INTENSIVE%20INSULIN%20THERAPY - PowerPoint PPT Presentation

About This Presentation
Title:

INTENSIVE%20INSULIN%20THERAPY

Description:

Levemir (Detemir) cartridge. Prolonged action. Start 1.5 hrs. Peak 7 ... Vial and cartridge. Start 15 min. Aspart (NovoRapid ) Lispro (Humalog ) Rapid-acting ... – PowerPoint PPT presentation

Number of Views:568
Avg rating:3.0/5.0
Slides: 55
Provided by: drjames87
Category:

less

Transcript and Presenter's Notes

Title: INTENSIVE%20INSULIN%20THERAPY


1
INTENSIVE INSULIN THERAPY
  • J. Robin Conway M.D.
  • Diabetes Clinic, Smiths Falls, ON
  • 1-800-717-0145

2
Objectives
  • Optimize diabetes management
  • Assist you in initiating insulin in your office
  • When to start insulin therapy?
  • Insulins, doses, delivery options
  • Patient training

3
Challenges in Initiating Insulin?
  • 1. Patient attitudes
  • Fear of needles
  • Insulin viewed as a threat by patient physician
  • Hypoglycemia
  • 2. Physician Attitudes
  • Discomfort with insulin
  • Lack of knowledge and experience
  • Fear of needles

4
Type 1 Diabetes
  • Impaired or absent ß cell function
  • ? insulin secretion
  • Normal insulin action
  • ? insulin sensitivity
  • The insulin deficiency results in unacceptable
    blood glucose control

5
Type 2 Diabetes Double Impairment
  • Impaired ß cell function
  • ? insulin secretion
  • Impaired insulin action
  • ? insulin resistance
  • Results in unacceptable blood glucose control

6
Type 1 2 Diabetes Key Concepts
  • Minimizing the complications of diabetes
    requires
  • Early diagnosis and treatment of diabetes
  • Maintaining HbA1C level lt 7
  • Achieving HbA1C lt 7 requires control of
    post-prandial and fasting hyperglycemia

7
CDA Guidelines (for glycemic control)

Normal
Optimal

A1C level
(0.04-0.06)
(lt 0.07)
Preprandial
3.5-6.1
4-7
glycemia
(mmol/L)
Postprandial
glycemia
4.4-7.8
7-11
(
mmol/L)
Haars s et al., CMAJ 2003 159 (Suppl.) S1-29.
Gerstein, H.C. et al. CDA views on the UKPDS and
revision of the guidelines affected by the
results of this study.
8
Steps to Glycemic Control
  • Establish glycemic objectives
  • Target fasting and post-prandial glycemia
  • Diet counseling with exercise component
  • Diabetes education for every patient
  • Pharmacological treatment oral and insulin

9
Patient Counselling Topics
  • A.Review symptoms and treatment of
    hypoglycemia
  • B.Proper training and correct use of glucose
    monitor
  • C.Target desired glycemic levels for each patient

10
A. Hypoglycemia
  • Definition Glycemia lt 3.8 mmol
  • Patients may experience hypoglycemia at different
    glycemic levels

11
Symptoms of Hypoglycemia
  • Mild
  • lt 3.3 mmol/L
  • Neurovegetative symptoms
  • Sweating
  • Trembling
  • Palpitations
  • Anxiety
  • Tingling
  • Pallor
  • Hunger
  • Moderate to Severe
  • lt 2.8 mmol/L
  • Symptoms of glucopenia
  • Confusion
  • Visual disturbances
  • Weakness
  • Speech disorder
  • Behavioural disorder
  • Drowsiness
  • Coma
  • Convulsions

12
Preventing Hypoglycemia
  • Check BG 4-6 times per day
  • Carry glucose tablets
  • Have Glucagon Kit available

13
Preventing Hypoglycemia
  • Test before driving and ideally 1 hour later
    (target over 5.5 mmol/L)
  • Perform two SMBG 30 minutes apart prior to
    bedtime (confirming rising or falling BG)
  • When drinking alcohol, perform SMBG hourly
  • With exercise, perform SMBG pre- and
    post-exercise
  • If hypoglycemia episodes persist, raise target
    glucose levels

14
Hypoglycemia Treatment Guidelines
  • The Rule of 15
  • If BG is 4 mmol/L or below
  • Treat with 15 grams of carbohydrates (glucose
    tabs)
  • Check BG in 15 minutes, and if not above 4
    mmol/L, repeat treatment
  • Glucagon
  • Current emergency kit readily available and
    knowledgeable person trained to administer

15
PreventingHyperglycemia and DKA
  • Monitor BG 4-6 times per day
  • Use Correction Boluses when appropriate

16
Hyperglycemia Treatment GuidelinesThe Key to
Preventing DKA
  • 1st BG over 14 mmol/L
  • Take a correction bolus, check again in 1 hour
  • Call physician immediately or go to ER if nausea
    and vomiting are present

17
B. Patient Training
  • Training by a multidisciplinary team at DEC is
    IDEAL for
  • Diet counseling
  • Education on the injection sites
  • Education on the various injection devices
  • Evaluation of the patients support network
  • Other resources may exist for training, i.e.
    retail pharmacy

18
C. Blood Glucose Monitoring
  • To adjust the insulin treatment
  • To detect or confirm hypoglycemia or severe
    hyperglycemia
  • To adjust treatment to the circumstances of daily
    life using an insulin scale prescribed by the
    attending physician
  • To improve patient safety and increase motivation
    to comply with treatment

19
Ideal Testing Frequency
  • Stable type 2
  • 1-2 readings/day
  • Type 1 or Unstable type 2
  • 3-8 readings/day
  • Important to stress the need to vary testing
    times
  • AC, PC, h.s. and prn during the night

20
Injection Tools and Options
  • Durable delivery devices
  • Novolin-Pen 3
  • Novolin-Pen Junior
  • InDuo
  • Innovo
  • HumaPen
  • Insulin pumps
  • Syringes
  • Disposable multidose, prefilled (3.0 mL)
  • NovolinSet (NPH, Toronto, 30/70 )
  • Humulin N

21
Advancing Insulin Therapy Through Device
Innovation
22
Goal of Insulin Therapy
We are trying to duplicate how the pancreas works
in releasing insulin for someone who doesnt have
diabetes
23
Non-diabetic Insulin and Glucose Profiles
Breakfast
Lunch
Supper
75
Insulin
50
Insulin (µU/mL)
25
Basal insulin
0
9.0
Glucose
6.0
Glucose (mmo/L)
3.0
Basal glucose
0
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
a.m.
p.m.
Time of Day
24
Insulin Preparations
25
Insulin PreMixes
  • Regular intermediate
  • Novolin 10/90, 20/80, 30/70, 40/60, 50/50
  • Humulin 30/70, 20/80
  • Analogue Pre-Mix
  • Humalog 25/75 (insulin lispro protamine
    suspension)
  • NovoMix 30 (protaminated insulin aspart)

Not available
26
Normal Blood Glucose Levels
Blood Glucose (mmols)
10- 8- 6- 4- 2- 0

8am noon 6pm
2am 4am
8am
Time
27
Normal Blood Glucose Levels
Blood Glucose (mmols)
10- 8- 6- 4- 2- 0

8am noon 6pm
2am 4am
8am
Time
28
Blood Glucose (mmols)
10- 8- 6- 4- 2-
0
Two injections/day
R or H N in AM
R or H N at Supper
8am noon 6pm
2am 4am
8am
Time
29
Blood Glucose (mmols)
10- 8- 6- 4- 2-
0
Three injections/day
R or H N in AM
R or H at Supper
N before bed
8am noon 6pm
2am 4am
8am
Time
30
Blood Glucose (mmols)
Four injections/day
10- 8- 6- 4- 2-
0
R or H at every meal
N or U once or twice/day
8am noon 6pm
2am 4am
8am
Time
31
Blood Glucose (mmols)
Continuous Infusion
10- 8- 6- 4- 2-
0
8am noon 6pm
2am 4am
8am
Time
32
Limitations of Regular Human Insulin
  • Slow onset of activity
  • Should be given 30 to 45 minutes before meal
  • Inconvenient for patients
  • Long duration of activity
  • Lasts up to 12 hours
  • Potential for late postprandial hypoglycaemia
    (4-6 hours)
  • Need for additional snack

33
Adherence to Injection Recommendation (Canada)
"When do you inject your insulin?"
100
42
of Respondents
32
22
4
0
1998 Roper Starch Canada, Premix Insulin Using
Respondents.
34
Dissociation of Regular Human Insulin
Regular Human Insulin
peak time2-4 hr
10-3 M
10-3 M
10-5 M
10-8 M
Û
Û
Û
formulation
hexamers
dimers
monomers
capillary membrane
35
Objectives for the Development of Short-Acting
Insulin Analogues
  • Modify time action to address
  • Postprandial hyperglycemia
  • Hypoglycemia
  • Improve safety and convenience

36
Whats new in type 1 diabetes treatment?
  • Insulin analogues.
  • Physiological insulin replacement
  • Aggressive intensive management
  • 4 injections per day
  • Insulin infusion pumps
  • Continuous glucose monitoring systems
  • Integrated technologies for monitoring control

37
Non-diabetic Insulin and Glucose Profiles
Breakfast
Lunch
Supper
75
Insulin
50
Insulin (µU/mL)
25
Basal insulin
0
9.0
Glucose
6.0
Glucose (mmo/L)
3.0
Basal glucose
0
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
a.m.
p.m.
Time of Day
38
NovoRapid (insulin aspart)
  • Time-Action Profile

NovoRapid Rapid-acting insulin analogue
Onset 10-20 minutes Maximum effect 1-3
hours Duration 3-5 hours
39
Goal of Insulin Therapy
We are trying to duplicate how the pancreas works
in releasing insulin for someone who doesnt have
diabetes
40
Insulin Therapy Options
  • MDI therapy
  • 0.5 units/kg total daily dose
  • 4x/day 40 NPH _at_ hs and 60 rapid acting
    analogue ac meals
  • For patients with significant complications (i.e.
    renal failure, foot infections, CVD, etc)

41
Basal Insulin
In someone without diabetes, the pancreas
delivers a small amount of insulin continuously
to cover the bodys non-food related insulin
needs.
42
Bolus Insulin
The amount of insulin required to cover the food
you eat.
Fast-acting or Short-acting (clear) insulin works
as a Bolus Insulin
43
Why count carbs?
  • More precise way of measuring the impact of a
    meal on blood sugar
  • Lets you decide how much insulin is needed to
    cover the meal
  • Greater flexibility -eat what you want, when you
    want to eat it

44
Fine Tuning Bolus Doses
  • Carbohydrate counting or pre-determined meal
    portion
  • Individualized insulin to carbohydrate dose or
    insulin to meal dose
  • Adjust bolus based on post-meal BGs or next
    pre-meal BG

45
Fine Tuning Basal Rate
  • Monitor BG pre-meal, post-meal, bedtime, 12am,
    and 2-4am
  • Test fasting BG with skipped meals
  • Adjust nighttime basal based on 2-4am and
    pre-breakfast BG
  • Adjust basal by 0.1 u/hr to avoid over-correction

46
Novolinge 30/70
  • Time-Action Profile

Premixed insulin
Onset 0.5 hour Maximum effect 2-12
hours Duration 24 hours
47
30/70 - Twice/day
48
30/70 Dose Calculation
  • Weight 80 kg
  • 80 kg x 0.3 U/kg 24 U
  • 2/3 in the AM 16 Units
  • 1/3 at supper 8 Units

49
Dosage Changes
  • Change insulin dose so that peak of action
    corresponds to most abnormal value (pre-meal)
  • If all values are abnormal - start with fasting
    glycemia followed by lunch, supper and bedtime
  • Change the dose by increments of 1-4 U
  • Not more than twice/week
  • Monitor for PATTERNS in hypoglycemia

50
Full Range of Novo Nordisk Insulins
NovoRapid Penfill Rapid-acting human insulin
analogue (insulin aspart)
Onset 10-20 minutes Maximum effect 1-3
hours Duration 3-5 hours
Novolinge Toronto Penfill Short-acting
insulin (insulin injection, human biosynthetic)
Onset 0.5 hour Maximum effect 1-3
hours Duration 8 hours
Novolinge NPH Penfill Intermediate-acting
Insulin (insulin injection, human biosynthetic)
Onset 1.5 hours Maximum effect 4-12
hours Duration 24 hours
51
Somogyi Effect
  • Hyperglycemia secondary to asymptomatic
    hypoglycemia (especially at night)
  • If the insulin is increased in evening, the
    problem worsens
  • Check capillary glycemia around 3 a.m. to
    eliminate hypoglycemia
  • In this case, reduce the h.s. NPH

52
Follow-Up The Patients Role
  • Every Day
  • Check BG 4-6 times a day, and always before bed
  • Follow hypoglycemia guidelines
  • Follow hyperglycemia guidelines
  • Every 3 months
  • Visit healthcare provider - even if feeling well
  • Review log book and pump settings with physician
  • Get an A1c test
  • Every month
  • Review DKA prevention
  • Check BG
  • 3am (overnight)
  • 1 and/or 2-hour post-meal BG for all meals on a
    given day

53
Case Study 1
  • Patient R.M., DM for 9 years
  • BMI 34,
  • Meds metformin 1000 mg BID and glyburide
    10 mg BID, Avandia 8 mg OD
  • HbA1C is 9.5 , FBS 11.8
  • What is the next step?

54
Case Study 2
  • Patient K.G., DM for 15 years
  • BMI 23
  • Meds Metformin 1000 mg BID and Gluconorm 2 mg
    TID
  • HbA1C 8.5, FBS 7.4
  • Post MI
  • What is the next step?
Write a Comment
User Comments (0)
About PowerShow.com