Basal-Bolus, Insulin Pumps, Carbohydrate Counting, Combination Therapy

1
Basal-Bolus, Insulin Pumps, Carbohydrate
Counting, Combination Therapy

• Dr.Ihab Tadros
• Medical Director
• Daisy Care Medical USA
• The Leader in insulin Pump Therapy

2
Educational Objectives

• At the completion of this presentation the
  attendee will be able to
• Describe the principles behind physiologic
  basal-bolus insulin therapy.
• Recite the principles and the indications for
  CSII (Insulin pump therapy) in the management of
  diabetes.
• Apply the concepts of counting grams for
  appropriate insulin therapy and review the
  Quick-Carb Count system for determining
  carbohydrate grams.
• Discuss the principles and appropriate
  indications for combination therapy.

3
Physiological Insulin Secretion Profile
75
Breakfast
Lunch
Dinner
50
Plasma Insulin µU/ml)
25
400
400
800
1200
1600
2000
2400
Time
4
Comparative Action of Insulins
Onset Peak Duration
Lispro 5-15 min 0.5-1.5 hr 5 hr
Aspart 5-15 min 0.5-1.5 hr 5 hr
Glulisine 5-15 min 0.5-1.5 hr 5 hr
Regular 30-60 min 2-3 hr 6-8 hr
NPH 2-4 hr 4-10 hr 10-16 hr
Glargine 2-4 hr None 20-24 hr
Detemir 2-4 hr None 12-24 hr
5
Profiles of Human Insulins and Analogs
6
Insulins That Most Closely Match the Physiologic
Insulin Profile

• Bolus (prandial) insulin analogs
• Rapid acting
• When taken ten minutes before eating, most
  closely coincides with CHO absorption rate
• Basal (background) insulin analogs
• Long-acting
• Slow and steady rate of absorption

7
Ideal Insulin Replacement Pattern
75
Breakfast
Lunch
Dinner
50
Plasma Insulin µU/ml)
25
400
1600
2000
2400
400
1200
800
Time
8
Augmentation of the Beta-Cell

• Exogenous insulin administered to augment
  endogenous production
• Often required at about 6 years post diagnosis
• Glucose rises in spite of treatment with oral
  antidiabetic drug(s)

9
Mr. Brown

• 52 yo CM with T2DM for 7 years
• Treated with SU, metformin, lifestyle changes
• Has lost 28 pounds since diagnosis
• Walks 30-45 minutes 5-6 days per week
• Last A1C has increased from 7.2 to 9.3 and HGM
  has indicated rising values

10
ARS Question 1

• What do you recommend?
• Do you add another oral agent?
• Do you consider an alternative agent?
• Do you consider insulin?

11
Mr. Brown

• Insulin therapy has the best chance of achieving
  target A1C
• The natural history indicates that insulin is
  needed
• Other agents work in the presence of adequate
  insulinendogenous plus exogenous

12
Mr. Brown

• Choices for beginning insulin
• Basal insulin each evening
• Insulin detemir (Levemir)
• Insulin glargine (Lantus)
• NPH
• Combination (rapid-acting/ intermediate acting)
  insulin before evening meal
• Insulin protaminated aspart/ aspart (NovoLog
  70/30)
• Insulin protaminated lispro/lispro (Humalog 75/25)

13
Basal Insulin Bedtime Only
Breakfast
Lunch
Dinner
Plasma Insulin
Detemir, Glargine
400
1600
2000
2400
400
1200
800
Time
14
Analog Mixed Insulin Program
Breakfast
Lunch
Dinner
Plasma Insulin
400
1600
2000
2400
400
1200
800
Time
15
ARS Question 2

• How do you begin insulin therapy?
• Insulin detemir 0.1-0.2 units/kg or 10-20 units
  each evening
• Insulin glargine 0.1-0.2 units/kg or 10-20 units
  each evening
• Insulin protaminated aspart/aspart (NovoLog Mix
  70/30) 12 units before evening meal
• Any of the above

16
24-Hour Plasma Glucose CurveNormal and Type 2
Diabetes
400
300
200
Glucose (mg/dL)
Normal
100
0
0600
0600
1000
1400
1800
2200
0200
Time of Day
NEJM 318 1231-1239, 1988
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ARS Question 3

• What do you do with the existing oral agents?
• Continue the SU and metformin
• Continue the SU but not metformin
• Continue metformin but not the SU
• Discontinue the SU and metformin

18
Mrs. Blue

• 59 yo AAF with T2DM for 13 years
• Currently treated with SU, MF, and insulin
  detemir once each evening
• Recently her A1C has increased from 7.4 to 8.5

19
ARS Question 4

• What do you now recommend?
• Continue SU and metformin give insulin detemir
  twice daily
• Discontinue SU and metformin give insulin
  detemir twice daily
• Discontinue SU, add bolus insulin before largest
  meal (dinner)
• Discontinue SU, add bolus insulin before
  breakfast and dinner
• None of the above

20
UKPDS ß-Cell Function over 6 Years
Decline to insulin deficiency 12 yrs after Dx!
Insulin loss starts 10 yrs before Dx.
Half gone by Dx.
Insulin loss is part of T2 DM
?-Cell Function ( ?)
51 residual secretion
28 residual insulin secretion
N376
Years After Diagnosis
Diabetes 44 1249-1258, 1995
10/22/02
21
Replacement Insulin Therapy

• Beta cells are now producing very little insulin
• She requires a physiologic insulin replacement
  regimen
• Basal-bolus system
• Similar to a patient with T1DM

22
Physiological Insulin Secretion Profile
75
Breakfast
Lunch
Dinner
50
Plasma Insulin µU/ml)
25
400
400
800
1200
1600
2000
2400
Time
23
Mrs. Blue

• Insulin choices
• Basal
• Insulin detemir
• Insulin glargine
• Bolus
• Insulin aspart
• Insulin lispro
• Insulin glulisine

24
Ideal Insulin Replacement Pattern
75
Breakfast
Lunch
Dinner
50
Plasma Insulin µU/ml)
25
400
1600
2000
2400
400
1200
800
Time
25
As Patients Get Closer to A1C Goal, the Need to
Manage PPG Significantly Increases
Increasing Contribution of PPG as A1C Improves
Contribution
A1C Range ()
Adapted from Monnier L, Lapinski H, Collette C.
Contributions of fasting and postprandial plasma
glucose increments to the overall diurnal
hyperglycemia of Type 2 diabetic patients
variations with increasing levels of HBA(1c).
Diabetes Care. 200326881-885.
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Basal Meal-Related Regimen
Breakfast
Lunch
Dinner
Plasma Insulin
Detemir/ Glargine
400
1600
2000
2400
400
1200
800
Time
27
Basal Insulin Twice Daily - AM Bedtime
Breakfast
Lunch
Dinner
Plasma Insulin
Detemir/ Glargine
400
1600
2000
2400
400
1200
800
Time
28
Mrs. Blue

• In a person with T2DM
• Total daily insulin dose 1.0 -1.2 units/ kg
• Divide total daily dose
• 50 basal insulin (insulin detemir, glargine)
• Give each evening and adjust based on the fasting
  glucose
• 50 bolus insulin (insulin aspart, glulisine,
  lispro)
• Give pre-meal and adjust based on the next
  pre-meal glucose or ideally 2 hours post-meal
• Goal 2 h post-meal pre-meal /- 40 mg/dL

29
Mrs. Blue

• Most patients will require more insulin on board
  in the AM (physiologic basis)
• Start with bolus dose divided pre-meal 1/3, 1/3,
  1/3
• Adjust based on post-prandial blood glucose
• Most patients require
• 38 of total bolus dose pre-breakfast
• 28 of total bolus dose pre-lunch
• 33 of total bolus dose pre-dinner

30
ARS Question 5

• What to do with the oral agents?
• Discontinue the SU and metformin
• Discontinue the SU, continue metformin
• Discontinue metformin, continue the SU
• Continue the SU and metformin

31
Mrs. Blue

• Discontinue the SU
• Very little beta-cell reserve
• No reason to give an agent to stimulate phase 2
  insulin release
• Continue metformin
• Improve insulin resistance
• Lowers total insulin requirement
• Limits potential weight gain

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Continuous Subcutaneous Insulin Infusion (CSII)
Insulin Pump Therapy

• Principles
• Allows reproduction of an intact endogenous
  system of insulin release
• Allows variation in the basal infusion rate
  during the 24-hour period
• Allows an immediate insulin bolus with
  carbohydrate intake
• Allows temporary suspension (cessation) of
  insulin infusion

33
Variable Basal Rate CSII Program
Breakfast
Lunch
Dinner
Bolus
Bolus
Bolus
Plasma insulin
Basal infusion
400
1600
2000
2400
400
800
1200
800
Time
34
Indications for CSII

• Elevated A1C
• Hypoglycemia
• Exercise
• Dawn phenomenon
• Pregnancy
• Gastroparesis

• Changing work schedules
• Changing work/ activity demands
• Pediatric patients requiring small insulin
  dosages
• Special situationsmenstrual cycles

35
Applications of CSII

• Any person with diabetes who faces specific
  problems or complications
• Type 1 diabetes
• Type 2 diabetes
• Loss of beta-cell reserve and endogenous insulin
  production
• Requires a C-peptide of less than 110 percent of
  the lower limit of normal of the laboratorys
  measurement method
• Required by Medicare and many insurance companies

36
Patient Requirements for Pump Use

• Motivated to improve control
• Willingness to monitor BG 4-6 times a day
• Willingness to do CHO counting
• Willingness to participate in regular medical
  follow-up
• Covered by insurance or can afford increased costs

37
Carbohydrate Counting

• Insulin dosing (bolus) is based on CHO intake
• Permits more exact dosing of insulin
• Carbohydrate content can be easily determined
• Requires familiarity with CHO vs. proteins or
  fats
• Requires familiarity with portion sizes
• Requires ability to do simple calculations
• Consider referral to CDE
• Direct patient to materials on CHO counting

38
Quick-carb Counting

• All of the below contain approximately 15 grams
  of carbohydrate
• ½ cup or 4 oz of fruit juice
• ½ cup canned fruit
• 1 cup or 8 oz of whole fresh fruit
• 1 slice of bread, 6 inch tortilla, 2 oz bagel
• 1 cup of milk
• ½ cup of potatoes, rice, pasta, beans, peas

39
Reading Food Labels
40

• Fat free can be misleading

41
Quick-carb Counting

• Dosage of insulin is based on total grams of
  carbohydrates
• Insulin CHO ratio of 115
• If the total grams of carbohydrate is 60, then
  4.0 units of insulin would be administered.
• Insulin CHO ratio of 110
• If the total grams of CHO is 60, then 6.0 units
  of insulin would be administered.
• T2DM patients may require 1 unit for each 3-5
  grams of CHO
• Ex 60 g ? 3 units/g 20 units or 60 g ? 5
  units/g 12 units
• How do you know?
• Test the blood glucose 2 hours post prandial

42
Correction Factor

• Generally 1 unit of insulin will drop blood
  glucose by 30-50 points
• To determine if this is true for your patient
  ask them to test
• Use either the 1500 or 1800 rule
• 1500 rule for short-acting insulin (Regular)
• 1800 rule for rapid-acting insulin
• It is an art not an exact science

43
Insulin Sensitivity Factor

• 1800 Insulin Sensitivity Factor
• TDD
• Example
• 1800 50
• 36 units
• One unit of rapid-acting insulin will affect
  glucose by 50 mg/dL
• TDD Total Daily Dose of Insulin

44
Putting it All Together

• GH is about to eat lunch. His BG is 183. He is
  planning to eat a salad, a six inch Subway club
  sandwich, a small bag of Sunchips and a diet
  soda.
• How many CHO in this meal?
• How much insulin to cover the CHO?
• (Imagine a 115 insulin to CHO ratio)
• What is target pre-meal BG?
• How much insulin to correct for 183?
• How much total insulin for this meal?

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What Does My Patient Need to Know About Using
Insulin?

• Blood glucose goals and testing regimen
• Insulin action profile and how insulin, physical
  activity and food all impact blood glucose
• Signs and symptoms of hypoglycemia
• How to treat
• How to prevent
• Sharps disposal
• Storage of insulin

46
Finding the Right Therapy for Your Patient

• Who is the patient?
• BG profile
• Fairly stable or wide variation?
• Psychosocial/cultural factors
• Dexterity
• Lifestyle and willingness to adhere to regimen
• About the insulin regimen
• Ability to mimic endogenous insulin secretion
• Potential adverse effect
• Cost
• Complexity

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Summary

• Timely initiation of insulin is critical
• Insulin analogs most closely match normal
  physiology
• There is a wide variety of insulin regimens and
  insulin delivery methods
• It is important to match the insulin regimen to
  patient lifestyle and characteristics
• When blood glucose goals are not met, titrate
  insulin in a timely manner
• Refer to a Certified Diabetes Educator

48
Basal-Bolus, Insulin Pumps, Carbohydrate
Counting, Combination Therapy

• Dr.Ihab Tadros
• Daisy Care Medical USA
• The Leader in Insulin Pump Therapy
• And Diabetes Management