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learn.extension.org/events/3369

This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military

Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.

The ABCs of MDI: Gaining a working knowledge of

Multiple Daily Injection insulin therapy

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FD Title Slide

3This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military

Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.

The ABCs of MDI: Gaining a working knowledge of

Multiple Daily Injection insulin therapy

learn.extension.org/events/3369

Kimberly Bisanz, MFCS, RDN, LD, CDE

•At age 14, decided to become a dietitian (thank

you 4-H!) as long as she didn’t have to work with

diabetes

•At age 20, still wanted to be a dietitian, as long as

she could specialize in diabetes

•At age 27, earned the CDE designation

•Research Interest: Flexible intensive insulin

therapy in people with Type 2 Diabetes

Today’s Presenter

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Objectives

After this presentation, you should be able to:

• Identify at least 2 types of basal insulin and 2 types

of bolus insulin used for MDI therapy

• Explain 3 approaches to carbohydrate quantification

• Describe snacking guidelines for persons using MDI

therapy

5

Disclosures

• No financial relationships outside of my

current employer, Mayo Clinic

6

What is your experience

with diabetes?

7Photo by Daniel Frese from Pexels

By the numbers…

8

Bisanz K, Parker A, Byrne C, Parker S, Thomas J, Mancino J, Hand RK. Identification of generalist RDN knowledge gaps in diabetes MNT

compared to diabetes credentialed RDNs: results of a survey to inform educational opportunities. Journal of the Academy of Nutrition and

Dietetics. E published: http://jandonline.org/article/S2212-2672(18)30072-8/fulltext

Diabetes Self-Management Education & Support

Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care 2015;38:1372–1382

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MDI = 4 or more

injections per day

• Multiple Daily Injections/Multi-Dose

Injections

• Basal-Bolus Insulin Therapy

• Intensive Insulin Therapy

10Pixabay.com

Insulin OptionsBasal Insulins

Long-acting

• glargine: Lantus (2000),

Basaglar (2015), Toujeo (2015)

• detemir: Levemir (2005)

Ultra Long-acting

• degludec: Tresiba (2015)

Bolus Insulins

Short-acting

• regular (10/1982)

Rapid-acting

• aspart: Novolog (11/2001), Fiasp

(9/2017)

• lispro: Humalog (6/1996)

• glulisine: Apridra (2/2004)

11©2012 Mayo Foundation for Medical Education and Research. All rights reserved. “Used with permission of Mayo Foundation for Medical

Education & Research”

Which of the following patient scenarios has

the strongest indication for initiating MDI?

A. PWDT2, new diagnosis, A1c 10%

B. PWDT2 on metformin, A1c 10%

C. PWDT2 on basal insulin, SGLT2, GLP-1, A1c 10%

D. PWDT1, new diagnosis, A1c 10%

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13

SGLT2i Metformin

DPP-4iSulfonylureas

Pumps GLP-1

NPHBasal Insulin

Non-diabetic State

14

©2012 Mayo Foundation for Medical

Education and Research. All rights reserved.

“Used with permission of Mayo Foundation for

Medical Education & Research”

This illustration was made available by written permission of The Regents

of the University of California. All rights reserved.

Type 1 diabetes mellitus

Gold-standard for full pancreas replacement

– Most people with type 1 diabetes should be

treated with multiple daily injections of

prandial insulin and basal insulin or

continuous subcutaneous insulin infusion. A

15American Diabetes Association (2018). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2018.

Diabetes Care, 41(Supplement 1), S73-S85. Accessed April 03, 2018. https://doi.org/10.2337/dc18-S008.

Insulin pump (continuous insulin infusion – CII)

•Only uses rapid acting insulin

•Always attached so no injections

•Allows for fine tuning of basal rates

•Drawbacks: technology, troubleshooting, DKA, attached, cost

Type 2 Diabetes Mellitus

When control cannot be achieved with other agents

For patients with type 2 diabetes who are not achieving glycemic goals, drug intensification, including consideration of insulin therapy, should not be delayed. B

• Diabetes Progression– Long-standing T2DM can result in insulin deficiency

• Co-morbidities – Contra-indication of non-insulin oral medications & injectables

16

American Diabetes Association (2018). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2018.

Diabetes Care, 41(Supplement 1), S73-S85. Accessed April 03, 2018. https://doi.org/10.2337/dc18-S008.

Which of the following patient scenarios has

the strongest indication for initiating MDI?

A. PWDT2, new diagnosis, A1c 10%

B. PWDT2 on metformin, A1c 10%

C. PWDT2 on basal insulin, SGLT2, GLP-1, A1c 10%

D. PWDT1, new diagnosis, A1c 10%

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Pro’s

• “Flexibility”

• Efficacy

• Neutral CV risk

Con’s

• Hypo Risk

• Weight Gain

• Cost

• Injection

• Complexity

MDI Considerations

18American Diabetes Association (2018). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2018.

Diabetes Care, 41(Supplement 1), S73-S85. Accessed April 03, 2018. https://doi.org/10.2337/dc18-S008.

T2DM Diagnosis

• 57 year old male financial manager.

• Motivated to improve eating and increase physical activity along with starting metformin.

5 years

• First follow-up with PCP. Presents with fatigue & ED. A1c 9.1%

• SGLT2 initiated and 3 months later GLP-1 added.

• 3 months later A1c 6.9%.

3 years

• Continues on triple-therapy, A1c slowly deteriorating (7.3%)

• CKD stage 3 diagnosed.

6 months

• NSTEMI with stent placement and AKI from contrast. CKD stage 4.

• Metformin, SGLT2, and GLP-1 discontinued.

• Basal insulin started.

3 months

• A1c 8.1%

• Rapid-acting insulin added to meals – 1st to dinner then sequentially to breakfast and lunch as BG targets not met.

19

Pexels

Intermission

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Pixabay

What are your priority topics when

educating PWD (pick 2)?

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Limiting sugar/carbohydrate

Macronutrient distribution

Label reading

Meal timing

Meal planning

Weight management

Heart health

Medical Nutrition Therapy –

Diabetes Goals• Encourage healthful eating patterns, to

– achieve glycemic, blood pressure, and lipid goals

– achieve and maintain body weight goals.

– delay or prevent complications of diabetes.

• Individualize MNT based on personal and cultural preferences,

health literacy and numeracy, access to healthful food choices,

willingness and ability to make behavioral changes, as well as

barriers to change.

• To maintain the pleasure of eating by providing positive messages

about food choices while limiting foods only when indicated by

scientific evidence.

• Focus on practical, day-to-day meal planning rather than on

individual macronutrients, micronutrients, or single foods.

22

Evert, A. B., Boucher, J. L., Cypress, M., Dunbar, S. A., Franz, M. J., Mayer-Davis, E. J., Neumiller, J. J., Nwankwo, R., Verdi, C. L., Urbanski,

P., & Yancy, W. S. (2014). Nutrition Therapy Recommendations for the Management of Adults With Diabetes. Diabetes Care, 37(Supplement

1), S120-S143. https://doi.org/10.2337/dc14-S120

Medical Nutrition Therapy - MDI

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Healthy Eating

I.D.

Timing

Counting

Fruit

Vegetables

Breads,

StarchesMeats/

Protein

Milk

Carbohydrate Identification

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Protein

Carbohydrates

Sugar

Fruits

Milks

Sweets

Starch

Breads

Starchy Veggie

Grains

Fat

Photo by Miguel Á. Padriñán, Pexels

Carbohydrate Intake - Timing

• Carbohydrate with bolus insulin

– Non-carb snacking

– Non-carb beverages

• Separate “meals” by at least 4 hours to

avoid insulin stacking

26©2012 Mayo Foundation for Medical Education and Research. All rights reserved. “Used with permission of Mayo Foundation for Medical

Education & Research”

4 hours

Carbohydrate Intake - Quantity

• Counting in choices (=15g)

• Counting in grams

• Estimation/Consistency with Plate Method

• Estimation of small/medium/large

27©2012 Mayo Foundation for Medical Education and Research. All rights reserved. “Used with permission of Mayo Foundation for Medical

Education & Research”

Carbohydrate Intake - Goals

DM: Individualize Macronutrient Composition

The registered dietitian nutritionist (RDN), in collaboration with the adult with diabetes,

should individualize the macronutrient composition of the healthful eating plan within the

appropriate energy intake. Limited research regarding differing amounts of carbohydrate

(39% to 57% of energy) and fat (27% to 40% of energy), reported no significant effects

on A1C or insulin levels in adults with diabetes, independent of weight loss. Limited

research reports mixed results regarding the effects of the amount of protein (ranging

from 0.8g to 2.0g per kg per day) on fasting glucose levels and A1C.

Rating: Fair

Imperative

• Consider co-morbidities

28Academy of Nutrition and Dietetics Evidence Analysis Library Diabetes Type 1 and 2. Accessed 4 May 2018

https://www.andeal.org/topic.cfm?menu=5305&pcat=5488&cat=5470

Insulin Dose Adjustment/

Pattern Management• American Diabetes Association

• Consider: blood glucose levels, pharmacodynamic profile of each

formulation

• Yale Diabetes Center• Rely SMBG for several days to 1–2 weeks

• Consider: diet, activity level, and stress

• In absence of severe hyper/hypoglycemia, adjust in 10–20% increments

• Mayo Clinic• Based on 3-day patterns

• Basal: adjust by 10% if BG +/- for >40mg/dL HS to pre-breakfast (-20% if

>80mg/dL drop

• Bolus: adjust preceding bolus +/-10% if BG outside of pre-prandial BG goal

range. (-20% if severe hypoglycemia)

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Yale Diabetes Center. (2011). Diabetes Facts and Guidelines. Silvio E. Inzucchi, M.D. Available at:

https://medicine.yale.edu/intmed/drc/diabetescenter/living/50135_Yale%20National%20F_102165_284_13584_v1.pdf

American Diabetes Association (2018). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2018.

Diabetes Care, 41(Supplement 1), S73-S85. Accessed April 03, 2018. https://doi.org/10.2337/dc18-S008.

Mayo Clinic Integrated Outpatient Adult Protocol: Multiple Daily Injection (MDI) Insulin Dose Adjustment, MC2222-160. Internal document.

Real Life Challenges

– Using insulin to carbohydrate ratio (1:15)• Flexibility vs. responsibility

– How to snack• non-carb vs. >3-4 hours

– Alcohol• Risk of hypoglycemia but hyperglycemia possible too

– Exercise• Type of activity and timing with food matters

• Dose adjustment of bolus insulin vs. adjust food intake

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Beyond Vial & Syringe

• NovoPen Echo: • Half units dosing increments

• Memory: records dose, time since last injection

• https://www.novologpro.com/prescribing/insulin-pens/novopen-echo.html

• Insulin Delivery: V-Go• T2DM only

• Daily application

• U-100 rapid-acting insulin only

• Preset basal rate (20, 30, or 40u/24 hours)

• Bolus, 2u/click, up to 36u/day

• https://www.go-vgo.com/hcp

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Image used with permission from Valeritas

Innovations in BG Monitoring

CGM: Libre• Factory calibration = no daily fingerstick calibrations

• Wear for 10 days

• Measure BG every minute, records readings q 15 min,

stores up to 8 hours of data

• https://www.myfreestyle.com/provider/freestyle-libre-product

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Image used with permission of Abbott

Resources

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Questions

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Pixabay

Evaluation

Continuing Education Credits

MFLN Nutrition & Wellness is offering 1.0 CPEU for

today’s webinar.

Please complete the evaluation at:

https://vte.co1.qualtrics.com/jfe/form/SV_bI3QDkNDE7jYhH7

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Upcoming Event

Enhancing the U.S.

Army Performance

through Key

Nutrition Initiatives

• Tuesday June 19, 2018

• 11:00am - 12:00pm EDT

• learn.extension.org/events/3370

36

militaryfamilies.extension.org/webinars

37This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military Family

Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.