Module ii insulin therapy

SDM: Focus on Insulin Therapy

Major microvascular and macrovascularcomplications of diabetes

Sexual dysfunction

Peripheral sensorydysfunction

Coronary heart disease

Skin infection

Atherosclerosis

Gastro-intestinal andbladder dysfunction

Diabetic foot

Diabetic retinopathy

Diabetic nephropathy

Diabetic neuropathy

Cerebrovascular disease

Peripheral vasculardisease

Coronary disease

Cognitive impairment3

Cardiac autonomicneuropathy

Microvascular1,2Microvascular1,2 Macrovascular1,2Macrovascular1,2

Adapted from: 1. International Diabetes Foundation. Time to Act: Type 2 diabetes, the metabolic syndrome and cardiovascular disease in Europe. 2006. 2. International Diabetes Federation. Time to Act. 2001. 3. Seaguist ER. Diabetes. 2010;59:4-6.

HbA1c

Microvascular complications e.g. kidney disease and blindness *

Heart attack *

UKPDS: Tight Glycaemic Control Reduces UKPDS: Tight Glycaemic Control Reduces ComplicationsComplications

Deaths related to diabetes *

21%

Stratton IM et al. UKPDS 35. BMJ 2000; 321: 405–412

Amputation or fatal peripheral blood vessel disease *

37%

14%

12%

43%

Stroke **

1%

Epidemiological extrapolation showing benefit of a 1% reduction in mean HbA1c

* p<0.0001

** p=0.035

Scientific Foundation for Insulin Therapy in Type 2 Diabetes

Why is insulin needed?

When is insulin needed?

Is insulin therapy effective?

Is insulin therapy safe?

The first step is to set a glycemic target (agreed to by the patient)

Achieving Glycemic Control

HbA1c target (%)ADA/EASD <7

IDF ≤6.5

NICE <6.5

AACE ≤6.5

France <6.5*

Canada ≤7

Australia ≤7

Latin America <6.5

Are these HbA1c targets still appropriate in light of recent clinical trials?






To achieve glycemic targets

Clinical Inertia: “Failure to Advance Therapy When Recommended”

Mea

n A

1C a

t La

st V

isit*

(%

)

8.2 Years8.2 Years

ADA GoalADA Goal

Diet and ExerciseDiet and Exercise

Years Elapsed Since Initial Diagnosis

Initiation of

insulin therapy

Initiation of

insulin therapy

SU or metformin

SU or metformin

Combination oral agents

Combination oral agents

8.6%8.9%

9.6%

7

8

9

10

2.5 Years 2.9 Years 2.8 Years

*Adapted from: Brown JB et al. Diabetes Care. 2004;27:1535-1540.

Mazze, Strock, Simonson, Kendall, Cuddihy, Bergenstal. SDM Quick Guide 5th Edition, International Diabetes Center, 2009

Staged DiabetesManagement

* Liraglutide approved in EU

*

ADA/EASD Revised Algorithm for T2DM Nathan DM, et al. Diabetes Care & Diabetologia January 2009.

At diagnosis:Lifestyle + Metformin

Lifestyle + Metformin+ Basal insulin

Lifestyle + Metformin+ Sulfonylureas

Lifestyle + Metformin+ Intensive insulin

Tier 1: well-validated therapies

STEP 1 STEP 2 STEP 3

Tier 2: Less well validated therapies

Lifestyle + Metformin+ Pioglitazone

No hypoglycaemiaOedema/CHF

Bone loss

Lifestyle + metformin+ GLP-1 agonist

No hypoglycaemiaWeight loss

Nausea/vomiting

Lifestyle + metformin+ Pioglitazone+ Sulfonylurea

Lifestyle + metformin+ Pioglitazone+ Basal insulin

Insulin


* Liraglutide approved in EU

*







Earlier in the treatment plan

Titrate to clinically effective dose Advance if not at target in 3 months

TWO DRUG THERAPYTWO DRUG THERAPY

THREE DRUG THERAPYTHREE DRUG THERAPY

Add Background InsulinOr TZD, SU

METFORMINMETFORMIN

Background & Mealtime (main meal) + Oral Agent(s)*

Background & Mealtime (all meals) + Sensitizers*

Premixed Insulin + Sensitizers*

MULTI-DOSE INSULIN THERAPY MULTI-DOSE INSULIN THERAPY

* Limited published data for use of insulin plus either DPP-4 inhibitor or GLP-1 agonist

A1C >11%FPG >300 mg/dL

RPG >350 mg/dL

Start Insulin (Multi-Dose

Insulin therapy preferred)

Type 2 Diabetes Master DecisionPath

Advance if not at target in 3 monthsTitrate to clinically effective dose

Add SU Add DPP4-I Add GLP-1 Agonist Add TZD

2 meals

Add Background Insulin or

TZD, DPP-4, GLP1

Add Background Insulin or

SU, DPP-4, GLP1


Relative contributions of postprandial glucose and FPG to A1C

20

40

60

80

100

Fasting plasma glucose Postprandial plasma glucose

Monnier L et al. Diabetes Care. 2003;26:881-5.

A1C quintiles (%)

0>10.29.3–10.28.5–9.27.3–8.4<7.3

Contribution(%)

Plasma Glucose Normally Maintained in Narrow Range

Adapted from Polonsky KS, et al. N Engl J Med. 1988;318:1231-1239.

6 AM 10 AM 2 PM 6 PM 10 PM 2 AM

Time of Day

400400

300300

200200

100100

00

Diabetes

No diabetescontrol

Fix fasting firstFix fasting first

Pla

sma

Glu

cose

(m

g/dL

)

Plasma Glucose Normally Maintained in Narrow Range

Adapted from Polonsky KS, et al. N Engl J Med. 1988;318:1231-1239.

6 AM 10 AM 2 PM 6 PM 10 PM 2 AM

Time of Day

400400

300300

200200

100100

00

Fix fasting firstFix fasting first

Diabetes

No diabetescontrol

Pla

sma

Glu

cose

(m

g/dL

)

8.5

9.0

8.0

7.5

7.0

6.5

0 4 8 12 16 20 24

HbA

1c (%

)

NPH + OADInsulin glargine + OAD

Weeks

0

2

4

6

8

10

12

14

16 21% risk reduction p <0.02

42% risk reduction p <0.01

Overall Nocturnal Hypoglycemia

Events

per

pati

ent

per

year

Insulin Glargine vs. NPH in Treat-to-Target Trial: HbA1c and Hypoglycemia

Riddle et al. Diabetes Care 2003;26:3080-6.

Randomized to NPH or Glargine + OAD with target HbA1c <7%

Insulin Detemir vs. NPH in Treat-to-Target Trial: HbA1c and Hypoglycemia

Hermansen et al. Diabetes Care 29:1269, 2006

-2 0 12 24

8.5

9.0

8.0

7.5

7.0

6.5

HbA

1c (%

)

Weeks

NPH + OADInsulin detemir + OAD 47% risk reduction

p < 0.001

Events

per

pati

ent

per

year

55% risk reduction p < 0.001

0

2

4

6

8

10

12

14

16

18

Overall Nocturnal Hypoglycaemia

Long-acting

0

10

20

30

40

50

0 2 4 6 8 10 12 14 16 18 20 22 24

Using Insulin EffectivelyPhysiologic Insulin Replacement

Insu

lin L

eve

ls

Time of DayAdapted from Polonsky. N Engl J Med. 1996;334:777-783.Kendall DM. N Engl J Med 322: 898-903, 1990.

Sensitizers

Sulfonylurea / GLP-1 A / DPP-4 I

Long-ActingLong-Acting

24-Hour Plasma Glucose CurveNormal and People with Type 2 Diabetes

Time of Day

400

300

200

100

00600 06001000 1400 1800 2200 0200

Glucose(mg/dL)

Meal Meal MealNormal

Fix Fasting First

Adapted from Polonsky et al, N Engl J Med 1988.

Premixed: 75/25 with lispro, 70/30 with aspart,

50/50 with lispro

Premixed Regimen with Rapid-acting Insulin

Background / Mealtime (Basal / Bolus) Insulin Regimen

Rapid-acting insulin at meals Long-acting insulin at bed

Improvement in HbA1c with Basal – Bolus Insulin Regimen (Glargine / Glulisine) in Type 2 Diabetes

The majority of patients achieved HbA1c <7.0%

• Simple algorithm: 73.0%

• CHO counting: 69.2%p = NS

Simple algorithm

CHO counting

Bergenstal RM, Johnson M, Powers M et al. Diabetes Care 2008;31:1305–10.








Yes – if regimen is matched to patient’s glucose profile and lifestyle








Yes – if regimen matched to patient’s glucose profile and lifestyle

Used effectively – the benefits of glycemic control out weight risks

Weight Gain

Hypoglycemia

Cancer

Minimize by lifestyle advice & matching glycemic profile Minimize by lifestyle advice & matching glycemic profile

Not clear risk of exogenous insulin and cancer established – likely some increased risk of cancer with diabetes

Starting and Adjusting Insulin in Type 2 Diabetes

Steps for Starting Insulin Therapy in Type 2 Diabetes

1. Set a target or goal for glucose control• HbA1c and self-monitored blood glucose

2. Use an algorithm to advance therapy

Apply a consistent approach with timelines to reach goal

3. Determine the appropriate insulin regimen

4. Calculate the starting insulin dose

5. Educate patient and family

IDF ADA IDC/SDM

HbA1c <6.5% <7% <7%

Fasting and

Premeal

<100 mg/dL

5.5 mmol/l

90 -130 mg/dL

6.0-7.2 mmol/l

70-120 mg/dL

3.9-6.7 mmol/l

2 hour Postmeal

<140 mg/dL

7.8 mmol/l

<180 mg/dL

<10 mmol/l

<160 mg/dL

8.9 mmol/l

Glycemic Targets for Type 2 Diabetes*

Diabetes Care 33 Supp1, Jan 2010Insulin BASICS 2nd ed 2008:p25, International Diabetes Center

* non-pregnant adults


Staged DiabetesManagement at IDC

*

Preparing for Insulin in Type 2 DiabetesClinical Indicators

Initiate insulin if:

HbA1c above target for >3 months and on maximum effective dose of 2 or more glucose-lowering agents

HbA1c >11% and/or symptomatic and blood glucose >300 mg/dL

– If clinically stable and high intake of sweetened beverages (>36 oz or 3 cans/day), eliminate sweetened beverages and re-evaluate need for insulin in 1-2 weeks

SDM Quick Guide 5th Edition, 2009 International Diabetes Center, Park Nicollet Institute

0

10

20

30

40

50

0 2 4 6 8 10 12 14 16 18 20 22 24

Using Insulin EffectivelyPhysiologic Insulin Replacement

Insu

lin L

eve

ls

Time of Day

Meal Meal Meal

Basal (background) insulin needs = 50%

Mealtime (bolus) insulin needs = 50%

Adapted from Polonsky. N Engl J Med. 1996;334:777-783.Kendall DM. N Engl J Med 322: 898-903, 1990.

Re

lati

ve

Ins

ulin

Eff

ec

tR

ela

tiv

e In

su

lin E

ffe

ct

Time (Hours)

0 2 4 6 8 10 12 14 16

Long-Acting: Glargine (Lantus®)Detemir (Levemir®)

18 20

Intermediate: NPH (Humulin® N, Novolin® N)

Short-Acting: Regular (Humulin® R, Novolin® R)

Rapid-Acting: Lispro (Humalog®), Aspart (NovoLog®),Glulisine (Apidra®)

Insulin Time Action Curves

Bergenstal, “Effective insulin therapy,” International Textbook of Diabetes Mellitus vol 1. 3rd ed, Chichester NY, John Wiley and Sons, Inc., 2004:995-1015.

Background (Basal) Insulin

+ 2 Drugs

Elevated FPG

Stable daytime BG

Overwhelmed

Desire single injection

Premixed Insulin Sensitizer(s)

Elevated PPG

Increasing daytime BG

HbA1c >11%

Decreased dexterity

or visual acuity

Regular schedule

Background andMealtime Insulin

Sensitizer(s)

Elevated fasting

and/or post-meal

HbA1c >11%

Intensive control

More flexibility

Erratic schedule

Selecting an Insulin Regimen

Glycemic Factors

Patient Factors

Case Study: Khalida

73 year-old woman

Glycemic factors

Diabetes for 7 years

Taking metformin 1000 BID; and 10 mg glyburide BID

Current HbA1c 7.9%

SMBG in morning and evening are high

Patient factors

Very Fearful of injections

Background (Basal) Insulin Options

Glargine (Lantus®) and Detemir (Levemir®)– No significant peak; lasts up to 24 hours

– Twice daily dosing may be required

– Decreases risk of nocturnal hypoglycemia

NPH (Humulin® N and Novolin® N)– Less expensive

– Twice daily dosing required

Riddle et al. Diabetes Care. 26:3080-3086; 2003Raskin et al Diabetes Care. 28:260-265; 2005

Starting Background (Basal) Insulin

HbA1c <9% HbA1c ≥9%

Background Insulin Dose

0.1 units/kg 0.2 units/kg

Start with single dose of long-acting insulin (glargine or detemir) or intermediate-acting insulin (NPH) at bedtime if cost is a concern.

Maintain oral agents: 1-2 of them - SU, Metformin, (maybe TZD), NOTE: DPP-4 Inhibitors and/or GLP-1 mimetic with insulin is “off-label”

Starting Background (Basal) Insulin

Example: Khalida with HbA1c of 7.9%

Determine weight in kg

Weight in lbs _____ ÷ 2.2 = _____ kg

Calculate initial dose of background insulin

Weight in kg ______ x units/kg _____ = _____units

100 0.1 10

Plan

BedPMNoonAM

10-LA

100222


+ 2 Drugs

Elevated FPG Stable daytime BG

Overwhelmed Desire single injection


Elevated PPG Increasing daytime BG HbA1c >11%

Decreased dexterity or visual acuity Regular schedule


Sensitizer(s)

Elevated fasting and/or post-meal HbA1c >11% Intensive control

More flexibility Erratic schedule


Glycemic Factors

Patient Factors

Premixed Insulin

Human Insulin Begins to Work

Works Hardest

Stops Working

75/25 with Lispro Humalog Mix 75/25

50/50 with Lispro Humalog Mix 50/50

70/30 with Aspart NovoLog Mix 70/30

5-15 min 1-2 hrs 10-16 hrs

70/30 with Reg Humulin 70/30 Novolin 70/30

30-45 min 4-8 / 2-3 hrs 10-16 hrs

Based on package insert data

Case Study: Saleem Ahmad

63-year-old

Glycemic factorsCame to the Emergency Room with a foot infection

HbA1c 11.8%

Patient factorsFatigued, thirsty, dehydrated, +family history of diabetes but surprised he got diabetes and he is scared

Starting Premixed Insulin

HbA1c < 9% HbA1c ≥ 9%

Premixed Insulin Dose

0.1 units/kg

(2 times/day)

0.2 units/kg total

0.2 units/kg

(2 times/day)

0.4 units/kg total

Start with two doses; before breakfast and dinner

Consider adding insulin sensitizer (metformin)

Guide to Starting and Adjusting Insulin for Types 2 Diabetes © 2008 International Diabetes Center, Park Nicollet

Premixed regimen with rapid-acting insulin

Premixed: 75/25 with lispro, 70/30 with aspart,

50/50 with lispro

© 2007 International Diabetes Center, Minneapolis, MN All rights reserved..


+ 2 Drugs

Elevated FPG Stable daytime BG


Elevated PPG Increasing daytime BG HbA1c >11%


Sensitizer(s)

Elevated fasting and/or post-meal HbA1c >11% Intensive control

More flexibility Erratic schedule


Glycemic Factors

Patient Factors

Overwhelmed Desire single injection

Decreased dexterity or visual acuity Regular schedule

Case Study: A Qudoos

58 year old male

Glycemic factors

Diabetes for 14 years

Sitagliptin/metformin (Janumet™) 50/1000 BID and 30 mg pioglitazone (Actos®)

Current HbA1c 9.4%, elevated fasting and post-meal glucose

Patient factors

Eats healthy diet, exercises regularly

Desire flexible schedule for work

Starting Background (Basal) and Mealtime (Bolus) Insulin

HbA1c <9% HbA1c ≥9%

Background

Insulin Dose

0.1 units/kg

(once daily)

0.2 units/kg

(once daily)

Mealtime

Insulin Dose

0.1 units/kg (divided evenly between meals)

0.2 units/kg(divided evenly between meals)

Total Insulin

Dose

0.2 units/kg 0.4 units/kg

Stop meal related therapy (Janumet™) and begin metformin 1000 mg BID.

Consider pros and cons of maintaining pioglitazone (Actos®).

Background (Basal) and Mealtime (Bolus) Insulin Regimen

RA = rapid-acting insulin: Lispro, aspart, glulisine

Rapid-acting insulin at meals Long-acting insulin at bed

Team Approach to Starting Insulin

What Gets in the Way of Starting Insulin?Patient Concerns

1. Injections (Shots)

2. Diabetes more

serious

3. Complicated

4. Inconvenient

5. Sense of failure

6. Hypoglycemia

Bergenstal Chapter 53, International Textbook of Diabetes Mellitus 3rd Edition, 2004 John Wiley & Sons and International Diabetes Center, unpublished survey data

How does diabetes change over the years?

© From Let’s Talk About Insulin 2008, © International Diabetes Center

YearsYears-10-10 -5-5 00 55 1010 1515 2020 2525 3030

Insulin Resistance

Insulin LevelPre DiabetesMetabolic Syndrome

-15-15

Impaired Incretin Action

What Gets in the Way of Starting Insulin?

1. Complexity of starting and

adjusting insulin

2. Not sure what it is like to take

an insulin injection

3. Weight gain

4. Hypoglycemia

5. Other concerns?

Bergenstal Chapter 53, International Textbook of Diabetes Mellitus 3rd Edition, 2004 John Wiley & Sons; Jeavons D et al. Postgrad Med J 2006; 82:347-350.

Doctor Concerns

Begin with a practice injection (saline)

Can help to allay apprehension about injections

Information that follows may be better heard

You try it!

Saline Injection Demonstration

1. Remove cap from the end of the syringe

2. Remove the needle cap 3. Pull back on plungerto the amount calculated(e.g. 10 units)

5. Pull back on the plunger to measure the correct amount (e.g. 10 units)

6. To remove air bubbles, push plunger back in.

4. Insert needle and push air into the vial

7. Pull back on the plunger to measure the correct amount (e.g. 10 units). Remove needle from vial

You are ready to give the injection

Saline Injection Demonstration

9. Administer the injection into the abdomen. Remove needle and cover area with your finger for a few seconds.

10. Throw away the used syringe in a sharps container (do not re-cap)

8. Hold the syringein your hand as shown (like holding a pen)

Important Education Topics for Starting Insulin Therapy

Diabetes overview

Insulin administration

Glucose monitoring

Simple eating guidelines

Hypoglycemia

FlexPen®

SoloStar® (sanofi aventis)

Examples of Insulin Pens

Pre-filled (Disposable)

Re-usable (uses insulin cartridges)

NovoPen® 4

HumaPen ®

Sites for Insulin Administration

Abdomen preferred

Insulin BASICS 2nd ed 2008:p19, International Diabetes Center

Insulin storageCheck package insert for specific instructions

Keep unopened insulin in refrigerator or cool temperature

Insulin in use can be stored at room temperature

Range is from 10 days to 42 days depending on insulin

Check package insert for specific instructions

Keep above freezing and below 86F ( 30C)



Diabetes overview


Glucose monitoring


Hypoglycemia

Blood Glucose Monitoring

To improve clinical decision-making

To evaluate efficacy of the therapy

To pin point problems

To support adherence to regimen

Feedback for the patient

IDF ADA IDC

HbA1c <6.5% <7% <7.0%

Fasting and

Premeal

<100 mg/dL

5.5 mmol/l

70 -130 mg/dL

3.9-7.2 mmol/l

70-120 mg/dL

3.9-6.7 mmol/l

2 hour Postmeal

<140 mg/dL

7.8 mmol/l

<180 mg/dL

<10 mmol/l

<160 mg/dL

8.9 mmol/l

Glycemic Targets for Type 2 Diabetes*

Diabetes Care 29(8), Aug 2006Diabetes Care 32 Supp1, Jan 2009Insulin BASICS 2nd ed 2008:p25, International Diabetes Center

* non-pregnant adults

Ideal Testing FrequencyPatients Taking Insulin

Minimum four times/day recommended

Glucose testing:

– Before each meal and before bedtime

– Consider pre-meal and 30-90 minutes post meal to evaluate effect of insulin on post-meal glucose

Modify frequency of monitoring if necessary

Encourage patients to record values in a record book

Use meter with a memory for verified data

Modify based on individual patient circumstances; vary the times of testing to build a profile


Diabetes overview


Glucose monitoring


Hypoglycemia

2009 International Diabetes Center

2. Choose a variety of foods 1. Eat 3 meals per day

Quick Start: Healthy Eating Guidelines

Eat fewer or smaller portions of sweetened foods or beverages (soft drinks, juices, desserts, candy)

Include carbohydrate at each meal

Avoid alcohol for now

Choose healthy foods when possible

Replace, reduce, restrict

Small to moderately sized portions

Similar portions from day to day at a given meal time

Consistent meal times (initially for all insulin regimens)

Include small snacks, if desired



Diabetes overview


Glucose monitoring


Hypoglycemia

Hypoglycemia

BG

Below

70 mg/dL

(3.9 mmol/L)


Common Symptoms

Weak, shaky, lightheaded

Sweaty, clammy

Irritability

Tingling or numb lips

Confusion

Hungry

Treatment of Hypoglycemia(Routine 15)

Test blood glucose if possible

Treat with 15 gm carbohydrate if <70 mg/dL (3.8 mol/L)

– 3-4 glucose tablets or 1/2 cup

juice or soda pop

– BG ~50-60 mg/dL (3 mmol/L)

– Have carbohydrate readily available

– Avoid high-fat carbohydrates

(slower absorption)

Wait 15 minutes

Test and treat again if glucose below target

Insulin BASICS 2nd edition 2008: p 31, © International Diabetes Center

Treatment of Severe Hypoglycemia Requires assistance to treat

Note: Severe hypoglycemia is rare in type 2 diabetes

Unable to swallow safely

Needs injection of glucagon– Hormone that releases stored glycogen (glucose)– Given intramuscular or subcutaneous– Standard dose: 1.0 mg adults; 0.5 mg for children

Precautions– May cause nausea/vomiting/headache– Increase fluids following injection

Call for emergency assistance

Insulin BASICS 2nd edition 2008: p 77, © International Diabetes Center

Hypoglycemia Prevention

Follow food/insulin plan

Test BG daily

Be prepared and carry carbohydrate

Keep records

Wear medical ID

Inform family, friends, co-workers how to recognize and treat lows

Inform doctor of low glucose patterns

Check BG before driving

Insulin BASICS 2nd edition 2008, © International Diabetes Center

http://www.laurenshope.com/category.asp?cat=1


1. Set a target or goal for glucose control

HbA1c and self-monitored blood glucose






Fine-Tuning Glycemic Control

Overview

Nutrition Messages

Insulin Adjustments

Glucose Data

Treating Hypoglycemia

Nutrition Messages

Insulin Regimen

Meals Snacks

Background Control carbohydrate3-4 carb choice*/meal

Not needed

Pre-Mixed Eat at consistent times with consistent carb

May be needed depending on schedule & insulin

Background and Mealtime

Start with consistent carb

Not neededif snack is eaten, add RA insulin to cover

*One carb choice = 15 grams of carbohydrate

Titrating Insulin for Background Regimen

If most AM fasting BG >120 mg/dL

Titrate until fasting glucose at target BG

If most AM fasting BG <120 mg/dL and HbA1c remains above target

Test pre dinner and bedtime (or 2-hour post dinner) and consider need for mealtime insulin


Titration Guide (Table 6)

SDM Quick Guide, 2009, IDCGuide to Starting and Adjusting Insulin for Types 2 Diabetes © 2008 International Diabetes Center, Park Nicollet

If most BG <200 mg/dL

<70 mg/dL Decrease by 1-3 units

70-120 mg/dL No change

121-200 mg/dL Increase by 1-3 units

>200 mg/dL Increase by 3-5 units or 10%

What adjustments would youmake for Khalida?

Pre- Bkfst

Ins-Med

Post Pre Ins-Med

Pt Pre-Din

Ins Post HS

Mon 155 Met. 1000Glyb.

10

121 Met. 1000Glyb.

10

148 10LA

Tue 163 142 199 10LA

Wed 143 112 143 10LA

Thur 133 96 116 12 LA

Started at 0.1 units/kg x 100 kg (220#) =10 units

After Insulin Adjustment

Pre- Bkfst

Ins-Med

Post Pre Ins-Med

Pt Pre-Din

Ins Post HS

Mon 137 Met. 1000Glyb.

10

111 Met. 1000Glyb.

10

147 12LA

Tue 140 125 165 12LA

Wed 122 102 137 12LA

Thur 148 114 156?

Titrating Insulin for Background Regimen

If most AM fasting BG >120 mg/dL

Titrate until fasting glucose at target BG

If dose reaches 0.5-0.7 units/kg body weight, consider adding mealtime insulin

If most AM fasting BG <120 mg/dL and HbA1c remains above target

Test pre dinner and bedtime (or 2-hour post dinner) and consider need for mealtime insulin


Step-wise Transition from Background to Background & Mealtime Regimen

Start with single injection rapid-acting insulin before largest meal (most carb. choices)

– 0.1 units/kg rapid-acting (RA) insulin

Subtract 0.1 units/kg from background insulin dose

Consider maintaining oral agents

Example 100 kg patient on 60 units background insulin

New dose: 100 kg x 0.1 units/kg = 10 units RA before largest meal

60 units – (0.1 units/kg) = 50 units background insulin

Staged Diabetes Management Quick Guide © 2007 International Diabetes Center, Park Nicollet

Titrating Insulin for Premixed Regimen

If most BG >200 mg/dL Increase total insulin by 0.1 units/kg

Distribute equally between doses

If most BG <200 mg/dL Use titration guide to adjust

AM FBG: adjust pre-dinner insulin dose

Pre-dinner: adjust pre-breakfast insulin

How would you adjust Saleem Ahmad dose of Mix 75/25?

Pre-

Bkfst

Ins Post Pre Ins Post Pre-

Din

Ins Post HS

Mon 265 19 201 19 236

Tue 244 19 198 19 254

Wed 254 19 205 19 215

Thur 195 206 22724 24

Started at 0.2 units/kg x 95 kg (209#) = 19 units AM and PM

0.1 units/kg x 95 kg (209#) = 9.5 units

After Insulin Adjustment

Pre-

Bkfst


Din

Ins Post HS

Mon 184 24 162 24 210

Tue 193 24 182 24 219

Wed 174 24 158 24 183

Thur 160 155 19426 26

Use titration guide to adjust

Titrating Insulin for Background & Mealtime Regimen

If most BG >200 mg/dL Increase total insulin by 0.1 units/kgAdd half to backgroundDistribute remaining half between mealtime doses

If most BG <200 mg/dL Use titration guide to adjustAM FBG: adjust backgroundPre-lunch/dinner: adjust previous mealtime insulinIf more than 40 mg/dL pre- to 2 hr. postmeal rise, increase RA 1-3 units

What adjustment would you make to A. Qudoos insulin doses?

Pre-

Bkfst


Din

Ins Post HS

Mon 133 5 RA

244 5 RA

115 6 RA

156 16

LATue 125 5

RA201 5

RA124 6

RA170 16

LA

Wed 114 5

RA

199 5

RA

117 6 RA

187 16 LA

Thur 139 7 RA

8 RA

Started at 0.2 units/kg x 80 kg (176#) = 16 units LA and 16 units RA divided between 3 meals

5 RA

16 LA

After Insulin Adjustment3 carbs for breakfast - 2 carbs for lunch 4 carbs for dinner

Pre-

Bkfst


Din

Ins Post HS

Mon 105 7

RA

142 5 RA 78 72 8 RA 139 16

LA

Tue 112 7 RA

151 5 RA 85 70 8 RA 125 16 LA

Wed 98 7

RA

125 5

RA

66 69 8 RA 98 16 LA

Thur 110 132 74 65 1127 RA

8 RA

5 RA

16 LA

Starting vs. Final Insulin Dose

Typical Patient

(Type 2 DM)

Regimen Starting Dose (units)

Common Final Dose

(units)Background Insulin

0.2 units/kg

(20 units)

0.5-0.7 units/kg

(50-70 units)

Premixed Insulin

0.2 units/kg BID (40 units total)

1.0-1.2 units/kg (100-120 units)

Background & Mealtime Insulin

0.2 units/kg background 0.2 units/kg mealtime (40 units total)

1.0-1.2 units/kg (100-120 units)

220 lbs

(100 kg)

HbA1c 9%

Average dose for type 1 diabetes is 0.7 units/kg

Follow-up and Summary

Recommended follow-up

– Every 1-2 weeks while adjusting dose

– Every 3 months once dose established

Have patient monitor BG more extensively 1-2 weeks prior to visit to have recent data for adjusting

Use a team approach when starting insulin

Consider enabling patients to make adjustments to their insulin regimen

Case Studies

Module ii insulin therapy

Health & Medicine

Transcript of Module ii insulin therapy