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Irl B. Hirsch, M.D. University of Washington, Seattle

Maximizing MDI. Irl B. Hirsch, M.D. University of Washington, Seattle. First, Why is Mealtime Insulin So Important?. Raise your hand if you or your child take 1 shot daily Raise your hand if you or your child take 2 shots daily Raise your hand if you or your child take 3 shots daily

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Irl B. Hirsch, M.D. University of Washington, Seattle

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  1. Maximizing MDI Irl B. Hirsch, M.D. University of Washington, Seattle

  2. First, Why is Mealtime Insulin So Important? • Raise your hand if you or your child take 1 shot daily • Raise your hand if you or your child take 2 shots daily • Raise your hand if you or your child take 3 shots daily • Raise your hand if you or your child take 4 or more shots daily • Raise your hand if you or your child wear an insulin pump

  3. Why do so many physicians frown when they meet patients with type 1 diabetes on one or two daily injections?

  4. 24 20 16 12 8 4 0 Intensive Rate Per Patient Year 9% Mean HbA1c 8% 7% 0 1 2 3 4 5 6 7 8 9 Time During Study (Years) Risk for Retinopathy in Conventional and Intensive Treatment: Thinking Out of the Box Risk for Retinopathy in Subgroups of the DCCT 11% 24 20 16 12 8 4 0 10% 9% Mean HbA1c Conventional Rate Per Patient Year 8% 7% 0 1 2 3 4 5 6 7 8 9 Time During Study (Years) Adapted from Diabetes 44:968-983, 1995

  5. What We Now Know • The more up AND down the more damage to cells through a mechanism called “oxidative stress” • Most of this is based on very basic science data, but clinical studies now supporting this finding • New goal of therapy: improve A1c AND reduce glucose variability

  6. Does Intensive Therapy (Reduced GV) Preserve Beta Cell Function? 1.0 Could some of this preservation also be related to improvement in glucose variability? 0.9 0.8 0.7 Patient probability of maintaining C-peptide > 2.0 0.6 0.5 0.4 0.3 Intensive therapy 0.2 Conventional 0.1 therapy 0.0 0 0 1 2 3 4 5 6 Years Post Enrollment Number of evaluated patients in each treatment group 2 Intensive 108 131 80 53 32 8 Conventional 165 150 63 32 22 3 0 Adapted from: DCCT Study Group: Ann Intern Med. 1998;128:517-523.

  7. Trends in Average # Injections/Day, 2001-2005 U=678 W=3995 GfK Market Measures

  8. Implications? • Postprandial hyperglycemia and glycemic variability • Ability to proceed to more sophisticated diabetes regimens • What are the main barriers why so many receiving insulin do so poorly?

  9. Basics of MDI: What to Consider

  10. POINT 1 Who Does Best With MDI (or CSII!?) • Minimum of 4-6 SMBG/day • Carb counting or similar system for estimation of prandial insulin dosing • Frequent SMBG can make up for poor carb estimation! • Understanding basics of insulin therapy, knowing how to correct ac and pc hyperglycemia

  11. POINT 2 The Physiological Insulin Profile Short-lived, rapidly generatedprandial insulin peaks 70 Normal free insulin levelsfrom genuine data (mean) 60 50 40 Insulin(mU/l) Low, steady, basalinsulin profile 30 20 10 0 0600 0900 1200 1500 1800 2100 2400 0300 0600 Breakfast Lunch Dinner Adapted from Polonsky,et al. 1988.

  12. Standardization of Terminology Definitions for Flexible Diabetes Management • Basal insulin replacement • that insulin required to suppress hepatic glucose production over night and between meals • Bolus (prandial or mealtime) insulin replacement • that insulin required to dispose of glucose in muscle after eating

  13. Standardization of Terminology Definitions for Flexible Diabetes Management • Correction dose (also called a supplement) • additional insulin for premeal hyperglycemia • can also be between-meal hyperglycemia • this insulin can only be regular, lispro, aspart or glulisine (Humulin R, Novolin R, Humalog, Novalog, Apidra)

  14. Basal/Bolus Treatment Program withRapid-acting and Long-acting Analogs Breakfast Lunch Dinner Aspart, Aspart, Aspart, Lispro Lispro Lispro or or or Glulisine Glulisine Glulisine Plasma insulin Glargine or Detemir 4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00 Time

  15. Does Basal Insulin Really Look Like a Flat Line?

  16. Klein et al: 325-OR, ADA, 2006

  17. POINT 3 In general, 40-50% of insulin should be basal insulin glargine (Lantus), insulin detemir (Levemir), or delivery from a pump and the rest should be mealtime (bolus) insulin

  18. Pearls with MDI Basal Insulin • Basal insulin approximately 40-50% total daily insulin dose (TDD) • Basal insulin best assessed by fasting glucose levels and glycemic curves with missed meals • Lower doses often require twice daily injections of basal insulin • With MDI, most patients prefer pens for prandial insulin; however, less likely to make an error in insulin if basal insulin used is vial (or at least pens are different brands)

  19. Pearls with MDI: Prandial Insulin • LAG times • The amount of time between giving the prandial insulin and eating the meal • Due to the timing of insulin absorption compared to carbohydrate absorption, insulin usually needs to be injected a minimum of 10 min prior to eating, even if glucose levels are within target. • Longer lag times are required for pre-meal hyperglycemia

  20. Humalog with Different Lag Times 270 230 180 200 160 Diabetes Care 22:133, 1999

  21. Pearls with MDI: Prandial Insulin • Insulin-on-Board (IOB)

  22. Key Concepts • Pharmacokinetics • Measurement of insulin levels after subcutaneous injection • Pharmacodynamics • Measurement of insulin action in a glucose clamp study

  23. Key Concepts • INSULIN-ON-BOARD (IOB, insulin remaining) • The amount of insulin from the last prandial dose which has not yet been absorbed based on insulin action (not insulin blood levels) • INSULIN STACKING • Using correction dose insulin to treat before-meal or between-meal hyperglycemia in a situation when there is still significant IOB

  24. Insulin lispro (Humalog) and insulin aspart (NovoLog) “insulin action” disappearance curves 100 80 60 % insulin remaining 40 20 0 0 1 2 3 4 5 6 7 8

  25. Correction Dose (insulin sensitivity factor) • The amount of glucose reduction (in mg/dL) to expect from 1 unit of insulin • Numerous formulas published but in general most type 1’s start with an ISF of about 50

  26. Example TIME BG DOSE 7 PM 95 8 U 8 PM 9 PM 9:30 PM 180 With a target of 120 mg% and an ISF of 30, how much insulin should be provided at 9:30 pm?

  27. Example TIME BG DOSE 7 PM 95 8 U IOB 8 PM 7.2 U 9 PM 5.0 U 9:30 PM 180 4.0 U 10:00 PM 210 3.2 U NOW what should be done with the insulin?

  28. Example 210 – 120 = 90 mg/dL over target Correction dose = 90/30 = 3 units 3.2 units on board – 3 units for correction dose So how much insulin should be given?

  29. TAKE HOME POINT Glycemic trend trumps IOB! One can only know GT by frequent SMBG

  30. Pearls for Success • Frequent SMBG (until CGM available) • Knowledge of how to best use lag times • General knowledge of insulin requirements for food, but with frequent SMBG not required • Keeping track of IOB • Keeping track of glycemic trend

  31. Some Concerning Facts • ¼-1/3 of those with T1DM are still taking 1 or 2 shots daily-shown ineffective in 1993 • < 20% of T1DM in US with A1c < 7% • Insulin therapy is not taught in medical schools or residency • The average primary care resident doesn’t know what 1 unit of insulin is.

  32. Conclusion (1) After 84 years we are finally starting to understand a little about how to use insulin

  33. Conclusion (2) Although it is a lot of work, rewards later on are huge. Frequencies of PDR, ESRD, LEA are declining rapidly

  34. Conclusion (3) The number 1 barrier to type 1 diabetes therapy (especially in adults) in 2006 is…?

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