Title: INTENSIVE%20INSULIN%20THERAPY
1INTENSIVE INSULIN THERAPY
- J. Robin Conway M.D.
- Diabetes Clinic, Smiths Falls, ON
- 1-800-717-0145
2Objectives
- Optimize diabetes management
- Assist you in initiating insulin in your office
- When to start insulin therapy?
- Insulins, doses, delivery options
- Patient training
3Challenges 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
4Type 1 Diabetes
- Impaired or absent ß cell function
- ? insulin secretion
- Normal insulin action
- ? insulin sensitivity
- The insulin deficiency results in unacceptable
blood glucose control
5Type 2 Diabetes Double Impairment
- Impaired ß cell function
- ? insulin secretion
- Impaired insulin action
- ? insulin resistance
- Results in unacceptable blood glucose control
6Type 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
7CDA 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
9Patient 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
10A. 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
12Preventing Hypoglycemia
- Check BG 4-6 times per day
- Carry glucose tablets
- Have Glucagon Kit available
13Preventing 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
14Hypoglycemia 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
15PreventingHyperglycemia and DKA
- Monitor BG 4-6 times per day
- Use Correction Boluses when appropriate
16Hyperglycemia 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
17B. 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
18C. 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
19Ideal 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
20Injection 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
21Advancing Insulin Therapy Through Device
Innovation
22Goal of Insulin Therapy
We are trying to duplicate how the pancreas works
in releasing insulin for someone who doesnt have
diabetes
23Non-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
24Insulin Preparations
25Insulin 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
26Normal Blood Glucose Levels
Blood Glucose (mmols)
10- 8- 6- 4- 2- 0
8am noon 6pm
2am 4am
8am
Time
27Normal Blood Glucose Levels
Blood Glucose (mmols)
10- 8- 6- 4- 2- 0
8am noon 6pm
2am 4am
8am
Time
28Blood 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
29Blood 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
30Blood 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
31Blood Glucose (mmols)
Continuous Infusion
10- 8- 6- 4- 2-
0
8am noon 6pm
2am 4am
8am
Time
32Limitations 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
33Adherence 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.
34Dissociation 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
35Objectives for the Development of Short-Acting
Insulin Analogues
- Modify time action to address
- Postprandial hyperglycemia
- Hypoglycemia
- Improve safety and convenience
36Whats 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
37Non-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
38NovoRapid (insulin aspart)
NovoRapid Rapid-acting insulin analogue
Onset 10-20 minutes Maximum effect 1-3
hours Duration 3-5 hours
39Goal of Insulin Therapy
We are trying to duplicate how the pancreas works
in releasing insulin for someone who doesnt have
diabetes
40Insulin 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)
41Basal Insulin
In someone without diabetes, the pancreas
delivers a small amount of insulin continuously
to cover the bodys non-food related insulin
needs.
42Bolus Insulin
The amount of insulin required to cover the food
you eat.
Fast-acting or Short-acting (clear) insulin works
as a Bolus Insulin
43Why 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
44Fine 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
45Fine 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
46Novolinge 30/70
Premixed insulin
Onset 0.5 hour Maximum effect 2-12
hours Duration 24 hours
4730/70 - Twice/day
4830/70 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
49Dosage 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
50Full 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
51Somogyi 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
52Follow-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
53Case 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?
54Case 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?