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New Insulins and Insulin Delivery Systems

New Insulins and Insulin Delivery Systems. Bruce W. Bode, MD, FACE Atlanta Diabetes Associates Part 3. Insulin Therapy in Type 2 Diabetes Indications. Significant hyperglycemia at presentation Hyperglycemia on maximal doses of oral agents Decompensation

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New Insulins and Insulin Delivery Systems

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  1. New Insulins and Insulin Delivery Systems Bruce W. Bode, MD, FACE Atlanta Diabetes Associates Part 3

  2. Insulin Therapy in Type 2 Diabetes Indications • Significant hyperglycemia at presentation • Hyperglycemia on maximal doses of oral agents • Decompensation • Acute injury, stress, infection, myocardial ischemia • Severe hyperglycemia with ketonemia and/or ketonuria • Uncontrolled weight loss • Use of diabetogenic medications (eg, corticosteroids) • Surgery • Pregnancy

  3. Starting With Basal Insulin in DM 2Advantages • 1 injection with no mixing • Insulin pens for increased acceptance • Slow, safe, and simple titration • Low dosage • Effective improvement in glycemic control • Limited weight gain 6-37

  4. Treatment to Target Study: NPH vs Glargine in DM2 patients on OHA • Add 10 units Basal insulin at bedtime (NPH or Glargine) • Continue current oral agents • Titrate insulin weekly to fasting BG < 100 mg/dL - if 100-120 mg/dL, increase 2 units - if 120-140 mg/dL, increase 4 units - if 140-180 mg/dL, increase 6 units - if >180 mg/dL, increase 8 units

  5. Treatment to Target Study; A1C Decrease

  6. Treatment to Target Study: % at Goal Results • 57% of patients in both groups reached A1C 7% • At wk 24, mean insulin glargine dose was higher than mean NPH insulin dose: Insulin glargine NPH insulin 48.8 IU/day 42.4 IU/day , P<0.001 Rosenstock J, Riddle M, HOE901/4002 Study Group. Diabetes 2002;51(suppl 2):A482. Abstract 1982-PO

  7. Treat to Target Study: Glargine vs NPH Added to Oral Therapy of Type 2 Diabetes • Nocturnal Hypoglycemia reduced by 40% in the Glargine group (532 events) vs NPH group (886 events) Riddle et al, Diabetes June 2002, Abstract 457-p

  8. Morning Glargine Bedtime Glargine Bedtime NPH 0 –0.84 –0.96 -1 A1C Change From Baseline (%) –1.24 -2 P=0.008 P<0.001 Morning vs Bedtime Insulin Baseline: 9.11.0 Adapted from Fritsche A et al, and the 4001 Study Group. Ann Intern Med. 2003:138:952

  9. Starting with Bolus Insulin • 16 obese Type 2 patients on NPH or Human 70/30 insulin twice daily randomized to: Insulin aspart premeal with metformin and rosiglitazone NPH or Human 70/30 twice daily • Insulin titrated to 90 to 126 mg/dl at 1.5 hr post meal in the aspart group and premeal in the conventional group with goal A1C <7% Diabetes Care 2003

  10. Insulin Aspart Premeal with Metformin and Rosiglitazone vs Conventional Insulin N =16 P = 0.03 A1C% 0.42 units/kg 3 kg weight gain 0.67 units/kg 1 kg weight gain

  11. Advancing Basal/Bolus Insulin • Indicated when FBG acceptable but • A1C > 7% or > 6.5% and/or • SMBG before dinner > 140 mg/dL • Insulin options • To glargine or NPH, add mealtime aspart / lispro • To suppertime 70/30, add morning 70/30 • Consider insulin pump therapy • Oral agent options • Usually stop sulfonylurea • Continue metformin for weight control • Continue glitazone for glycemic stability?

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