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

1. Basal-Bolus, Insulin Pumps, Carbohydrate Counting, Combination Therapy Teresa Pearson, MS, RN, CDE Director, Diabetes Care Fairview Health Services Minneapolis, Minnesota Russell D. White, MD Professor of Medicine Director, Sports Medicine Fellowship Program Department of Community & Family Medicine University of Missouri Kansas City, School of Medicine Truman Medical Center Lakewood Kansas City, Missouri

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.

4. Comparative Action of Insulins

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

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 insulin—endogenous 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)

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

17. 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

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

23. Mrs. Blue Insulin choices Basal Insulin detemir Insulin glargine Bolus Insulin aspart Insulin lispro Insulin glulisine

25. As Patients Get Closer to A1C Goal, the Need to Manage PPG Significantly Increases As Patients Get Closer to A1C Goal, the Need to Successfully Manage PPG Significantly Increases Postprandial glycemic excursions become more predominant in patients with good control of fasting plasma glucose. Therefore, treatment should focus on both FPG and PPG excursions in order to reach and maintain A1C targets.As Patients Get Closer to A1C Goal, the Need to Successfully Manage PPG Significantly Increases Postprandial glycemic excursions become more predominant in patients with good control of fasting plasma glucose. Therefore, treatment should focus on both FPG and PPG excursions in order to reach and maintain A1C targets.

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

32. 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

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 situations—menstrual 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 laboratory’s 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 1:15 If the total grams of carbohydrate is 60, then 4.0 units of insulin would be administered. Insulin: CHO ratio of 1:10 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 1:15 insulin to CHO ratio) What is target pre-meal BG? How much insulin to correct for 183? How much total insulin for this meal? 6 inch club sandwich = 47g CHO Small bag Sunchips = 19g CHO Target premeal BG = 110 Actual BG is 73 points above target Sensitivity (correction) factor is 1:50 Take 4.5 units to cover the CHO and 1 unit to correct for the elevated BG = 5.5 total units for this meal6 inch club sandwich = 47g CHO Small bag Sunchips = 19g CHO Target premeal BG = 110 Actual BG is 73 points above target Sensitivity (correction) factor is 1:50 Take 4.5 units to cover the CHO and 1 unit to correct for the elevated BG = 5.5 total units for this meal

45. 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

47. 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 Teresa Pearson, MS, RN, CDE Director, Diabetes Care Fairview Health Services Minneapolis, Minnesota Russell D. White, MD Professor of Medicine Director, Sports Medicine Fellowship Program Department of Community & Family Medicine University of Missouri Kansas City, School of Medicine Truman Medical Center Lakewood Kansas City, Missouri