1 / 93

Initiating and adjusting insulin

Initiating and adjusting insulin. Gerry Rayman The Diabetes Centre Ipswich Hospital. 1922 Elizabeth Hughes.

cayenne
Download Presentation

Initiating and adjusting insulin

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Initiating and adjusting insulin Gerry Rayman The Diabetes Centre Ipswich Hospital

  2. 1922 Elizabeth Hughes age 14, wt 45 lb., height 5 ft., extermely emaciated, oedema of ankles, skin dry & scaly, hair brittle, muscles extremely wasted, sc tissue almost completely absorbed, scarcely able to walk on account of weakness.

  3. 1922 Elizabeth Hughes Imagine, I have to take 5cc at a time. Isn’t it awful. We only have a 2cc syringe. Blanche gives it to me... unscrews the needle which is left sticking in me, fills it again.. and then the fifth cc.... My hip feels as if it would burst.

  4. 1922ElizabethHughes I experienced a severe anaphylactic reaction...persisting for 2 days..... generalized skin eruption, nausea, vomiting, profound weakness. I thought I was going to die.

  5. Barriers to insulin therapyin Type 2 • Fear of injections/needles/syringes • 6mm length, 30g siliconised needles • Pens (autoinjectors & needle guards) • Weight gain • Coma

  6. Barriers to intensified insulin therapy in Type 1 • Additional injections and testing • 6mm length, 30g siliconised needles • Pens (autoinjectors & needle guards) • Weight gain • Hypoglycaemia

  7. Hypoglycaemia - RD Lawrence Listlessness, shakiness, nervousness, apprehension, irritability palpitations, mental vagueness and confusion. The patient may stagger like a drunken man and appear quite intoxicated and perhaps confused, delirious or maniacal. Complete coma is the end result.

  8. Do you start the following people with diabetes on insulin?

  9. Do you regularly advise on insulin dose adjustment in the following groups?

  10. Making the diagnosis Type 1 or Type 2

  11. More dramatic presentation- short history of severe polydipsia & polyuria Younger Weight loss Ketones Strong FH of Type 1 Often no osmotic symptoms Age related More common amongst certain ethnic groups Central obesity & other features of metabolic syndrome FH of Type 2 Type 1 vs Type 2

  12. Type 1 or Type 2 • 32 yr old woman presents with lethargy, recurrent thrush, blurred vision • Blood glucose 12 mmol/l, BMI 27 • FH of type 2 diabetes in both parental GM • No ketones

  13. 18 months later • Weight loss of 3 stone • On maximum doses of metformin & gliclazide • Still feeling unwell • Thrush persists • Frequently off work • Fasting blood glucose ~10

  14. Type 1 or Type 2 • 14 yr old caucasian girl presents with moderate thirst, polyuria, nocturia X3-4, listleness • Blood glucose 32 mmol/l • Ketones ++ • BMI 32 • Mother Type 2 diabetes BMI 34

  15. What would be the correct approach?

  16. Type 2 diabetes Very high c-peptide and insulin levels Negative insulin anti-bodies Managed on insulin and metformin Acanthosis Nigricans

  17. Insulin initiation and dose adjustment • There is no one perfect insulin regimen for either Type 1 or Type 2 diabetes (hence the different regimens used across the globe) • There are a number of simple principles which can guide insulin initiation but an individual’s response cannot be predicted • Similarly for dose adjustment one can follow simplified guidelines but these must be modified depending on an individual’s response

  18. Insulin Species

  19. Regular (short acting) • Actrapid, Humulin • Rapid acting Analogues • Humalog, Novorapid • Isophanes/NPH (Intermediate) • Insulatard, Humulin I • Basal analogues • Glargine, Detimer 0 6 12 18 24 0 6 12 18 24

  20. Normal 24 Hr Insulin Profiles & Bd premix Plasma Insulin

  21. Normal 24 Hr Insulin Profiles & basal bolus Plasma Insulin

  22. When initiating insulin in Type 1 diabetes do you use?

  23. Easy to teach Does not overload patient Improves symptoms just as well Can get excellent control early- honeymoon period Advantages of BD pre-mix vs basal bolus

  24. Principles • Use a relatively narrow range of insulins, regimens and devices • Makes it easier to gain a ‘feel’ for these variables and is less confusing • Start low and very gradually build up (Avoid hypoglycaemia) • E.g Mixtard (30) or Novomix (30) 10 units bd • Regular blood glucose monitoring • Gradual increase in information • Patient empowerment

  25. Humalog Mix 25 10units 10 units 12 12 16 12 8 4 EM B’F

  26. Humalog Mix 25 14units 16 units 18 16 12 8 4

  27. Humalog Mix 25 14units 24 units 16 12 8 4

  28. Practical Considerations when Optimising Control • Set realistic yet changeable targets • Essential to have more intensive monitoring- set a trouble shooting period • Improve control gradually • avoids severe hypos, hypo unawareness and loss of confidence • gives patients time to adjust • possibly reduces risk of flare up of neuropathy and retinopathy

  29. Changing insulin species or regimen • Always reduce insulin dose by 10-20% • Avoids hypoglycaemia and loss of confidence

  30. Education “ the person with diabetes must be his own doctor, biochemist and dietitian”. R. D. Lawrence. Assuming four 1 hr visits/yr patients spend 0.0005% of their time with diabetic staff! As diabetes does not look after itself the patient must make his own decisions. Education must therefore aim to empower.

  31. Patients need Motivation Unlike pregnancy no immediate gains. Motivating factor include the attitudes of family and diabetes team.

  32. Patients need Feedback Blood glucose monitoring The patient needs to know his own HbA1c result.

  33. 27 yr female with Type 1 diabetes of 8yr duration- BMI 20 • FH- mother Type 1 diagnosed age 31 & two uncles diagnosed in their 30’s one on insulin • Problem- recurrent hypos so patient frequently omitting insulin • HbA1c 6.9% (highest over last 3yr = 7.3%) • Treatment- Actrapid 2u pre-meals & insulatard 8u nocte (dose unchanged from diagnosis)

  34. What would you do?

  35. Type 1 MODY Young-adult diabetes (15-30yrs) • “Diabetes is a diagnostic speciality” Type 2 Genetic Syndromes

  36. HNF1a (MODY3) Commonest cause of MODY May be misdiagnosed as type 1 Typically develop 12-30 yr FPG maybe normal initially Large rise (>5mmol/l) in OGTTWorsening glycaemia with age Low renal threshold (glycosuria)Not obese (usually) Parents and grandparents usually diabetic

  37. HNF1a: very sensitive to sulphonylureas HbA1c (%) Years since diagnosis

  38. Insulin therapy in Type 2 diabetes

  39. Early Type 2 Type 2 diabetes 24-hr insulin profiles in normal, IGT & late Type 2 diabetic subjects 160 140 120 100 Insulin (mU/mL) 80 60 IGT 40 20 Normal 0 0800 1200 1600 2000 2400 0400 Clock time (hours) Polonsky KS et al. Horm Res1998; 49: 178–84.

  40. Early Type 2 Type 2 diabetes Glargine (Lantus) 160 140 120 100 Insulin (mU/mL) 80 60 IGT 40 20 0 0800 1200 1600 2000 2400 0400 Clock time (hours)

  41. IGT Type 2 diabetes 24-hr insulin profiles in normal, IGT & late Type 2 diabetic subjects 160 140 120 100 Insulin (mU/mL) 80 60 IGT 40 20 0 0800 1200 1600 2000 2400 0400

  42. Target HbA1c • Diabetes UK 7% • NICE 2002 (Type 2 DM) 6.5 – 7.5% • GP Contract 7.4%

  43. “Effective Diabetes Care: a need for realistic targets”(P Winocour, BMJ 2002: 324; 1577-80) • Proposed targets for individuals (Type 2) • 6.5% within 3 years if diet only & no complications • 8% at 5 years especially if complications • 9% for insulin-treated obese

  44. 66 yr old male, type 2 DM for 10 years, on metformin & sulphonylurea • Consecutive 6 monthly HbA1c 7.3, 6.9, 7.3, 7.9, 8.9% • BMI 35 and slowly increasing • Hypertensive and hyperlipidaemic

  45. What would you do?

  46. Group starts vs one to one • Increasing numbers warrants an alternative to one to one • One to one tends to lead to a dependency model in which the patient may not take ownership of self-adjustment • Allows patients to learn from others experiences eg how others would adjust their insulin in a particular circumstance • Useful in the community where one practice takes on initiation for a number of practices

  47. Insulin injection devices • Syringes- 100u, 50u, 30u with varying needle gauges and lengths • Reusable insulin pens eg NovoPen III, Optipen, HumaPen Ergo. • Disposable pen eg HumaPen, Flexpen • Other devices- Innolet

More Related