1 / 29

Insulin Basics

Insulin Basics. Insulin initiation in a busy primary care office. Jennifer Berry November 2013. Objectives. To identify barriers to insulin initiation To understand the different insulin regimes To increase confidence in initiating and titrating basal insulin

ghazi
Download Presentation

Insulin Basics

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. Insulin Basics Insulin initiation in a busy primary care office Jennifer Berry November 2013

  2. Objectives To identify barriers to insulin initiation To understand the different insulin regimes To increase confidence in initiating and titrating basal insulin To increase confidence in initiating mixed insulin

  3. The Perfect Storm • Growing epidemic • Diabetes is progressive • 50% decline in β-Cell function at time of diagnosis • Lose another 3-5% each year • Aging population Canadian Diabetes Association (2010). At the Tipping Point: Diabetes in Ontario

  4. IMPROVE Study: Insulin Initiation • Mean time to insulin initiation is 9.2 years • Mean A1c prior to insulin initiation is 9.5% • In 55% of patients, insulin was initiated by the family physician • 35% by endocrinologist • 8% at diabetes centre • 74% of patients had a diabetes-related complication at time of insulin initiation Harris SB et al. Canadian Family Physician 2011. in press.

  5. Progressive Nature Average time from diagnosis to insulin  9 years

  6. Barriers to Insulin Initiation Only 12% of patients are prescribed insulin – should be closer to 40% S. B. Harris et al. (2005). Diabetes Research and Clinical Practice 70: 90-97 Provider Patient Peyrot et al. Diabetes Care 2005:28: 2673-2679 Clinical Cornerstone Vol 8 No 2 33-43 Lack of time Fear of hypoglycemia Assume patient will not be interested Assume patient will not comply Knowledge gap regarding insulin regimens Feeling of personal failure Fear of weight gain Injection anxiety Time commitment / inconvenient Fear of worsening disease Cost

  7. Tearing Down Barriers Introduce insulin early Discuss the progressive nature of DM Avoid blame and highlight that up to 40% of DM2 patients may require insulin Establish a rapport and set meaningful goals Explain relationship between good glycemic and lowered risk for health complications Referral to diabetes education programs Marrero, D. 2007 Clinical Cornerstone Vol 8 No 2 33-40 Diabetes Spectrum: Summer 2010: 23, 188-193

  8. BASAL INSULIN • NPH, Lantus, Levemir • “Bedtime Insulin” • “Long Acting” BOLUS INSULIN • Apidra, Humalog, Novorapid • “Mealtime Insulin” • Rapid Insulin BASAL-BOLUS • Rapid insulin PLUS Long acting insulin PREMIXED INSULIN • NovoMix 30, Novolin 30/70, Humalog Mix25 • Mix of rapid or short acting with intermediate insulin Insulin Options

  9. Insulin Action

  10. Choose a type of insulin Choose a brand Dosing (tips on next slide) Select a pen device Check off supplies Quantity and repeats www.ocfp.on.ca

  11. www.ocfp.on.ca

  12. Case Study: Susan Susan is a 62 yo woman with DM2 and comorbidities. She is married and works retail during the day. Meds: ramipril 2.5mg Lipitor 20mg Metformin 1gm BID Glicazide MR 90mg daily Labs: A1C 8.2%; eGFR 90; urine ACR <2.0 SMBG: FBG 7-9 mmol/L; Hs 6-8mmol/L What are your next steps?

  13. Did You Consider… Drug coverage? 3rd oral agent versus basal insulin Start basal insulin at 10 units at bedtime. Titrate by 1-2 units every night until target FBG met Note most patients will require ~ 40-50 units Keep oral medications

  14. Case Study: Jeremy Jeremy is a 48 yo obese man with DM2. He was successfully started on levemir at Hs. He is currently taking 42units. His other meds include: Crestor 20mg HCTZ 25mg Labs: A1C 7.8 ; eGFR 66 SMBG: FBG range 5.5 – 7 What would you do next?

  15. Did you consider… Why is the patient not on any oral agents? Asking the patient to test at other times during the day to identify trouble spots?

  16. Case Study: Jeremy (part 2) Jeremy comes back to see you 3 months later. He has started and titrated metformin to 1000mg BID as directed in the last visit. He has also titrated his basal insulin to 54 units. He is reporting an increase in his FBG (range 6.5-8.1) while ac supper readings were within target (<7). He has experienced 2 lows early in the morning. And he has not tested at lunch or bedtime. What might be happening? How would you proceed?

  17. Did you consider… Somogyi Phenomenon versus Dawn Effect Progressive nature of diabetes

  18. Case Study: Jessica Jessica is a 54 year old woman came to see you 3 months ago with an A1c of 8.2%. She was on metformin 1000 mg twice daily, sitagliptin 100 mg daily and gliclazide MR 120 mg daily. You started on glargine 10 units at bedtime. How would you advise the patient to titrate her insulin at home? Titrate by 1-2 units every night until FBG <7 OR reaches 0.5 units/kg (80 kg x 0.5 = 40 units) OR when reaches 60 units

  19. Case Study: Jessica (part 2) Jessica has come back to see you for DM review. She is taking 40 units and her A1c dropped to 7.8% Her FBG <7. She was still taking metformin 1000mg twice daily, Sitagliptin 100 mg daily and gliclazide MR 120 mg daily. What is your next step?

  20. Did you consider… Does Jessica need to test at alternate times? Is she having lows during the day? Therefore, eating additional snacks? Do you titrate? Do you change timing? Do you change medications? Always consider referral for dietary counseling.

  21. Method 1. Sequential addition of bolus doses Fix the FPG first usual basal insulin Goal: FPG 4 to 7 mmol/L Consider adding bolus insulin when: A1c > 7% and FPG at goal or basal insulin dose > 0.5 units/kg Add bolus 4 units at largest meal Titrate to next pre-prandial (or bedtime) goal daily If subsequent pre-meal glucoses are: < 4 mmol/L : - 1 unit 4 to 7 mmol/L : Same dose > 7 mmol/L: + 1 unit Discontinue SU on addition of bolus insulin Get your patients to do the work. Teach them self-titration! If A1c > 7% after 3 months despite titrating bolus dose, or bolus dose is more than 30 units per meal: Add 2nd bolus of 4 units at 2nd largest meal and titrate as before. Repeat for 3rd bolus dose at final meal of the day Adapted from Nathan D. Diabetes Care 2008;32:193

  22. Method 2. Straight to three boluses Fix the FPG first usual basal insulin Goal: FPG 4 to 7 mmol/L Consider adding bolus insulin when: A1c > 7% and FPG at goal or basal insulin dose > 0.5 units/kg Add bolus 2 units at each meal Titrate to next pre-prandial (or bedtime) goal daily If subsequent pre-meal glucoses are: < 4 mmol/L : - 1 unit 4 to 7 mmol/L : Same dose > 7 mmol/L: + 1 unit Discontinue SU on addition of bolus insulin. Patients need to monitor up to 4x/day Get your patients to do the work. Teach them self-titration! If A1c > 7% after 3 months despite titrating bolus dose, or bolus dose is more than 30 units per meal: Resume titration of basal insulin and/or consider performing a 7 point profile Adapted from Nathan D. Diabetes Care 2008;32:193

  23. Case Study: Evelyn Evelyn is a 75 yo woman who lives alone and has a set daily routine. Evelyn previously told you she wanted to remain in control of her diabetes but not at the expense of more frequent injections and more frequent BG testing. She is currently using 30/70 premixed human insulin (30% regular human insulin and 70% NPH insulin) twice daily at breakfast (48 units) and dinner (24 units). Evelyn has hypoglycemia during the day between meals, which has led her to snack between meals. When she shows you her log book, you see that her PC values are slightly high. Her current A1C is 8.4%. What would you suggest as the next step?

  24. Insulin Action

  25. Case Study: Ted Ted is a 59 yo man with DM2. He is a retail store manager with a busy schedule, who has been on MDI (total 50 units per day). Ted complains that he feels lethargic and drowsy after meals. He has not been checking his blood glucose more than twice a week, but when he does, his PC sugars are high (> 11 mmol/L). His A1C is 13%. When you ask Ted about his routine over the past few days he admits he often takes his injections at mealtime, and occasionally forgets altogether. He mentions that he would like to be more compliant but because of work demands he has difficulty timing injections to 30 minutes before meals. What options are available to Ted?

  26. Did you consider… Tailor treatment - consider individual risk factors, lifestyle, and preferences. Ted prefers fewer injections, mixed insulin may be preferable to basal-bolus treatment with MDI Appropriate insulin that coincides with his meals? An insulin analogue does not require the 30 minute wait, which may be more acceptable for this patient. Premixed insulin analogue has been shown to be safe and effective, with improved PC sugars and fewer hypoglycemic events than human premixed insulin.

  27. Case Study: Annie Annie is a 53 yo woman who is currently taking mix25 insulin at 56 units BID. Her A1C is 9.1 Her fasting BG is 6-8; ac supper 8-10; Bedtime >10 What is your next step?

  28. Switching from Premixed insulin to Basal Bolus Therapy • Calculate total daily dose on premixed insulin • e.g., premix 30 units bid = 60 units TDD • Calculate basal insulin dose as 50% of TDD • e.g. glargine, levemir, NPH = 50% of 60 units = 30 units • Calculate bolus insulin dose as 50% of TDD • e.g. aspart, lispro, glulisine = 50% of 60 units = 30 units • Divide as three equally divided doses before meals = 10 units before meals

  29. Key points • Fix lows and fasting blood sugars first • Basal insulin is best targeted to ac breakfast sugars but will also help to bring down sugars throughout the rest of the day • Mixed insulin is good option for patients who have consistent routine • Discontinue secretagogues when adding bolus insulin • Does your patient need financial assistance with medication, supplies or equipment? • Use 3 principles for pattern management: • What did the patient do / activity? • What did the patient eat? • What did the patient take? TITRATE! TITRATE! TITRATE! Stay tuned… more practice with pattern management At next session

More Related