Insulin Dose Adjustment : What’s new for 2015 and Patient Self-Adjustment of Insulin Survey Findings

Carrie Haggett RN, BScN, CDE DCPNS Diabetes Consultant

Conflict of Interest

•  In the past 12 months, I have received speaker honoraria from – BD Medical

•  I am an employee of the NS Health Authority, Central Zone and the DCPNS

Presentation Overview

•  Discuss the need for the revision of the Insulin Dose Adjustment Policies and Guidelines Manual, 2012. Section 4-NEW

•  Discuss the findings from the Patient Self- Adjustment of Insulin survey (Sept 2014).

•  Discuss how the findings impact the need for change. •  Formation of a working group.

Revision 2012 DCPNS Insulin Dose Adjustment Polices and Guidelines Manual •  Formal agreements in place with PEI and NB, with

agreements in the works for NL—Eastern and Western Regions (use our guidelines, processes, and exams)

•  CDA guidelines released 2013 •  Growing list of new and emerging therapies. •  Potential formulary differences across Atlantic Provinces

Revision Process

•  Engage specialist physicians for review of sections. •  Invite review from partnering provinces. •  Develop a new section on insulin and non insulin therapies.

New Section includes use with pregnancy and paediatrics. •  Aiming to have revisions completed by the end of April

2015. (March 31,2015)

Dates   Carrie’s  Timeline   Reality  

Jan  19,2015   Meet  with  sec3on  authors   Mee3ngs  went  well.  All  on  board.  

Feb  2,2015   Return  first  dra@s  to  Barb.   First  dra@s  in  to  Barb.  

Feb  17,2015   Out  to  Atlan3c  Provinces   Third  dra@s  in…Barb  can  be  bribed  with  Tootsie  pops!  

March  2,2015   Out  to  Medical  Advisors   Fi@h  dra@s  in  …Need  more  Tootsie  pops  for  Barb.  

March  17,2015   All  sec3ons  returned.  To  be  reviewed  by  educator  reviewers.  

No  Luck  of  the  Irish  here.  Sec3ons  are  s3ll  in  dra@  mode.  Start  physician  Engagement  for  completed  sec3ons.  

March  30,2015   Send  to  print.   Feels  like  the  50th  dra@.  Tootsie  rolls  are  not  effec3ve.  

April  2,2015   Comple3on  May  ,2015   S3ll  in  dra@  mode…..  

Section work Insulin  Dose  Adjustment  

Policies  and  Guidelines  Manual  Sec<ons  

Sec<on  Authors   Physician  Reviewers  From  the  Atlan<c  Provinces  

Sec3on  1  and  2-­‐  Travel    and  Shi@  Work  

Carrie  HaggeY  RN  BScN  CDE   ✔  

Sec3on  2  –Illness  &  Physical  Ac3vity/Exercise  

Catherine  Splane    RN  BComm    CDE   ✔  

Sec3on  3  -­‐Pregnancy     Lois  Ferguson  RN  CDE   ✔  

Sec3on  3  –Children/  Adolescents  

Sheilagh  Crowley  RN  BN  CDE   ✔  

Sec3on  3-­‐  Pump  Therapy   Shawna  Boudreau  BScN  RN  CDE   ✔  Sec3on  4  –  Formulary  Coverage  of  Insulin  therapy(1A),  non-­‐insulin  therapy  (1B)  and  considera3ons  for  use  (2A).  

Kim  Kelly  BSc.Pharm  (Drug  Evalua3on  Unit  of  Nova  Sco3a)  Peggy  Dunbar  MEd  PDt  CDE      Carrie  HaggeY  RN  BScN  CDE  

✔  

Sec3on  Overviewers   Bev  Harris  PDt  CDE  Peggy  Dunbar  MEd  PDt  CDE  Carrie  HaggeY  RN  BScN  CDE  

✔  

Draft DCPNS April 2, 2015

DRAFT Table 1B: Formulary Coverage of Non-Insulin Therapies (oral and injectable) and Indications for Use in Various Populations Formulary Coverage Indication for use with:

Other Therapeutic Considerations

NON-INSULIN THERAPIES

NS

NB

NL

PE

ADULTS×

PEDIATRICS×

PREGNANCY

LACTATION€

ORAL ANTIHYPERGLYCEMIC AGENTS

Alpha-glucosidase inhibitor Safety not established. ¥

No data, probably compatible

• Acarbose (Glucobay®)

! ! "1 ! Type 2 Not for use < 18

Insulin Secretagogues Glyburide may be considered through the first trimester (under care of a specialist) until insulin is initiated - Diabetes Care Program Nova Scotia (DCPNS)

Sulfonylureas: • Gliclazide (Diamicron®, Diamicron® MR) ! ! ! ! Safety not established. § No data

• Glimepiride (Amaryl®) # ! ! ! Type 2 Not for use <18 Safety not established. ¥ No data, probably hazardous

• Glyburide (Diabeta®, Euglucon®) ! ! ! ! Human data suggest low risk¥

No data, probably compatible

• Chlorpropamide # ! ! ! Type 2 Safety, efficacy not

established Human data suggest risk in 3rd trimester. ¥

No data, probably compatible

• Tolbutamide ! ! ! ! Type 2 Safety, efficacy not established

Human data suggest risk in 3rd trimester. ¥

Limited data, probably compatible

Meglitinides: • Nateglinide (Starlix®) # # # # Type 2

Not for use <18 Safety not established¥ No data, probably

compatible • Repaglinide (Gluconorm®)

# "2 "3 # Type 2 Not for use <18 Safety not established¥ No data, probably

hazardous

Biguanides Use in Polycystic Ovarian Syndrome (PCOS). Use in the first trimester until insulin initiated. Increasing use in GDM and type 2 DM in pregnancy.

• Metformin (generics Glucophage®, Glumetza® once-daily formulation)

! ! ! ! Type 2 Safety & efficacy not established

Human data suggest low risk¥

Limited data, compatible

DPP-4 Inhibitor • Sitagliptin (Januvia®) "4 "5 "6 # Safety not established ¥ No data, probably

compatible • Saxagliptin (Onglyza®) # # # # Type 2 Not for use <18 Safety not established ¥ No data

• Linagliptin (Trajenta®) "6 "6 "6 # Safety not established ¥ No data, probably compatible

• Alogliptin (Nesina®)

# # # # Safety not established ¥ No data

Patient Self- Adjustment of Insulin. Is it actually happening?

What the DCPNS Registry tells us?

•  Using data from calendar year 2013, the DCPNS Registry shows us: –  12% of follow-up patients (not newly diagnosed) have A1C values

≥ 9% with another 6% between 8.5% and 8.99%. Total of 18% with A1Cs ≥ 8.5%

–  Of those using insulin therapy (alone or in combination), 34% have A1Cs ≥ 8.5% (24% ≥ 9%)

–  For those age 19-39 years, 35% have values ≥ 8.5% (27% ≥ 9%)

•  The DHW Target Setting Initiative (2011-2013) selected A1C ≥ 9% as a key indicator. A specific target was set to reduce the proportion, for those ages 19-39 yrs., from 29.5% to 20 % by 2020. …We are moving in the right direction, but there is more to do…

Nova Scotia 2013 A1C by Treatment Type

0%

20%

40%

60%

80%

100% Li

fest

yle

Onl

y

Insu

lin

OA

A

In/O

AA

Tota

l

≥ 9% 8.5- 8.99% 7-8.49% < 7%

Source: DCPNS Registry. Follow-up Indicator Report. October 2014

Nova Scotia 2013 A1C by Age Group (N = 10,432)

0%

20%

40%

60%

80%

100% 19

-39

40-4

9

50-5

9

60-6

9

70-7

9

≥ 80

Tota

l

≥ 9% 8.5- 8.99% 7-8.49% < 7%

Source: DCPNS Registry. Follow-up Indicator Report. October 2014  

Why This Work?

•  With these numbers in hand, we needed to find out if

patients are being taught how to self-adjust insulin on their own.

•  We know people are being started on insulin in Diabetes Centers, Pharmacies and Doctor’s offices.

•  We started with a survey of Diabetes Educators …with the intent of working with other groups FPNs, Pharmacists as we move forward.

Patient Self-Adjustment of Insulin Survey Overall Survey Results from:

Registered Nurses Registered Dietitians

22 15

We reached out to educators across the province with varying degrees of experience

SSH=4   SWH=2   AVH=6   CEDHA=1   CHA=2  

PCHA=2   GASHA=4   CBDHA=3   CDHA=8   IWK=5  

<2  years   2-­‐4.9   5-­‐9.9   10-­‐14.9   15  or  more  

1   6   7   5   18  

Sample of Survey Questions Yes No

1. Do you currently adjust insulin for your patients (by phone and/or in person)?

30 = 86% 5 = 14%

2. Do you teach your patients how to self-adjust their insulin doses?

30 = 86% 5 = 14%

3. Do your patients self-adjust their insulin dose? 10 = 26% Some 28 = 74%

6. Do you currently use tools or instruments that you have adapted for patient self-adjustment of insulin?

14 = 42% 19 = 58%

8. Within your practice do you have a defined approach to teaching patient self-adjustment of insulin?

17 = 46% 20 = 54%

9. Do you offer a patient education groups for insulin dose adjustment?

14 = 39% 22 = 61%

14. Would it be beneficial to have a standardized approach?

29 = 85% 5 = 15%

15. Would you be interested in working on a provincial approach to patient self-adjustment of insulin and/or the development of the supporting tools?

18 = 53% 16 = 47%

Survey Findings

Patient Self-Adjustment of Insulin Traits that……Hinder… •  Poor cognition (10) •  Lack confidence ,

motivation or unwilling (10) •  Fear of hypoglycemia(6) “Lack of good easy to understand tools. Low literacy levels. Fear.”

…Allow… •  Motivated , willing (5) •  Basic knowledge (6) •  Confidence (4)

“Acceptance of uncontrolled diabetes, readiness for change”

What tools are currently being used to teach self-adjustment of insulin? •  CDA education tools (11) •  DCPNS Insulin Dose Adjustment Policies and Guideline

manual(15) -checklist and insulin dose adjustment guidelines

•  Other (11)- insulin company tools, homemade tools. “Writing instructions in logbooks”

Would it be beneficial to have a standardized approach to patient self-adjustment of insulin?

Yes No No Response

28 5 4

“Yes. So all educators are comfortable with following the same protocol.” “Yes. It would be great to have standard tools which have been tested with patients.” “No. Important to be flexible in approaches to meet the needs.”

Plan 1.  Form a working group and approach review group. 2.  Find a tool that could be used to assess the patients

cognitive level prior to starting them on insulin.* 3.  Consider tools to address fear of hypoglycemia. 4.  Tools to address confidence. 5.  Consider other HCPs who could benefit from use of this

standardized tool. *Dr.L.Mallery, Dr.P.Moorehouse, Heather Moffatt BSc BA

Approach •  The approach will take into consideration the patients level

of cognition. •  Develop a standardized approach that can be used to

assist with insulin adjustment. •  Offer this approach to other HCP who start patients on

insulin. •  Create a self-adjustment insulin tool for patients that also

takes into consideration- cognition, readiness to change and fear of hypoglycaemia.

Thank You

Questions?