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InsulinTherapyinDiabetesSoManyChoices…

DianaMcNeillMD,FACPProfessorofMedicine

DukeUniversityMedicalCenter

Disclosures

• Mytonomy-consultant• Quantia –webinars• Acknowledgements:

– Dr.SueKirkman-UNC- ChapelHill– Dr.SteveEdelman-UC-SanDiego– JanNicolleratDiabetes EducatorEmeritusDuke

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• 45yearoldmalewithType2diabetestimes5years

• MetforminandGlipizide• HgbA1C9.5(decreasedfrom11%atdiagnosis)

• Feelspoorly-• Hisbossaskedhim-”whyareyousolethargic?”

Shouldhestartinsulin?

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Basal

• Backgroundinsulin

Bolus

• Mealinsulin• Correction(Notslidingscale)

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InsulinPreparationsModifiedhumaninsulins Regular,NPH

Insulinanalogs RapidActing:Aspart,Glulisine,LisproLongActing:Glargine,Detemir,Degludec

Premixedinsulins HumanN/R:70/30,50/50(Proportions) “N”/Analog:70/30,75/25

Degludec/Aspart:70/30

ConcentrationsotherthanU-100 U-500RegularDegludec U-200Lispro U-200GlargineU-300

Basalinsulin+GLP1agonists IDegLira,LixiLan

BiosimilarInsulin BasaGlar (glargine)

Insulinotherthanbyshots InhaledinsulinDisposableinsulindeliverydevice

Kirkman,ACPPrecourse,2017

Whatdoesitallmean?

• U-100• U-200• U-300• U-500

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Aunitisaunit

WhichBasaltoUse?

• NPHmuchcheaper(uninsured/doughnutholepatient);cautionregardinghypoglycemia

• Ifhypoglycemiaaconcern:Basalanalog– Biosimilarglarginemodestlylesscostly(discusslater)

• Ifhypoglycemiaonglargineordetemir– Considerdegludec orglargineU-300

Kirkman,ACP2017

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Patientscanadjusttheirinsulin

• Mathliteracy• Checkbloodglucose• Clearglycemicgoals• Avoidhypoglycemia

CostisafactorInsulin Cost Delivery

NPH(Novolin) $24.00 10mlof100units/ml

Lantus $266.78 5pens/3ml

Basalgar $333.32 5pens/3ml

Toujeo $275.28 3pens/1.5ml

Tresiba $464.38 5pens/3ml

PricesfromGoodRx atWalmart5/2017

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Factorsthataffectinsulinabsorption

Exercise Strenuous use of injected limb within one hour

Massage of area Do not rub site vigorously

Temperature Heat increases, cold decreases

Site of Injection Abdomen>arms>thigh (R & N only)

Lipohypertrophy Delays absorption

Large doses (>80 units)

Delay onset and duration

Adapted from www.endotext.org, 2004

PatternAdjustmentsinInsulinTherapy

• KnowTargetBloodGlucoses• Gatherdata• Lookforpatterns• Assessinfluencingfactors• Takeaction

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DiabetesManagementDosingInfoforSQInsulin:KEYisWEIGHT-

BASEDTotalDailyDose

Type1– start0.3-0.5units/kg/dayOftenquitesensitive;startonlowend

Type2– start0.3-0.7units/kg/dayNewtoinsulin:startonlowend

Somepatientsmayrequire>1unit/kg/day

Lien LF, Cox ME, Feinglos MN, Corsino L. (eds.) Glycemic Control in the Hospitalized Patient, 1st Edition. Springer, 2010

EXAMPLE: 100 kilogram patient X 0.3 units/kg/day = 30 units /day = Total Daily Dose

TruthorMyth?Addingasingleinjectionofinsulinatbedtimetoyouroralmedicationscan

makealargeimprovementinyourbloodsugarlevels?

Absolutely TrueJanNicolleratANP,CDE

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CombinationTherapy

• 1injectionperday• Convenience(usuallygivenatnight)• Slow,safe,andsimpletitration• Noneorlimitedweightgain• Effectiveimprovementinglucosecontrol

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DiabetesManagement

DistributionoftheTotalDailyDoseBasicStartingRegimens:(Type2…)(Oralplus)BasalInsulinTherapy(1-injection)

PremixedInsulinTherapy(2-injections)

Intensification:(Type1andType2)MostIntensive:Basal-BolusInsulinTherapy(4-shots)

Inbetween:StepwiseAdditionofBolusInsulintoBasalInsulin

Leahy JL. “Insulin Therapy in Type 2 Diabetes Mellitus” Endocrinol Metab Clin North Am01-MAR-2012; 41(1): 119-44

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A59year-oldeducatedbusinessmaniscurrentlyonmaximumdosesof3oralagents:Metformin1000mgBID,Glipizide20mgBIDandPioglitazone45mgQD

Refusedtostartinsulinforyears,butdidtry10unitsofglargine atbedtime.It“didnotwork”andhestoppeditweeksago.A1c>8.8%forthepast3years.CurrentHGMresultsbelow.

JanNicolleratANP,CDE

B L D HS

Mon 227 --- --- 195

Tues 241 --- 179 ---Wed 199 --- --- ---Thurs 265 --- 168 ---

Case Presentation

JanNicolleratANP,CDE

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Why did this person with diabetes have such a hard time?

A.Patient inertia: He was afraid to start insulin

B.PCP inertia: The physician waited too long to discuss insulin

C.The dose of insulin was not increased appropriately