Dr David Kim Mr Rab Burtun - gpcme.co.nz North/Thur_room2_0831- Rab Basic.pdfHeart failure 12% ↓...
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Dr David Kim Endocrinologist and General Physician Waitemata DHB and Apollo Specialist Clinic Albany Auckland 8:30 - 10:30 WS #2: Diabetes Basic 11:00 - 13:00 WS #9: Diabetes Basic (Repeated) Mr Rab Burtun Diabetes Nurse Specialist Waitemata DHB Waitakere Hospital Auckland
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Transcript of Dr David Kim Mr Rab Burtun - gpcme.co.nz North/Thur_room2_0831- Rab Basic.pdfHeart failure 12% ↓...
Dr David KimEndocrinologist and General Physician
Waitemata DHB and Apollo Specialist
Clinic Albany
Auckland
830 - 1030 WS 2 Diabetes Basic
1100 - 1300 WS 9 Diabetes Basic (Repeated)
Mr Rab BurtunDiabetes Nurse Specialist
Waitemata DHB
Waitakere Hospital
Auckland
06062018 Rab Burtun DSN
Breaking Down the Barriers
to Insulin use
06062018
Rab Burtun DSN
WDHB Waitakere Hospital
06062018
Where do we start
Dear DrThank you for seeing Mr Tough
guy who is a 48 yrs old builder
Type 2 for 8 yrs on
Metformin 850 mg bd
Glipizide 10 mg bd
Hba1c is 99mmolmol(112)
Says he take his pills everyday
Does not monitor BS says he feels
well
Has Hypertention
Hyperlipedemia microalbuminuria
early retinopathy was found at last
retinal screening
Smokes 20 cigs a day
Very reluctant to go on Insulin
Used to be rugby player Stopped
about 7 yrs ago
Says he can beat Diabetes
06062018 Rab Burtun DSN
06062018
For every
1 (11mmolmol)
Reduction in
HbA1c
43darrAmputations
19 darrCataract
extraction
21 darr All diabetes
related
end points
14darrFatal amp
non-fatal MI
21darrDiabetes related
Death
35darrNephropathy
37darrRetinopathy
16darrHeart failure
12darrFatal or
Non-fatal stroke
Stratton IM Adler AI Andrew H et al Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS35) prospective observational studyBritish Medical Journal 2000 321 405-11
14 darr All cause
mortality
06062018
Progressive nature of Diabetesbull Before insulin initiation patients may have
spent an average of about 5 years with an A1C gt8 or 64 mmolsmol and nearly 10 years gt7 or 53 mmolmol
bull At diagnosis up to 50 of a patients β-cell function may have been lost and may continue to decline by about 4 annually
bull Remind patients that diabetes is a progressive disease and that their treatment plans may be adjusted over time An overall treatment plan to lower A1C consists of diet exercise and diabetes medication which may include insulin
bull 50 of Type 2 needs to go on Insulin within 7 yrs (UKPDS)
bull Let patients know fear of insulin is not uncommon Help them understand the facts about insulin therapy
Islet β-cell function (HOMA B)
in the UKPDS
06062018HOMA=homeostasis model assessment UKPDS=United Kingdom Prospective Diabetes Study
UKPDS Group Diabetes 1995
Conservative
(primarily diet)Islet β-cell function ()
100
80
60
40
20
0
Non-overweight Overweight
0 1 2 3 4 5 6 0 1 2 3 4 5 6
Sulfonylurea
Metformin
Loss ~4 per year
Years from randomization
-2
-1
0
1C
han
ge i
n H
bA
1c (
)
TIME (years)0 1 2 3 4 5 6 10
Hanefeld (n=250)
Charbonnel (n=313)
Chicago (n=230)
ADOPT (n=1441)
UKPDS (n=1573)
Gliclazide
PERISCOPE (n=181)
GLY
GlimepirideGlyburide Glyburide
Glyburide
Glyburide
SU
SU
Alvarsson (n=39)
Alvarsson (n=48)
RECORD (n=272)
Tan (n=297)
Gliclazide
DURABILITY OF GLYCEMIC CONTROL WITH
SULFONYLUREAS
06062018
Insulin-the most effective intervention3
It lowers mean blood glucose in a predictable dose-dependent manner
Can be tailored to individual needs on a unit-to-unit basis
It has the longest experience than any other drug (90 years)
No contraindications to its use
Advantages of insulin
The DAWN( DiabetesAttitudesWishes and Needs)
bull The DAWN study 2001 is to date the largest global psychosocial diabetes study of its kind addressing the perceptions and attitudes of more than 5000 people with diabetes and 3000 healthcare diabetes professionals in a total of thirteen countries
bull The 13 countries involved were Australia Denmark France Germany India Japan The Netherlands Norway Poland Sweden Spain UK and USA
bull The study involved
bull 5426 adults with diabetes
bull 2194 primary care physicians
bull 556 specialists (endocrinologists diabetologists)
bull 1122 nurses (specialist and general)
bull The people with diabetes interviewed were self-classified as 50 Type 1 and 50 Type 2
bull RESULTS
bull More than half of people with Type 2 diabetes are worried about starting insulin
bull 50 report insulin means they ldquofailed to manage their diseaserdquo
bull Only 20 believe insulin would ldquohelp them better manage their DMrdquo
bull 13 of Physicians postpone until ldquoabsolutely essentialrdquo
bull Reference
bull Geelhoed-Duijvestijn P et al Physician Resistance to Prescribing Insulin An International Study Diabetologia 2003
bull Peyrot M et al An International Study of Psychological Resistance to Insulin Use among Persons with Diabetes Diabetologia 2003
06062018
Global Attitudes of Patients and
Physicians in Insulin Therapy (GAPP) 2010
Surveyed gt2700 pts and MDs in 8 countries
bull 1 in 3 fail to take insulin as prescribed
bull Change in normal routine busy schedule
bull Forgetfulness and fear of hypoglycemia
bull
bull PTs Drs
bull Struggle to control BG 40 88
bull Concern re future hypoglycemia 67 74
bull Hard to comply with regimen over 50
bull Find it hard to fit insulin into schedule 33
bull Desired less frequent doses injections 90
06062018
Most patients chose one reason with substantial breadth of reasons (each reason reported by fewer than 20 of
respondents) Over half of the reported reasons reflect a lack of flexibility in the patientrsquos insulin regimen
which was a statistically significant predictor of frequency of insulin omission non-adherence Frequency of
hypoglycaemia was a statistically significant predictor of frequency of insulin omissionnon-adherence Pain
was not frequently cited as a reason and was not a statistically significant predictor of frequency of insulin
omissionnon-adherence
06062018
Many factors contributes to fears of insulin
Fear of Insulin
Its forever
Disease
getting
worst Some
people have
morphine
injections
when they are
about to die
Hypoglycaemia
Seen friend or
neighbour call
ambulance
Fitting Was
scary
Its forever
Addiction
Once you on it
you stay on it
Cultural beliefs
is it from
pigsCow
Personal
failureI am
a loser why I
cant beat this
Why have
I failed
Lifestyle change
Travelworkbeer
Will I still be able to
go out and have
sweets puddings
etc
Paindoes it go
into a
veinSeen it on
TV Huge needle
and drug addicts
have to find a
veinToo
complicated
Cost the pen
looks nice and
expensive can I
afford that
Overcoming the Barriers
bull Introduce concept of insulin deficiency early Draw picture to show UKPDS slide progressive nature of Type 2 DM
bull Tell the patient they are not ldquofailuresrdquo for needing insulin (Explain UKPDS study showing declining beta cells function over time 50 initially at diagnosis then 4 decline every year therefore 50 of pts need Insulin after about 7 yrs hellip)
bull Newer pens - ldquoeasyrdquo 4mm needles ndash painlessrdquoshow or demonstrate injectionhellip
bull Not complicatedPre-laoded Disposable pens 4 mm needles
bull Insulin is not addictive you can stop anytime but you will start feeling unwell again
bull Use simple regimens to start with (just one shot before bed helps to sleep betterhellip)
bull Weight gain the higher the Hba1c the more weight pt puts on avoid snacks or eating in between meals reduce carb portions benefits of Exercise
bull Emphasise the benefits of improved glycaemic control including ldquofeeling better more energy less infections less trips to toilets less thirsty benefits of or 11 mmols lowering Hba1c by 1 reduces complications by35 UKPDS study rdquo
bull Worst case agree to try Insulin for 1 months and review
662018Christchurch Masterclass 13
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018 Rab Burtun DSN
Breaking Down the Barriers
to Insulin use
06062018
Rab Burtun DSN
WDHB Waitakere Hospital
06062018
Where do we start
Dear DrThank you for seeing Mr Tough
guy who is a 48 yrs old builder
Type 2 for 8 yrs on
Metformin 850 mg bd
Glipizide 10 mg bd
Hba1c is 99mmolmol(112)
Says he take his pills everyday
Does not monitor BS says he feels
well
Has Hypertention
Hyperlipedemia microalbuminuria
early retinopathy was found at last
retinal screening
Smokes 20 cigs a day
Very reluctant to go on Insulin
Used to be rugby player Stopped
about 7 yrs ago
Says he can beat Diabetes
06062018 Rab Burtun DSN
06062018
For every
1 (11mmolmol)
Reduction in
HbA1c
43darrAmputations
19 darrCataract
extraction
21 darr All diabetes
related
end points
14darrFatal amp
non-fatal MI
21darrDiabetes related
Death
35darrNephropathy
37darrRetinopathy
16darrHeart failure
12darrFatal or
Non-fatal stroke
Stratton IM Adler AI Andrew H et al Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS35) prospective observational studyBritish Medical Journal 2000 321 405-11
14 darr All cause
mortality
06062018
Progressive nature of Diabetesbull Before insulin initiation patients may have
spent an average of about 5 years with an A1C gt8 or 64 mmolsmol and nearly 10 years gt7 or 53 mmolmol
bull At diagnosis up to 50 of a patients β-cell function may have been lost and may continue to decline by about 4 annually
bull Remind patients that diabetes is a progressive disease and that their treatment plans may be adjusted over time An overall treatment plan to lower A1C consists of diet exercise and diabetes medication which may include insulin
bull 50 of Type 2 needs to go on Insulin within 7 yrs (UKPDS)
bull Let patients know fear of insulin is not uncommon Help them understand the facts about insulin therapy
Islet β-cell function (HOMA B)
in the UKPDS
06062018HOMA=homeostasis model assessment UKPDS=United Kingdom Prospective Diabetes Study
UKPDS Group Diabetes 1995
Conservative
(primarily diet)Islet β-cell function ()
100
80
60
40
20
0
Non-overweight Overweight
0 1 2 3 4 5 6 0 1 2 3 4 5 6
Sulfonylurea
Metformin
Loss ~4 per year
Years from randomization
-2
-1
0
1C
han
ge i
n H
bA
1c (
)
TIME (years)0 1 2 3 4 5 6 10
Hanefeld (n=250)
Charbonnel (n=313)
Chicago (n=230)
ADOPT (n=1441)
UKPDS (n=1573)
Gliclazide
PERISCOPE (n=181)
GLY
GlimepirideGlyburide Glyburide
Glyburide
Glyburide
SU
SU
Alvarsson (n=39)
Alvarsson (n=48)
RECORD (n=272)
Tan (n=297)
Gliclazide
DURABILITY OF GLYCEMIC CONTROL WITH
SULFONYLUREAS
06062018
Insulin-the most effective intervention3
It lowers mean blood glucose in a predictable dose-dependent manner
Can be tailored to individual needs on a unit-to-unit basis
It has the longest experience than any other drug (90 years)
No contraindications to its use
Advantages of insulin
The DAWN( DiabetesAttitudesWishes and Needs)
bull The DAWN study 2001 is to date the largest global psychosocial diabetes study of its kind addressing the perceptions and attitudes of more than 5000 people with diabetes and 3000 healthcare diabetes professionals in a total of thirteen countries
bull The 13 countries involved were Australia Denmark France Germany India Japan The Netherlands Norway Poland Sweden Spain UK and USA
bull The study involved
bull 5426 adults with diabetes
bull 2194 primary care physicians
bull 556 specialists (endocrinologists diabetologists)
bull 1122 nurses (specialist and general)
bull The people with diabetes interviewed were self-classified as 50 Type 1 and 50 Type 2
bull RESULTS
bull More than half of people with Type 2 diabetes are worried about starting insulin
bull 50 report insulin means they ldquofailed to manage their diseaserdquo
bull Only 20 believe insulin would ldquohelp them better manage their DMrdquo
bull 13 of Physicians postpone until ldquoabsolutely essentialrdquo
bull Reference
bull Geelhoed-Duijvestijn P et al Physician Resistance to Prescribing Insulin An International Study Diabetologia 2003
bull Peyrot M et al An International Study of Psychological Resistance to Insulin Use among Persons with Diabetes Diabetologia 2003
06062018
Global Attitudes of Patients and
Physicians in Insulin Therapy (GAPP) 2010
Surveyed gt2700 pts and MDs in 8 countries
bull 1 in 3 fail to take insulin as prescribed
bull Change in normal routine busy schedule
bull Forgetfulness and fear of hypoglycemia
bull
bull PTs Drs
bull Struggle to control BG 40 88
bull Concern re future hypoglycemia 67 74
bull Hard to comply with regimen over 50
bull Find it hard to fit insulin into schedule 33
bull Desired less frequent doses injections 90
06062018
Most patients chose one reason with substantial breadth of reasons (each reason reported by fewer than 20 of
respondents) Over half of the reported reasons reflect a lack of flexibility in the patientrsquos insulin regimen
which was a statistically significant predictor of frequency of insulin omission non-adherence Frequency of
hypoglycaemia was a statistically significant predictor of frequency of insulin omissionnon-adherence Pain
was not frequently cited as a reason and was not a statistically significant predictor of frequency of insulin
omissionnon-adherence
06062018
Many factors contributes to fears of insulin
Fear of Insulin
Its forever
Disease
getting
worst Some
people have
morphine
injections
when they are
about to die
Hypoglycaemia
Seen friend or
neighbour call
ambulance
Fitting Was
scary
Its forever
Addiction
Once you on it
you stay on it
Cultural beliefs
is it from
pigsCow
Personal
failureI am
a loser why I
cant beat this
Why have
I failed
Lifestyle change
Travelworkbeer
Will I still be able to
go out and have
sweets puddings
etc
Paindoes it go
into a
veinSeen it on
TV Huge needle
and drug addicts
have to find a
veinToo
complicated
Cost the pen
looks nice and
expensive can I
afford that
Overcoming the Barriers
bull Introduce concept of insulin deficiency early Draw picture to show UKPDS slide progressive nature of Type 2 DM
bull Tell the patient they are not ldquofailuresrdquo for needing insulin (Explain UKPDS study showing declining beta cells function over time 50 initially at diagnosis then 4 decline every year therefore 50 of pts need Insulin after about 7 yrs hellip)
bull Newer pens - ldquoeasyrdquo 4mm needles ndash painlessrdquoshow or demonstrate injectionhellip
bull Not complicatedPre-laoded Disposable pens 4 mm needles
bull Insulin is not addictive you can stop anytime but you will start feeling unwell again
bull Use simple regimens to start with (just one shot before bed helps to sleep betterhellip)
bull Weight gain the higher the Hba1c the more weight pt puts on avoid snacks or eating in between meals reduce carb portions benefits of Exercise
bull Emphasise the benefits of improved glycaemic control including ldquofeeling better more energy less infections less trips to toilets less thirsty benefits of or 11 mmols lowering Hba1c by 1 reduces complications by35 UKPDS study rdquo
bull Worst case agree to try Insulin for 1 months and review
662018Christchurch Masterclass 13
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018
Where do we start
Dear DrThank you for seeing Mr Tough
guy who is a 48 yrs old builder
Type 2 for 8 yrs on
Metformin 850 mg bd
Glipizide 10 mg bd
Hba1c is 99mmolmol(112)
Says he take his pills everyday
Does not monitor BS says he feels
well
Has Hypertention
Hyperlipedemia microalbuminuria
early retinopathy was found at last
retinal screening
Smokes 20 cigs a day
Very reluctant to go on Insulin
Used to be rugby player Stopped
about 7 yrs ago
Says he can beat Diabetes
06062018 Rab Burtun DSN
06062018
For every
1 (11mmolmol)
Reduction in
HbA1c
43darrAmputations
19 darrCataract
extraction
21 darr All diabetes
related
end points
14darrFatal amp
non-fatal MI
21darrDiabetes related
Death
35darrNephropathy
37darrRetinopathy
16darrHeart failure
12darrFatal or
Non-fatal stroke
Stratton IM Adler AI Andrew H et al Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS35) prospective observational studyBritish Medical Journal 2000 321 405-11
14 darr All cause
mortality
06062018
Progressive nature of Diabetesbull Before insulin initiation patients may have
spent an average of about 5 years with an A1C gt8 or 64 mmolsmol and nearly 10 years gt7 or 53 mmolmol
bull At diagnosis up to 50 of a patients β-cell function may have been lost and may continue to decline by about 4 annually
bull Remind patients that diabetes is a progressive disease and that their treatment plans may be adjusted over time An overall treatment plan to lower A1C consists of diet exercise and diabetes medication which may include insulin
bull 50 of Type 2 needs to go on Insulin within 7 yrs (UKPDS)
bull Let patients know fear of insulin is not uncommon Help them understand the facts about insulin therapy
Islet β-cell function (HOMA B)
in the UKPDS
06062018HOMA=homeostasis model assessment UKPDS=United Kingdom Prospective Diabetes Study
UKPDS Group Diabetes 1995
Conservative
(primarily diet)Islet β-cell function ()
100
80
60
40
20
0
Non-overweight Overweight
0 1 2 3 4 5 6 0 1 2 3 4 5 6
Sulfonylurea
Metformin
Loss ~4 per year
Years from randomization
-2
-1
0
1C
han
ge i
n H
bA
1c (
)
TIME (years)0 1 2 3 4 5 6 10
Hanefeld (n=250)
Charbonnel (n=313)
Chicago (n=230)
ADOPT (n=1441)
UKPDS (n=1573)
Gliclazide
PERISCOPE (n=181)
GLY
GlimepirideGlyburide Glyburide
Glyburide
Glyburide
SU
SU
Alvarsson (n=39)
Alvarsson (n=48)
RECORD (n=272)
Tan (n=297)
Gliclazide
DURABILITY OF GLYCEMIC CONTROL WITH
SULFONYLUREAS
06062018
Insulin-the most effective intervention3
It lowers mean blood glucose in a predictable dose-dependent manner
Can be tailored to individual needs on a unit-to-unit basis
It has the longest experience than any other drug (90 years)
No contraindications to its use
Advantages of insulin
The DAWN( DiabetesAttitudesWishes and Needs)
bull The DAWN study 2001 is to date the largest global psychosocial diabetes study of its kind addressing the perceptions and attitudes of more than 5000 people with diabetes and 3000 healthcare diabetes professionals in a total of thirteen countries
bull The 13 countries involved were Australia Denmark France Germany India Japan The Netherlands Norway Poland Sweden Spain UK and USA
bull The study involved
bull 5426 adults with diabetes
bull 2194 primary care physicians
bull 556 specialists (endocrinologists diabetologists)
bull 1122 nurses (specialist and general)
bull The people with diabetes interviewed were self-classified as 50 Type 1 and 50 Type 2
bull RESULTS
bull More than half of people with Type 2 diabetes are worried about starting insulin
bull 50 report insulin means they ldquofailed to manage their diseaserdquo
bull Only 20 believe insulin would ldquohelp them better manage their DMrdquo
bull 13 of Physicians postpone until ldquoabsolutely essentialrdquo
bull Reference
bull Geelhoed-Duijvestijn P et al Physician Resistance to Prescribing Insulin An International Study Diabetologia 2003
bull Peyrot M et al An International Study of Psychological Resistance to Insulin Use among Persons with Diabetes Diabetologia 2003
06062018
Global Attitudes of Patients and
Physicians in Insulin Therapy (GAPP) 2010
Surveyed gt2700 pts and MDs in 8 countries
bull 1 in 3 fail to take insulin as prescribed
bull Change in normal routine busy schedule
bull Forgetfulness and fear of hypoglycemia
bull
bull PTs Drs
bull Struggle to control BG 40 88
bull Concern re future hypoglycemia 67 74
bull Hard to comply with regimen over 50
bull Find it hard to fit insulin into schedule 33
bull Desired less frequent doses injections 90
06062018
Most patients chose one reason with substantial breadth of reasons (each reason reported by fewer than 20 of
respondents) Over half of the reported reasons reflect a lack of flexibility in the patientrsquos insulin regimen
which was a statistically significant predictor of frequency of insulin omission non-adherence Frequency of
hypoglycaemia was a statistically significant predictor of frequency of insulin omissionnon-adherence Pain
was not frequently cited as a reason and was not a statistically significant predictor of frequency of insulin
omissionnon-adherence
06062018
Many factors contributes to fears of insulin
Fear of Insulin
Its forever
Disease
getting
worst Some
people have
morphine
injections
when they are
about to die
Hypoglycaemia
Seen friend or
neighbour call
ambulance
Fitting Was
scary
Its forever
Addiction
Once you on it
you stay on it
Cultural beliefs
is it from
pigsCow
Personal
failureI am
a loser why I
cant beat this
Why have
I failed
Lifestyle change
Travelworkbeer
Will I still be able to
go out and have
sweets puddings
etc
Paindoes it go
into a
veinSeen it on
TV Huge needle
and drug addicts
have to find a
veinToo
complicated
Cost the pen
looks nice and
expensive can I
afford that
Overcoming the Barriers
bull Introduce concept of insulin deficiency early Draw picture to show UKPDS slide progressive nature of Type 2 DM
bull Tell the patient they are not ldquofailuresrdquo for needing insulin (Explain UKPDS study showing declining beta cells function over time 50 initially at diagnosis then 4 decline every year therefore 50 of pts need Insulin after about 7 yrs hellip)
bull Newer pens - ldquoeasyrdquo 4mm needles ndash painlessrdquoshow or demonstrate injectionhellip
bull Not complicatedPre-laoded Disposable pens 4 mm needles
bull Insulin is not addictive you can stop anytime but you will start feeling unwell again
bull Use simple regimens to start with (just one shot before bed helps to sleep betterhellip)
bull Weight gain the higher the Hba1c the more weight pt puts on avoid snacks or eating in between meals reduce carb portions benefits of Exercise
bull Emphasise the benefits of improved glycaemic control including ldquofeeling better more energy less infections less trips to toilets less thirsty benefits of or 11 mmols lowering Hba1c by 1 reduces complications by35 UKPDS study rdquo
bull Worst case agree to try Insulin for 1 months and review
662018Christchurch Masterclass 13
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018 Rab Burtun DSN
06062018
For every
1 (11mmolmol)
Reduction in
HbA1c
43darrAmputations
19 darrCataract
extraction
21 darr All diabetes
related
end points
14darrFatal amp
non-fatal MI
21darrDiabetes related
Death
35darrNephropathy
37darrRetinopathy
16darrHeart failure
12darrFatal or
Non-fatal stroke
Stratton IM Adler AI Andrew H et al Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS35) prospective observational studyBritish Medical Journal 2000 321 405-11
14 darr All cause
mortality
06062018
Progressive nature of Diabetesbull Before insulin initiation patients may have
spent an average of about 5 years with an A1C gt8 or 64 mmolsmol and nearly 10 years gt7 or 53 mmolmol
bull At diagnosis up to 50 of a patients β-cell function may have been lost and may continue to decline by about 4 annually
bull Remind patients that diabetes is a progressive disease and that their treatment plans may be adjusted over time An overall treatment plan to lower A1C consists of diet exercise and diabetes medication which may include insulin
bull 50 of Type 2 needs to go on Insulin within 7 yrs (UKPDS)
bull Let patients know fear of insulin is not uncommon Help them understand the facts about insulin therapy
Islet β-cell function (HOMA B)
in the UKPDS
06062018HOMA=homeostasis model assessment UKPDS=United Kingdom Prospective Diabetes Study
UKPDS Group Diabetes 1995
Conservative
(primarily diet)Islet β-cell function ()
100
80
60
40
20
0
Non-overweight Overweight
0 1 2 3 4 5 6 0 1 2 3 4 5 6
Sulfonylurea
Metformin
Loss ~4 per year
Years from randomization
-2
-1
0
1C
han
ge i
n H
bA
1c (
)
TIME (years)0 1 2 3 4 5 6 10
Hanefeld (n=250)
Charbonnel (n=313)
Chicago (n=230)
ADOPT (n=1441)
UKPDS (n=1573)
Gliclazide
PERISCOPE (n=181)
GLY
GlimepirideGlyburide Glyburide
Glyburide
Glyburide
SU
SU
Alvarsson (n=39)
Alvarsson (n=48)
RECORD (n=272)
Tan (n=297)
Gliclazide
DURABILITY OF GLYCEMIC CONTROL WITH
SULFONYLUREAS
06062018
Insulin-the most effective intervention3
It lowers mean blood glucose in a predictable dose-dependent manner
Can be tailored to individual needs on a unit-to-unit basis
It has the longest experience than any other drug (90 years)
No contraindications to its use
Advantages of insulin
The DAWN( DiabetesAttitudesWishes and Needs)
bull The DAWN study 2001 is to date the largest global psychosocial diabetes study of its kind addressing the perceptions and attitudes of more than 5000 people with diabetes and 3000 healthcare diabetes professionals in a total of thirteen countries
bull The 13 countries involved were Australia Denmark France Germany India Japan The Netherlands Norway Poland Sweden Spain UK and USA
bull The study involved
bull 5426 adults with diabetes
bull 2194 primary care physicians
bull 556 specialists (endocrinologists diabetologists)
bull 1122 nurses (specialist and general)
bull The people with diabetes interviewed were self-classified as 50 Type 1 and 50 Type 2
bull RESULTS
bull More than half of people with Type 2 diabetes are worried about starting insulin
bull 50 report insulin means they ldquofailed to manage their diseaserdquo
bull Only 20 believe insulin would ldquohelp them better manage their DMrdquo
bull 13 of Physicians postpone until ldquoabsolutely essentialrdquo
bull Reference
bull Geelhoed-Duijvestijn P et al Physician Resistance to Prescribing Insulin An International Study Diabetologia 2003
bull Peyrot M et al An International Study of Psychological Resistance to Insulin Use among Persons with Diabetes Diabetologia 2003
06062018
Global Attitudes of Patients and
Physicians in Insulin Therapy (GAPP) 2010
Surveyed gt2700 pts and MDs in 8 countries
bull 1 in 3 fail to take insulin as prescribed
bull Change in normal routine busy schedule
bull Forgetfulness and fear of hypoglycemia
bull
bull PTs Drs
bull Struggle to control BG 40 88
bull Concern re future hypoglycemia 67 74
bull Hard to comply with regimen over 50
bull Find it hard to fit insulin into schedule 33
bull Desired less frequent doses injections 90
06062018
Most patients chose one reason with substantial breadth of reasons (each reason reported by fewer than 20 of
respondents) Over half of the reported reasons reflect a lack of flexibility in the patientrsquos insulin regimen
which was a statistically significant predictor of frequency of insulin omission non-adherence Frequency of
hypoglycaemia was a statistically significant predictor of frequency of insulin omissionnon-adherence Pain
was not frequently cited as a reason and was not a statistically significant predictor of frequency of insulin
omissionnon-adherence
06062018
Many factors contributes to fears of insulin
Fear of Insulin
Its forever
Disease
getting
worst Some
people have
morphine
injections
when they are
about to die
Hypoglycaemia
Seen friend or
neighbour call
ambulance
Fitting Was
scary
Its forever
Addiction
Once you on it
you stay on it
Cultural beliefs
is it from
pigsCow
Personal
failureI am
a loser why I
cant beat this
Why have
I failed
Lifestyle change
Travelworkbeer
Will I still be able to
go out and have
sweets puddings
etc
Paindoes it go
into a
veinSeen it on
TV Huge needle
and drug addicts
have to find a
veinToo
complicated
Cost the pen
looks nice and
expensive can I
afford that
Overcoming the Barriers
bull Introduce concept of insulin deficiency early Draw picture to show UKPDS slide progressive nature of Type 2 DM
bull Tell the patient they are not ldquofailuresrdquo for needing insulin (Explain UKPDS study showing declining beta cells function over time 50 initially at diagnosis then 4 decline every year therefore 50 of pts need Insulin after about 7 yrs hellip)
bull Newer pens - ldquoeasyrdquo 4mm needles ndash painlessrdquoshow or demonstrate injectionhellip
bull Not complicatedPre-laoded Disposable pens 4 mm needles
bull Insulin is not addictive you can stop anytime but you will start feeling unwell again
bull Use simple regimens to start with (just one shot before bed helps to sleep betterhellip)
bull Weight gain the higher the Hba1c the more weight pt puts on avoid snacks or eating in between meals reduce carb portions benefits of Exercise
bull Emphasise the benefits of improved glycaemic control including ldquofeeling better more energy less infections less trips to toilets less thirsty benefits of or 11 mmols lowering Hba1c by 1 reduces complications by35 UKPDS study rdquo
bull Worst case agree to try Insulin for 1 months and review
662018Christchurch Masterclass 13
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018
Progressive nature of Diabetesbull Before insulin initiation patients may have
spent an average of about 5 years with an A1C gt8 or 64 mmolsmol and nearly 10 years gt7 or 53 mmolmol
bull At diagnosis up to 50 of a patients β-cell function may have been lost and may continue to decline by about 4 annually
bull Remind patients that diabetes is a progressive disease and that their treatment plans may be adjusted over time An overall treatment plan to lower A1C consists of diet exercise and diabetes medication which may include insulin
bull 50 of Type 2 needs to go on Insulin within 7 yrs (UKPDS)
bull Let patients know fear of insulin is not uncommon Help them understand the facts about insulin therapy
Islet β-cell function (HOMA B)
in the UKPDS
06062018HOMA=homeostasis model assessment UKPDS=United Kingdom Prospective Diabetes Study
UKPDS Group Diabetes 1995
Conservative
(primarily diet)Islet β-cell function ()
100
80
60
40
20
0
Non-overweight Overweight
0 1 2 3 4 5 6 0 1 2 3 4 5 6
Sulfonylurea
Metformin
Loss ~4 per year
Years from randomization
-2
-1
0
1C
han
ge i
n H
bA
1c (
)
TIME (years)0 1 2 3 4 5 6 10
Hanefeld (n=250)
Charbonnel (n=313)
Chicago (n=230)
ADOPT (n=1441)
UKPDS (n=1573)
Gliclazide
PERISCOPE (n=181)
GLY
GlimepirideGlyburide Glyburide
Glyburide
Glyburide
SU
SU
Alvarsson (n=39)
Alvarsson (n=48)
RECORD (n=272)
Tan (n=297)
Gliclazide
DURABILITY OF GLYCEMIC CONTROL WITH
SULFONYLUREAS
06062018
Insulin-the most effective intervention3
It lowers mean blood glucose in a predictable dose-dependent manner
Can be tailored to individual needs on a unit-to-unit basis
It has the longest experience than any other drug (90 years)
No contraindications to its use
Advantages of insulin
The DAWN( DiabetesAttitudesWishes and Needs)
bull The DAWN study 2001 is to date the largest global psychosocial diabetes study of its kind addressing the perceptions and attitudes of more than 5000 people with diabetes and 3000 healthcare diabetes professionals in a total of thirteen countries
bull The 13 countries involved were Australia Denmark France Germany India Japan The Netherlands Norway Poland Sweden Spain UK and USA
bull The study involved
bull 5426 adults with diabetes
bull 2194 primary care physicians
bull 556 specialists (endocrinologists diabetologists)
bull 1122 nurses (specialist and general)
bull The people with diabetes interviewed were self-classified as 50 Type 1 and 50 Type 2
bull RESULTS
bull More than half of people with Type 2 diabetes are worried about starting insulin
bull 50 report insulin means they ldquofailed to manage their diseaserdquo
bull Only 20 believe insulin would ldquohelp them better manage their DMrdquo
bull 13 of Physicians postpone until ldquoabsolutely essentialrdquo
bull Reference
bull Geelhoed-Duijvestijn P et al Physician Resistance to Prescribing Insulin An International Study Diabetologia 2003
bull Peyrot M et al An International Study of Psychological Resistance to Insulin Use among Persons with Diabetes Diabetologia 2003
06062018
Global Attitudes of Patients and
Physicians in Insulin Therapy (GAPP) 2010
Surveyed gt2700 pts and MDs in 8 countries
bull 1 in 3 fail to take insulin as prescribed
bull Change in normal routine busy schedule
bull Forgetfulness and fear of hypoglycemia
bull
bull PTs Drs
bull Struggle to control BG 40 88
bull Concern re future hypoglycemia 67 74
bull Hard to comply with regimen over 50
bull Find it hard to fit insulin into schedule 33
bull Desired less frequent doses injections 90
06062018
Most patients chose one reason with substantial breadth of reasons (each reason reported by fewer than 20 of
respondents) Over half of the reported reasons reflect a lack of flexibility in the patientrsquos insulin regimen
which was a statistically significant predictor of frequency of insulin omission non-adherence Frequency of
hypoglycaemia was a statistically significant predictor of frequency of insulin omissionnon-adherence Pain
was not frequently cited as a reason and was not a statistically significant predictor of frequency of insulin
omissionnon-adherence
06062018
Many factors contributes to fears of insulin
Fear of Insulin
Its forever
Disease
getting
worst Some
people have
morphine
injections
when they are
about to die
Hypoglycaemia
Seen friend or
neighbour call
ambulance
Fitting Was
scary
Its forever
Addiction
Once you on it
you stay on it
Cultural beliefs
is it from
pigsCow
Personal
failureI am
a loser why I
cant beat this
Why have
I failed
Lifestyle change
Travelworkbeer
Will I still be able to
go out and have
sweets puddings
etc
Paindoes it go
into a
veinSeen it on
TV Huge needle
and drug addicts
have to find a
veinToo
complicated
Cost the pen
looks nice and
expensive can I
afford that
Overcoming the Barriers
bull Introduce concept of insulin deficiency early Draw picture to show UKPDS slide progressive nature of Type 2 DM
bull Tell the patient they are not ldquofailuresrdquo for needing insulin (Explain UKPDS study showing declining beta cells function over time 50 initially at diagnosis then 4 decline every year therefore 50 of pts need Insulin after about 7 yrs hellip)
bull Newer pens - ldquoeasyrdquo 4mm needles ndash painlessrdquoshow or demonstrate injectionhellip
bull Not complicatedPre-laoded Disposable pens 4 mm needles
bull Insulin is not addictive you can stop anytime but you will start feeling unwell again
bull Use simple regimens to start with (just one shot before bed helps to sleep betterhellip)
bull Weight gain the higher the Hba1c the more weight pt puts on avoid snacks or eating in between meals reduce carb portions benefits of Exercise
bull Emphasise the benefits of improved glycaemic control including ldquofeeling better more energy less infections less trips to toilets less thirsty benefits of or 11 mmols lowering Hba1c by 1 reduces complications by35 UKPDS study rdquo
bull Worst case agree to try Insulin for 1 months and review
662018Christchurch Masterclass 13
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Islet β-cell function (HOMA B)
in the UKPDS
06062018HOMA=homeostasis model assessment UKPDS=United Kingdom Prospective Diabetes Study
UKPDS Group Diabetes 1995
Conservative
(primarily diet)Islet β-cell function ()
100
80
60
40
20
0
Non-overweight Overweight
0 1 2 3 4 5 6 0 1 2 3 4 5 6
Sulfonylurea
Metformin
Loss ~4 per year
Years from randomization
-2
-1
0
1C
han
ge i
n H
bA
1c (
)
TIME (years)0 1 2 3 4 5 6 10
Hanefeld (n=250)
Charbonnel (n=313)
Chicago (n=230)
ADOPT (n=1441)
UKPDS (n=1573)
Gliclazide
PERISCOPE (n=181)
GLY
GlimepirideGlyburide Glyburide
Glyburide
Glyburide
SU
SU
Alvarsson (n=39)
Alvarsson (n=48)
RECORD (n=272)
Tan (n=297)
Gliclazide
DURABILITY OF GLYCEMIC CONTROL WITH
SULFONYLUREAS
06062018
Insulin-the most effective intervention3
It lowers mean blood glucose in a predictable dose-dependent manner
Can be tailored to individual needs on a unit-to-unit basis
It has the longest experience than any other drug (90 years)
No contraindications to its use
Advantages of insulin
The DAWN( DiabetesAttitudesWishes and Needs)
bull The DAWN study 2001 is to date the largest global psychosocial diabetes study of its kind addressing the perceptions and attitudes of more than 5000 people with diabetes and 3000 healthcare diabetes professionals in a total of thirteen countries
bull The 13 countries involved were Australia Denmark France Germany India Japan The Netherlands Norway Poland Sweden Spain UK and USA
bull The study involved
bull 5426 adults with diabetes
bull 2194 primary care physicians
bull 556 specialists (endocrinologists diabetologists)
bull 1122 nurses (specialist and general)
bull The people with diabetes interviewed were self-classified as 50 Type 1 and 50 Type 2
bull RESULTS
bull More than half of people with Type 2 diabetes are worried about starting insulin
bull 50 report insulin means they ldquofailed to manage their diseaserdquo
bull Only 20 believe insulin would ldquohelp them better manage their DMrdquo
bull 13 of Physicians postpone until ldquoabsolutely essentialrdquo
bull Reference
bull Geelhoed-Duijvestijn P et al Physician Resistance to Prescribing Insulin An International Study Diabetologia 2003
bull Peyrot M et al An International Study of Psychological Resistance to Insulin Use among Persons with Diabetes Diabetologia 2003
06062018
Global Attitudes of Patients and
Physicians in Insulin Therapy (GAPP) 2010
Surveyed gt2700 pts and MDs in 8 countries
bull 1 in 3 fail to take insulin as prescribed
bull Change in normal routine busy schedule
bull Forgetfulness and fear of hypoglycemia
bull
bull PTs Drs
bull Struggle to control BG 40 88
bull Concern re future hypoglycemia 67 74
bull Hard to comply with regimen over 50
bull Find it hard to fit insulin into schedule 33
bull Desired less frequent doses injections 90
06062018
Most patients chose one reason with substantial breadth of reasons (each reason reported by fewer than 20 of
respondents) Over half of the reported reasons reflect a lack of flexibility in the patientrsquos insulin regimen
which was a statistically significant predictor of frequency of insulin omission non-adherence Frequency of
hypoglycaemia was a statistically significant predictor of frequency of insulin omissionnon-adherence Pain
was not frequently cited as a reason and was not a statistically significant predictor of frequency of insulin
omissionnon-adherence
06062018
Many factors contributes to fears of insulin
Fear of Insulin
Its forever
Disease
getting
worst Some
people have
morphine
injections
when they are
about to die
Hypoglycaemia
Seen friend or
neighbour call
ambulance
Fitting Was
scary
Its forever
Addiction
Once you on it
you stay on it
Cultural beliefs
is it from
pigsCow
Personal
failureI am
a loser why I
cant beat this
Why have
I failed
Lifestyle change
Travelworkbeer
Will I still be able to
go out and have
sweets puddings
etc
Paindoes it go
into a
veinSeen it on
TV Huge needle
and drug addicts
have to find a
veinToo
complicated
Cost the pen
looks nice and
expensive can I
afford that
Overcoming the Barriers
bull Introduce concept of insulin deficiency early Draw picture to show UKPDS slide progressive nature of Type 2 DM
bull Tell the patient they are not ldquofailuresrdquo for needing insulin (Explain UKPDS study showing declining beta cells function over time 50 initially at diagnosis then 4 decline every year therefore 50 of pts need Insulin after about 7 yrs hellip)
bull Newer pens - ldquoeasyrdquo 4mm needles ndash painlessrdquoshow or demonstrate injectionhellip
bull Not complicatedPre-laoded Disposable pens 4 mm needles
bull Insulin is not addictive you can stop anytime but you will start feeling unwell again
bull Use simple regimens to start with (just one shot before bed helps to sleep betterhellip)
bull Weight gain the higher the Hba1c the more weight pt puts on avoid snacks or eating in between meals reduce carb portions benefits of Exercise
bull Emphasise the benefits of improved glycaemic control including ldquofeeling better more energy less infections less trips to toilets less thirsty benefits of or 11 mmols lowering Hba1c by 1 reduces complications by35 UKPDS study rdquo
bull Worst case agree to try Insulin for 1 months and review
662018Christchurch Masterclass 13
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
-2
-1
0
1C
han
ge i
n H
bA
1c (
)
TIME (years)0 1 2 3 4 5 6 10
Hanefeld (n=250)
Charbonnel (n=313)
Chicago (n=230)
ADOPT (n=1441)
UKPDS (n=1573)
Gliclazide
PERISCOPE (n=181)
GLY
GlimepirideGlyburide Glyburide
Glyburide
Glyburide
SU
SU
Alvarsson (n=39)
Alvarsson (n=48)
RECORD (n=272)
Tan (n=297)
Gliclazide
DURABILITY OF GLYCEMIC CONTROL WITH
SULFONYLUREAS
06062018
Insulin-the most effective intervention3
It lowers mean blood glucose in a predictable dose-dependent manner
Can be tailored to individual needs on a unit-to-unit basis
It has the longest experience than any other drug (90 years)
No contraindications to its use
Advantages of insulin
The DAWN( DiabetesAttitudesWishes and Needs)
bull The DAWN study 2001 is to date the largest global psychosocial diabetes study of its kind addressing the perceptions and attitudes of more than 5000 people with diabetes and 3000 healthcare diabetes professionals in a total of thirteen countries
bull The 13 countries involved were Australia Denmark France Germany India Japan The Netherlands Norway Poland Sweden Spain UK and USA
bull The study involved
bull 5426 adults with diabetes
bull 2194 primary care physicians
bull 556 specialists (endocrinologists diabetologists)
bull 1122 nurses (specialist and general)
bull The people with diabetes interviewed were self-classified as 50 Type 1 and 50 Type 2
bull RESULTS
bull More than half of people with Type 2 diabetes are worried about starting insulin
bull 50 report insulin means they ldquofailed to manage their diseaserdquo
bull Only 20 believe insulin would ldquohelp them better manage their DMrdquo
bull 13 of Physicians postpone until ldquoabsolutely essentialrdquo
bull Reference
bull Geelhoed-Duijvestijn P et al Physician Resistance to Prescribing Insulin An International Study Diabetologia 2003
bull Peyrot M et al An International Study of Psychological Resistance to Insulin Use among Persons with Diabetes Diabetologia 2003
06062018
Global Attitudes of Patients and
Physicians in Insulin Therapy (GAPP) 2010
Surveyed gt2700 pts and MDs in 8 countries
bull 1 in 3 fail to take insulin as prescribed
bull Change in normal routine busy schedule
bull Forgetfulness and fear of hypoglycemia
bull
bull PTs Drs
bull Struggle to control BG 40 88
bull Concern re future hypoglycemia 67 74
bull Hard to comply with regimen over 50
bull Find it hard to fit insulin into schedule 33
bull Desired less frequent doses injections 90
06062018
Most patients chose one reason with substantial breadth of reasons (each reason reported by fewer than 20 of
respondents) Over half of the reported reasons reflect a lack of flexibility in the patientrsquos insulin regimen
which was a statistically significant predictor of frequency of insulin omission non-adherence Frequency of
hypoglycaemia was a statistically significant predictor of frequency of insulin omissionnon-adherence Pain
was not frequently cited as a reason and was not a statistically significant predictor of frequency of insulin
omissionnon-adherence
06062018
Many factors contributes to fears of insulin
Fear of Insulin
Its forever
Disease
getting
worst Some
people have
morphine
injections
when they are
about to die
Hypoglycaemia
Seen friend or
neighbour call
ambulance
Fitting Was
scary
Its forever
Addiction
Once you on it
you stay on it
Cultural beliefs
is it from
pigsCow
Personal
failureI am
a loser why I
cant beat this
Why have
I failed
Lifestyle change
Travelworkbeer
Will I still be able to
go out and have
sweets puddings
etc
Paindoes it go
into a
veinSeen it on
TV Huge needle
and drug addicts
have to find a
veinToo
complicated
Cost the pen
looks nice and
expensive can I
afford that
Overcoming the Barriers
bull Introduce concept of insulin deficiency early Draw picture to show UKPDS slide progressive nature of Type 2 DM
bull Tell the patient they are not ldquofailuresrdquo for needing insulin (Explain UKPDS study showing declining beta cells function over time 50 initially at diagnosis then 4 decline every year therefore 50 of pts need Insulin after about 7 yrs hellip)
bull Newer pens - ldquoeasyrdquo 4mm needles ndash painlessrdquoshow or demonstrate injectionhellip
bull Not complicatedPre-laoded Disposable pens 4 mm needles
bull Insulin is not addictive you can stop anytime but you will start feeling unwell again
bull Use simple regimens to start with (just one shot before bed helps to sleep betterhellip)
bull Weight gain the higher the Hba1c the more weight pt puts on avoid snacks or eating in between meals reduce carb portions benefits of Exercise
bull Emphasise the benefits of improved glycaemic control including ldquofeeling better more energy less infections less trips to toilets less thirsty benefits of or 11 mmols lowering Hba1c by 1 reduces complications by35 UKPDS study rdquo
bull Worst case agree to try Insulin for 1 months and review
662018Christchurch Masterclass 13
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018
Insulin-the most effective intervention3
It lowers mean blood glucose in a predictable dose-dependent manner
Can be tailored to individual needs on a unit-to-unit basis
It has the longest experience than any other drug (90 years)
No contraindications to its use
Advantages of insulin
The DAWN( DiabetesAttitudesWishes and Needs)
bull The DAWN study 2001 is to date the largest global psychosocial diabetes study of its kind addressing the perceptions and attitudes of more than 5000 people with diabetes and 3000 healthcare diabetes professionals in a total of thirteen countries
bull The 13 countries involved were Australia Denmark France Germany India Japan The Netherlands Norway Poland Sweden Spain UK and USA
bull The study involved
bull 5426 adults with diabetes
bull 2194 primary care physicians
bull 556 specialists (endocrinologists diabetologists)
bull 1122 nurses (specialist and general)
bull The people with diabetes interviewed were self-classified as 50 Type 1 and 50 Type 2
bull RESULTS
bull More than half of people with Type 2 diabetes are worried about starting insulin
bull 50 report insulin means they ldquofailed to manage their diseaserdquo
bull Only 20 believe insulin would ldquohelp them better manage their DMrdquo
bull 13 of Physicians postpone until ldquoabsolutely essentialrdquo
bull Reference
bull Geelhoed-Duijvestijn P et al Physician Resistance to Prescribing Insulin An International Study Diabetologia 2003
bull Peyrot M et al An International Study of Psychological Resistance to Insulin Use among Persons with Diabetes Diabetologia 2003
06062018
Global Attitudes of Patients and
Physicians in Insulin Therapy (GAPP) 2010
Surveyed gt2700 pts and MDs in 8 countries
bull 1 in 3 fail to take insulin as prescribed
bull Change in normal routine busy schedule
bull Forgetfulness and fear of hypoglycemia
bull
bull PTs Drs
bull Struggle to control BG 40 88
bull Concern re future hypoglycemia 67 74
bull Hard to comply with regimen over 50
bull Find it hard to fit insulin into schedule 33
bull Desired less frequent doses injections 90
06062018
Most patients chose one reason with substantial breadth of reasons (each reason reported by fewer than 20 of
respondents) Over half of the reported reasons reflect a lack of flexibility in the patientrsquos insulin regimen
which was a statistically significant predictor of frequency of insulin omission non-adherence Frequency of
hypoglycaemia was a statistically significant predictor of frequency of insulin omissionnon-adherence Pain
was not frequently cited as a reason and was not a statistically significant predictor of frequency of insulin
omissionnon-adherence
06062018
Many factors contributes to fears of insulin
Fear of Insulin
Its forever
Disease
getting
worst Some
people have
morphine
injections
when they are
about to die
Hypoglycaemia
Seen friend or
neighbour call
ambulance
Fitting Was
scary
Its forever
Addiction
Once you on it
you stay on it
Cultural beliefs
is it from
pigsCow
Personal
failureI am
a loser why I
cant beat this
Why have
I failed
Lifestyle change
Travelworkbeer
Will I still be able to
go out and have
sweets puddings
etc
Paindoes it go
into a
veinSeen it on
TV Huge needle
and drug addicts
have to find a
veinToo
complicated
Cost the pen
looks nice and
expensive can I
afford that
Overcoming the Barriers
bull Introduce concept of insulin deficiency early Draw picture to show UKPDS slide progressive nature of Type 2 DM
bull Tell the patient they are not ldquofailuresrdquo for needing insulin (Explain UKPDS study showing declining beta cells function over time 50 initially at diagnosis then 4 decline every year therefore 50 of pts need Insulin after about 7 yrs hellip)
bull Newer pens - ldquoeasyrdquo 4mm needles ndash painlessrdquoshow or demonstrate injectionhellip
bull Not complicatedPre-laoded Disposable pens 4 mm needles
bull Insulin is not addictive you can stop anytime but you will start feeling unwell again
bull Use simple regimens to start with (just one shot before bed helps to sleep betterhellip)
bull Weight gain the higher the Hba1c the more weight pt puts on avoid snacks or eating in between meals reduce carb portions benefits of Exercise
bull Emphasise the benefits of improved glycaemic control including ldquofeeling better more energy less infections less trips to toilets less thirsty benefits of or 11 mmols lowering Hba1c by 1 reduces complications by35 UKPDS study rdquo
bull Worst case agree to try Insulin for 1 months and review
662018Christchurch Masterclass 13
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
The DAWN( DiabetesAttitudesWishes and Needs)
bull The DAWN study 2001 is to date the largest global psychosocial diabetes study of its kind addressing the perceptions and attitudes of more than 5000 people with diabetes and 3000 healthcare diabetes professionals in a total of thirteen countries
bull The 13 countries involved were Australia Denmark France Germany India Japan The Netherlands Norway Poland Sweden Spain UK and USA
bull The study involved
bull 5426 adults with diabetes
bull 2194 primary care physicians
bull 556 specialists (endocrinologists diabetologists)
bull 1122 nurses (specialist and general)
bull The people with diabetes interviewed were self-classified as 50 Type 1 and 50 Type 2
bull RESULTS
bull More than half of people with Type 2 diabetes are worried about starting insulin
bull 50 report insulin means they ldquofailed to manage their diseaserdquo
bull Only 20 believe insulin would ldquohelp them better manage their DMrdquo
bull 13 of Physicians postpone until ldquoabsolutely essentialrdquo
bull Reference
bull Geelhoed-Duijvestijn P et al Physician Resistance to Prescribing Insulin An International Study Diabetologia 2003
bull Peyrot M et al An International Study of Psychological Resistance to Insulin Use among Persons with Diabetes Diabetologia 2003
06062018
Global Attitudes of Patients and
Physicians in Insulin Therapy (GAPP) 2010
Surveyed gt2700 pts and MDs in 8 countries
bull 1 in 3 fail to take insulin as prescribed
bull Change in normal routine busy schedule
bull Forgetfulness and fear of hypoglycemia
bull
bull PTs Drs
bull Struggle to control BG 40 88
bull Concern re future hypoglycemia 67 74
bull Hard to comply with regimen over 50
bull Find it hard to fit insulin into schedule 33
bull Desired less frequent doses injections 90
06062018
Most patients chose one reason with substantial breadth of reasons (each reason reported by fewer than 20 of
respondents) Over half of the reported reasons reflect a lack of flexibility in the patientrsquos insulin regimen
which was a statistically significant predictor of frequency of insulin omission non-adherence Frequency of
hypoglycaemia was a statistically significant predictor of frequency of insulin omissionnon-adherence Pain
was not frequently cited as a reason and was not a statistically significant predictor of frequency of insulin
omissionnon-adherence
06062018
Many factors contributes to fears of insulin
Fear of Insulin
Its forever
Disease
getting
worst Some
people have
morphine
injections
when they are
about to die
Hypoglycaemia
Seen friend or
neighbour call
ambulance
Fitting Was
scary
Its forever
Addiction
Once you on it
you stay on it
Cultural beliefs
is it from
pigsCow
Personal
failureI am
a loser why I
cant beat this
Why have
I failed
Lifestyle change
Travelworkbeer
Will I still be able to
go out and have
sweets puddings
etc
Paindoes it go
into a
veinSeen it on
TV Huge needle
and drug addicts
have to find a
veinToo
complicated
Cost the pen
looks nice and
expensive can I
afford that
Overcoming the Barriers
bull Introduce concept of insulin deficiency early Draw picture to show UKPDS slide progressive nature of Type 2 DM
bull Tell the patient they are not ldquofailuresrdquo for needing insulin (Explain UKPDS study showing declining beta cells function over time 50 initially at diagnosis then 4 decline every year therefore 50 of pts need Insulin after about 7 yrs hellip)
bull Newer pens - ldquoeasyrdquo 4mm needles ndash painlessrdquoshow or demonstrate injectionhellip
bull Not complicatedPre-laoded Disposable pens 4 mm needles
bull Insulin is not addictive you can stop anytime but you will start feeling unwell again
bull Use simple regimens to start with (just one shot before bed helps to sleep betterhellip)
bull Weight gain the higher the Hba1c the more weight pt puts on avoid snacks or eating in between meals reduce carb portions benefits of Exercise
bull Emphasise the benefits of improved glycaemic control including ldquofeeling better more energy less infections less trips to toilets less thirsty benefits of or 11 mmols lowering Hba1c by 1 reduces complications by35 UKPDS study rdquo
bull Worst case agree to try Insulin for 1 months and review
662018Christchurch Masterclass 13
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Global Attitudes of Patients and
Physicians in Insulin Therapy (GAPP) 2010
Surveyed gt2700 pts and MDs in 8 countries
bull 1 in 3 fail to take insulin as prescribed
bull Change in normal routine busy schedule
bull Forgetfulness and fear of hypoglycemia
bull
bull PTs Drs
bull Struggle to control BG 40 88
bull Concern re future hypoglycemia 67 74
bull Hard to comply with regimen over 50
bull Find it hard to fit insulin into schedule 33
bull Desired less frequent doses injections 90
06062018
Most patients chose one reason with substantial breadth of reasons (each reason reported by fewer than 20 of
respondents) Over half of the reported reasons reflect a lack of flexibility in the patientrsquos insulin regimen
which was a statistically significant predictor of frequency of insulin omission non-adherence Frequency of
hypoglycaemia was a statistically significant predictor of frequency of insulin omissionnon-adherence Pain
was not frequently cited as a reason and was not a statistically significant predictor of frequency of insulin
omissionnon-adherence
06062018
Many factors contributes to fears of insulin
Fear of Insulin
Its forever
Disease
getting
worst Some
people have
morphine
injections
when they are
about to die
Hypoglycaemia
Seen friend or
neighbour call
ambulance
Fitting Was
scary
Its forever
Addiction
Once you on it
you stay on it
Cultural beliefs
is it from
pigsCow
Personal
failureI am
a loser why I
cant beat this
Why have
I failed
Lifestyle change
Travelworkbeer
Will I still be able to
go out and have
sweets puddings
etc
Paindoes it go
into a
veinSeen it on
TV Huge needle
and drug addicts
have to find a
veinToo
complicated
Cost the pen
looks nice and
expensive can I
afford that
Overcoming the Barriers
bull Introduce concept of insulin deficiency early Draw picture to show UKPDS slide progressive nature of Type 2 DM
bull Tell the patient they are not ldquofailuresrdquo for needing insulin (Explain UKPDS study showing declining beta cells function over time 50 initially at diagnosis then 4 decline every year therefore 50 of pts need Insulin after about 7 yrs hellip)
bull Newer pens - ldquoeasyrdquo 4mm needles ndash painlessrdquoshow or demonstrate injectionhellip
bull Not complicatedPre-laoded Disposable pens 4 mm needles
bull Insulin is not addictive you can stop anytime but you will start feeling unwell again
bull Use simple regimens to start with (just one shot before bed helps to sleep betterhellip)
bull Weight gain the higher the Hba1c the more weight pt puts on avoid snacks or eating in between meals reduce carb portions benefits of Exercise
bull Emphasise the benefits of improved glycaemic control including ldquofeeling better more energy less infections less trips to toilets less thirsty benefits of or 11 mmols lowering Hba1c by 1 reduces complications by35 UKPDS study rdquo
bull Worst case agree to try Insulin for 1 months and review
662018Christchurch Masterclass 13
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018
Many factors contributes to fears of insulin
Fear of Insulin
Its forever
Disease
getting
worst Some
people have
morphine
injections
when they are
about to die
Hypoglycaemia
Seen friend or
neighbour call
ambulance
Fitting Was
scary
Its forever
Addiction
Once you on it
you stay on it
Cultural beliefs
is it from
pigsCow
Personal
failureI am
a loser why I
cant beat this
Why have
I failed
Lifestyle change
Travelworkbeer
Will I still be able to
go out and have
sweets puddings
etc
Paindoes it go
into a
veinSeen it on
TV Huge needle
and drug addicts
have to find a
veinToo
complicated
Cost the pen
looks nice and
expensive can I
afford that
Overcoming the Barriers
bull Introduce concept of insulin deficiency early Draw picture to show UKPDS slide progressive nature of Type 2 DM
bull Tell the patient they are not ldquofailuresrdquo for needing insulin (Explain UKPDS study showing declining beta cells function over time 50 initially at diagnosis then 4 decline every year therefore 50 of pts need Insulin after about 7 yrs hellip)
bull Newer pens - ldquoeasyrdquo 4mm needles ndash painlessrdquoshow or demonstrate injectionhellip
bull Not complicatedPre-laoded Disposable pens 4 mm needles
bull Insulin is not addictive you can stop anytime but you will start feeling unwell again
bull Use simple regimens to start with (just one shot before bed helps to sleep betterhellip)
bull Weight gain the higher the Hba1c the more weight pt puts on avoid snacks or eating in between meals reduce carb portions benefits of Exercise
bull Emphasise the benefits of improved glycaemic control including ldquofeeling better more energy less infections less trips to toilets less thirsty benefits of or 11 mmols lowering Hba1c by 1 reduces complications by35 UKPDS study rdquo
bull Worst case agree to try Insulin for 1 months and review
662018Christchurch Masterclass 13
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Overcoming the Barriers
bull Introduce concept of insulin deficiency early Draw picture to show UKPDS slide progressive nature of Type 2 DM
bull Tell the patient they are not ldquofailuresrdquo for needing insulin (Explain UKPDS study showing declining beta cells function over time 50 initially at diagnosis then 4 decline every year therefore 50 of pts need Insulin after about 7 yrs hellip)
bull Newer pens - ldquoeasyrdquo 4mm needles ndash painlessrdquoshow or demonstrate injectionhellip
bull Not complicatedPre-laoded Disposable pens 4 mm needles
bull Insulin is not addictive you can stop anytime but you will start feeling unwell again
bull Use simple regimens to start with (just one shot before bed helps to sleep betterhellip)
bull Weight gain the higher the Hba1c the more weight pt puts on avoid snacks or eating in between meals reduce carb portions benefits of Exercise
bull Emphasise the benefits of improved glycaemic control including ldquofeeling better more energy less infections less trips to toilets less thirsty benefits of or 11 mmols lowering Hba1c by 1 reduces complications by35 UKPDS study rdquo
bull Worst case agree to try Insulin for 1 months and review
662018Christchurch Masterclass 13
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018
Continued
bull Failure
bull Reframe the perception of failure and self-blame
bull Educate patients that insulin helps to replace what the body isnt adequately making to lower blood glucose
bull Remind your patients that insulin may be an appropriate choice for them since it is effective at lowering A1C when added to an overall treatment plan
bull Educate patients about what they can do by making healthy food choices and increasing their physical activity Address problem of SNACKS or eating in between meals
bull Lifestyle changeMany patients believe that taking insulin will greatly disrupt their lives
bull Inform patients that insulin may help control blood glucose and lower A1C1
bull Present insulin as another effective option to add to their daily diabetes management routine
bull Patients may find that insulin can become a normal part of their routine
bull PainIf fear of pain is deterring your patient from taking insulin consider the following
bull Insulin is injected in the fatty layer just under the skin where there are fewer nerve endings and injections generally cause little discomfort
bull Tell patients that many people on insulin are surprised by how soon they get used to the injections
bull Get Partner or Friend parent or Children to try needle first
bull Provide information about insulin benefits Would sleep betterhave more energy not feel constantly tired mood thirsty thrush in women improve erectile dysfunction in men
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018
Combination Therapies With Insulin in Type 2 Diabetes
Hannele Yki-Jaumlrvinen MD FRCP1 102337diacare244758 Diabetes Care April 2001 vol 24 no 4
758-767
The higher the Hba1c is when Insulin is started the more weight is gained
which makes sense The more the the Glycosuria is the more calories they
will keep when Insulin is started
Weight GainhellipWhy1048708 Decreased glycosuria
1048708 Due to improved BG control
1048708 Aggressive or over-tx of hypoglycemia
1048708 Defensive eating to prevent hypoglycemia
Hba1c when Insulin started Weight Gain
12 (108 mmolmol) 5-10 kg
10 (86 mmolmol) 3-6 kg
75 (58 mmolmol) 05-1kg
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018
Intensify to a combination
insulin regimen in year one
if unacceptable hyperglycaemia
708
T2DM
on dual OAD
Add biphasic insulin
twice a day
Add prandial insulin
three times a dayR
Comparison of three
single insulin regimens
added to OADs
Add basal insulin
once (or twice) daily
Add prandial insulin
at midday
Add basal insulin
before bed
Years 2 and 3
If HbA1c gt65 stop sulfonylurea and add a
second insulin formulation
Add prandial insulin
three times a day
N Engl J Med 2007 357 1716-30
Three-arm trial in 708 patients with type 2 diabetes from 58 UK and Irish centres
Evaluating addition of three different analogue insulin regimens to dual oral antidiabetic therapy
Open-label randomisation to
Twice a day biphasic insulin (NovoMix 30)
Three times a day prandial insulin (NovoRapid)
Once a day basal insulin (Levemir) before bed with a morning injection added if necessary
Year 1
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018
Outcomes at One YearPrimary
To compare HbA1c levels achieved by the three regimens
Secondary outcomes include
Proportion with HbA1c le65
Proportion with unacceptable hyperglycemia
ie HbA1c gt10 or two successive values gt85
at or after 24 weeks
Hypoglycaemia rates
Impact on body weight
Quality of Life (EQ-5D)
Eight-point self-measured capillary glucose profiles
Proportion requiring a morning basal insulin injection
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018
Results Comparisonsbull Results ndash Harms
bull bull Basal Insulin gained less weight than those in the biphasic or prandial insulin groups
bull Weight gain in Kg
bull Basal +19 kg
bull Bi ndashPhasic + 47 kg and
bull Prandial + 57 kg Plt0001)
bull bull The weight gain was significantly higher in the prandial group than the biphasic group (P=0005)
bull bull Basal group significantly less likely to experience more severe hypoglycaemia than those in the biphasic or prandial groups (median 0 39 and 80 events per patient per year)
bull Results ndash benefits
bull bull The reduction in HbA1c from baseline --13 in the biphasic group
-14 in the prandial group
- 08 in the basal group
Bodyweight after 3
yrs
Hba1c after 3 yrs
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018
Basal Insulin Summary One injection a day with two capillary glucose tests for dose
titration
One third of patients require a morning insulin injection in
addition
More patients require a second insulin formulation than with
Biphasic or Prandial insulin
Basal slightly less HbA1c lowering than with Biphasic or
Prandial insulin
Basal Insulin causes less weight gain and less
hypoglycaemia than with Biphasic or Prandial insulin
No change in QoL as assessed by EQ-5D
N Engl J Med 2007 357 1716-30
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
What about their oral Medications
bull Hang on
bull Donrsquot throw away the Metformin
06062018
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018 Rab Burtun DSN
Metformin and Insulin
the benefits Arch Intern Med 2009169(6)616-625
bull 390 patients RCT with Metformin 850 tds or
placebo added to insulin with mean 43 year
follow-upbull Metformin patients on average
Hba1c 04 better
Weight307kg lighter
bull Needed ~20 units less insulin
bull Lower macrovascular event rate (NNT 16)
bull Metformin reduces risks cancers
06062018
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
06062018
bull ITS rewarding
bull To see Hba1c had come down
bull Pt feels a lot better
bull And when they say ldquohellipI wish I have gone on Insulin 4 yrs ago when it was first mentioned to me helliprdquo
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
ldquoType 2 Diabetesrdquo
bullLife-style treatment is the foundation for
managing Type 2 diabetes
bullEven though insulin is inevitable for many
patients with Type 2 diabetes if the foundation
isnrsquot right no amount of medication (including
insulin) will work
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Some of the current injection
devicesPrefilled insulin pens Reusable devices for use with
cartridges
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Insulin doses in T2D
bull Requirements depend on insulin (body) resistance
bull Duration of DM will affect remaining beta cell function
bull Correct dose of insulin is when you achieve target blood sugars
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Key information for patients to
know
bull Start low (Dose) and increase
bull No maximum dose
bull Different doses for different folk (Individual)
bull Target BSLrsquos = Organ protectionBG vs HbA1c ( UKPDS)
bull Dose changes can be done by phone fax or e-mails
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Key practice points
1 Lifestyle education
2 Suit device to patient
3 Insulin to match pt lifestyle
4 Expectation that dose will
increase
5 Constantly review
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Hypoglycaemia ndash blood sugar less than 4mmol
Explain what Hypoglycaemia is as patients can freak outSigns
Are they missing meals Are they changing quantity or quality of food in order to
lose weight-without changing the dose
Some Questions to ask Was insulin taken at appropriate time Are they missing doses and then overcompensating later Are they missing meals Are they changing quantity or quality of food in order to lose
weight-without changing the dose Are hypos occurring on particular days of the week ie at week
ends Was Alcohol a factor Was exercise a factor Have injection sites been checked for signs of
lipohypertrophyimens right for the patient 30
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Hypoglycaemia
Usually defined as lt 4 mmolL (people develop symptoms at different levels)
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Hypoglycaemia
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
HYPOGLYCAEMIA - Treatment
STEP 1 ndash 15-20g of fast acting carbohydrate
Regular fizzy drinks jellybeans (6-8) glucose
tablets 3 teaspoons of sugar [NOT chocolate
cakes or biscuits]
STEP 2 ndash Retest blood sugar if back above 4mmol then move to step 3 if not repeat step 1
STEP 3 ndash Meal if due or 15-20g of slow acting carbohydrate Piece of fruit slice of bread 2 plain biscuits
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Blood Glucose Testing bull Why
ndash Safety
ndash Accuracy (Pt washrsquos hands before testing)
ndash Titration of dose
ndash Patient education
bull When
Depends on insulin type and purpose
Value of identifying pattern fasting pre and post-prandial
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Why Do We Test
Breakfast Lunch Dinner Before Bed ONight Remarks activity
Before After Before After Before After
89
95 101
101 98
89 92
88 163 My Birthday
93 90
81 123
87
94 50 Played Golf
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
Eight DECADES OF DIABETES SUCCESS RECOGNISEDWaitakere Hospital diabetes nurse Rab Burtun always thought
(now 89yrs) Winsome Johnston deserved a medal ndash so he set
about ensuring his inspirational patient receive just that
On 12 September Mrs Johnston will be the first New Zealander
to be awarded the Diabetes UK Macleod Medal for living
successfully with insulin-dependent Type 1 diabetes for more
than (83 yrs) She will also receive Diabetes New Zealandrsquos Sir
Charles Burns Memorial Award
ldquoI tell my patients about Winrsquos story every day Shersquos living
proof that itrsquos possible to live long and well with diabetes Shersquos
an inspiration to everybody ndash me includedrdquo Rab says
A Type 1 diabetic himself Rab was diagnosed 30 years ago and
wrote to Diabetes UK last month to share Winsomersquos story
because of the motivation and encouragement it offers others
ldquoShe hasnrsquot got a single complication of diabetes shersquos had three
successful pregnancies ndash one with twins -and now has eight
grandchildren and two great-grandchildren
ldquoPregnancy itself is an achievement for people with diabetes
because their blood sugar helliphelliphelliphelliphellip
