruit juice, sport drinks,
choose water
Food label - focus on serving size & total carbs
Men: 60-70 gms carbs., Women: 45-60 gms
Barriers to insulin
Hypoglycemia
Weight gain
Psychological Barriers
Lipodystrophy
Allergic reactions
Glargine insulin associated with cancer risk
IN Summary
☤ Insulin is very effective but underused in T2DM
Insulin can be used earlier in disease and
☤
as an adjunct to oral medications
Transition
to
insulin
should
not
be
☤
regarded as a failure by patient or provider
Primary
care
providers
should
be
familiar
☤
with indications for insulin, insulin
regimens used & side effects
Adequate
support
for
patients
is
key
to
☤
transitioning and the success of treatment
♡ ♡
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"Too often we underestimate the power of a touch, a smile, a kind word,
a listening ear, an honest compliment, or the smallest act of caring, all of
which have the potential to turn a life around."
~ Leo Buscaglia ~