Insulin management in DM2

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DM2

• Outpatient Glycemic Control

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DM

• Inpatient Glycemic control

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Criteria for the Diagnosis of Diabetes

A1C 6.5
OR
Fasting plasma glucose (FPG)126 mg/dl (7.0 mmol/l)
OR
Two-hour plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT
OR
A random plasma glucose 200 mg/dl (11.1 mmol/l)
ADA. I. Classification and Diagnosis. Diabetes
Care 201134(suppl 1)S13. Table 2.
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Components of the Comprehensive Diabetes
Evaluation
Physical examination (1)
Height, weight, BMI
Blood pressure determination, including orthostatic measurements when indicated
Fundoscopic examination
Thyroid palpation
Skin examination (for acanthosis nigricans and insulin injection sites)

See appropriate referrals for these categories.
ADA. V. Diabetes Care. Diabetes Care
201134(suppl 1)S17. Table 8.
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Components of the Comprehensive Diabetes
Evaluation
Physical examination
Comprehensive foot examination
Inspection
Palpation of dorsalis pedis and posterior tibial pulses
Presence/absence of patellar and Achilles reflexes
Determination of proprioception, vibration, and monofilament sensation
See appropriate referrals for these categories.
ADA. V. Diabetes Care. Diabetes Care
201134(suppl 1)S17. Table 8.
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Initial Metabolic Evaluation

• Referrales

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Laboratory evaluation
A1C, if results not available within past 23 months
If not performed/available within past year Fasting lipid profile, including total, LDL- and HDL-cholesterol and triglycerides Liver function tests Test for urine albumin excretion with spot urine albumin/creatinine ratio Serum creatinine and calculated GFR TSH in type 1 diabetes, dyslipidemia, or womengt50 years of age
ADA. V. Diabetes Care. Diabetes Care
201134(suppl 1)S17. Table 8.
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Referrals
Annual dilated eye exam
Family planning for women of reproductive age
Registered dietitian for MNT
Diabetes self-management education
Dental examination
Mental health professional, if needed
ADA. V. Diabetes Care. Diabetes Care
201134(suppl 1)S17. Table 8.
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Target HbA1C

• A -B -C D- E

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Correlation of A1C with Estimated Average Glucose
(eAG)
Mean plasma glucose Mean plasma glucose
A1C () mg/dl mmol/l
6 126 7.0
7 154 8.6
8 183 10.2
9 212 11.8
10 240 13.4
11 269 14.9
12 298 16.5
These estimates are based on ADAG data of 2,700
glucose measurements over 3 months per A1C
measurement in 507 adults with type 1, type 2,
and no diabetes. The correlation between A1C and
average glucose was 0.92. A calculator for
converting A1C results into estimated average
glucose (eAG), in either mg/dl or mmol/l, is
available at http//professional.diabetes.org/Gluc
oseCalculator.aspx.
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Considering

• Age
• Body weight
• GFR

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Outpatient Management

• Bp control
• Lipid management
• Cigar discontinuous
• Glycemic control

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Early and aggressive insulin therapy

• Reduces long-term vascular risk and potentially
  may prolong B-cell lifespan and
• Function.
• .

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• initiating combination therapy or insulin
  immediately for all patients with A1C 9 at
  diagnosis.

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• Recent clinical treatment guidelines, suggest
  that these agents may be less effective as add-on
  therapy for patients with an A1C 9.5 and
  therefore recommend the initiation of insulin in
  all patients with an A1C gt 10.

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Indication for insulin therapy
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ketosis-prone type 2 diabetes

• At presentation, they have markedly impaired
  insulin secretion and insulin action, but
  aggressive management with insulin improves
  insulin secretion and action to levels similar to
  those of patients with type 2 diabetes without
  DKA.

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• Recently, it has been reported that the
  nearnormoglycemic remission is associated with a
  greater recovery of basal and stimulated insulin
  secretion and that 10 years after diabetes onset,
  40 of patients are still non-insulin dependent.

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• Fasting C-peptide levels of gt1.0 ng/dl (0.33
  nmol/1) and stimulated C-peptide levels gt1.5
  ng/dl (0.5 nmol/1) are predictive of long-term
  normoglycemic remission in patients with a
  history of DKA.

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Barriers to insulin initiation and
intensification

• The steps involved in insulin therapy
• Initiation
• Optimisation
• Intensification

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Patient barriers
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Physician barriers

• Low motivation
• Education barriers

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Insulin initiation strategies

• In general, patients are initiated on relatively
  less intensive insulin regimens to ease them into
  an appropriate routine. The insulin regimen can
  then be intensified as needed to meet
  glycemic
• goals. .

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Basal insulins

• NPH
• Glargin
• Detemir

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Treat-to-Target trial

• Glargine or NPH?
• A1c reduction of1.6
• Nocturnal hypoglycemia?
• Variablity in duration?

.
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• Long-acting analogs may also possess added
  benefit when compared to NPH insulin in regard to
  rates of hypoglycemia and, in the case of insulin
  detemir, decreased weight gain. .

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Titration
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Starting with a basal insulin analogue

• The OADs,
• including metformin and a secretagogue, are
  usually retained.

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• For patients who experience dose waning toward
  the end of the dosing interval, twice-daily
  dosing may be considered or the administration
  time for single-dose regimens can be moved to
  earlier in the day during the period the patient
  will be using prandial coverage or periods of
  greater physical activity.

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Premixed insulin

• initiating a once-daily regimen in patients for
  whom hyperglycemia is not severe and a
  twice-daily regimen in patients with an AlC gt
  8.5.

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Rapid-acting products

• Ideally, these agents should be administered with
  a lag time before eating that is proportional to
  the preprandial glucose level. The higher the
  glucose level, the greater amount of time before
  the meal the insulin should be administered to
  allow for onset of effect and a downward trend of
  premeal hyperglycemia before eating..

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Rapid-acting products

• rapid-acting insulin should be administered
  earlier (e.g., 10-15 minutes before the meal) for
  meals that contain primarily rapidly absorbed
  carbohydrates to ensure onset during carbohydrate
  absorption. Conversely, this insulin could be
  administered later (e.g., at the first bite or 15
  minutes after the meal) for meals with high fat
  content, which may slow carbohydrate absorption..

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• Most patients start a once-daily
• regimen before dinner, while maintaining
  sensitisers
• and discontinuing evening secretagogues, and
• should use 12 U initially.

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• A recent study shows 41 of
• patients with type 2 diabetes attained an A1C
  less than 7 on a once-daily
• regimen of BIAsp 30 and OADs.

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• the addition of oncedaily biphasic insulin aspart
  70/30 before the evening meal in patients failing
  to meet glycemic goals on metformin resulted in
  A1C reductions of 1.1-1.3.

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it is important to note that when A1C levels are
8.5 or above, initiating insulin therapy with a
twice-daily premixed insulin analogue is more
effective at achieving glycaemic control
than basal insulin.

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• Lingvay et al, recently demonstrated a 100
  success rate in achieving a goal AlC of lt 7.0 in
  patients with newly diagnosed type 2 diabetes by
  initiating twice-daily biphasic insulin aspart
  70/30 insulin in combination with metformin..

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• Patients usually remain on sensitisers
• whereas secretagogues are generally discontinued
  if using two or more injections.

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Basalbolus insulin regimens
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Use of insulin glargine and cancer incidence in
Scotlanda study from the Scottish Diabetes
Research NetworkEpidemiology Group-Diabetologia(2
009)

• Overall, insulin glargine use
• was not associated with an increased risk of all
  cancers over a 4 year time frame.
• In the subgroup of insulin glargine only users
• to more likely reflect allocation bias rather
• than an effect of insulin glargine itself.

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