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When to Start Insulin Doctors and Nurses Working Together

When to Start Insulin Doctors and Nurses Working Together. Dr Ketan Dhatariya Consultant in Diabetes and Endocrinology Norfolk and Norwich University Hospital NHS Trust. Good Timing!. Fred Banting – one of the co-discoverers of insulin Born on 14 th November 1891.

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When to Start Insulin Doctors and Nurses Working Together

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  1. When to Start InsulinDoctors and Nurses Working Together Dr Ketan Dhatariya Consultant in Diabetes and Endocrinology Norfolk and Norwich University Hospital NHS Trust

  2. Good Timing!

  3. Fred Banting – one of the co-discoverers of insulin Born on 14th November 1891 Why is it the 14th of November?

  4. We’re All Trying to Achieve The Same Thing – But Using Different Approaches

  5. Some Definitions • Type 1 • Type 2 • Others (not mentioned any more)

  6. Two Main Types • Type 1 • Autoimmune destruction of the β cells of the Islets of Langerhans in the pancreas. This leads to an absolute insulin deficiency. Insulin treatment is therefore mandatory • Previously known as IDDM or juvenile onset diabetes

  7. Two Main Types • Type 2 • Impaired insulin action (insulin resistance) and eventually, impaired insulin secretion as well • Usually treated with oral medication initially, then may move onto insulin • Formerly known as NIDDM or maturity onset diabetes

  8. Epidemiology • Diabetes currently affects approximately 3 to 4% of the population • 90% of whom have type 2 diabetes • Lifetime risk of developing diabetes is about 10%

  9. Why is it Important? • Poorly controlled diabetes leads to accelerated cardiovascular morbidity and mortality • A combination of microvascular and macrovascular disease Thom T et al Circulation 2006;113(6):e85-151

  10. Some Good News Health Consumer Power House Euro Consumer Diabetes Index Sept 2008

  11. 9 Conventional 8 (%) 1c Intensive HbA 7 6.2% upper limit of normal range 6 0 0 3 6 9 12 15 Years from randomisation UKPDS HbA1c Median Values

  12. Data From 3.3M Danes Schramm TK et al Circulation 2008;117:1945-1954

  13. An (?Uncontroversial) Starting Point • People with type 1 diabetes need to be referred to the specialist hospital team at the time of suspected diagnosis • Many people continue to be followed up in secondary care. • This depends heavily on the competence and confidence of the primary care team – and the support offered by secondary care

  14. Non-Insulin Hypoglycaemic Agents • α glucosidase inhibitors • Metaglinides • Metformin • Sulphonylureas • Thiazolidindiones • GLP – 1 analogues • DPP IV inhibitors

  15. α Glucosidase Inhibitors • There is only 1 – acarbose • Intestinal disaccharidase inhibitor • Taken one with each meal • If they don’t eat, no need to take the tablet • HbA1c reduction of 0.5 - 0.8%

  16. Metaglinides • There are 2 – repaglinide and nateglinide • Work by binding to the sulphonylurea receptor and ‘squeezing’ the β cell to release insulin • They stimulate first-phase insulin release in a glucose-sensitive manner • HbA1c reduction of 0.5 - 1.5%

  17. Metformin Derived from the plant known as Goat's Rue, French Lilac, Italian Fitch or Professor-weed (Galega officinalis)

  18. Metformin • First choice oral hypoglycaemic agent for people with type 2 diabetes, regardless of BMI • Works by decreasing hepatic gluconeogenesis, decreasing gut glucose uptake and increasing peripheral insulin sensitivity • Metformin does not (or very rarely) give people hypos, because it works by preventing blood glucose levels rising rather than by lowering glucose levels • HbA1c reduction of 1.0 – 2.0%

  19. Sulphonylureas • Have been around since the 1950’s • Act by binding to the SU receptor causing an influx of Ca2+ and an exocytosis of insulin containing vesicles • Use limited to individuals with a BMI < 25 or in whom metformin is contraindicated • HbA1c reduction of 1.0 – 2.0%

  20. Thiazolidinediones • Work by increasing peripheral insulin sensitivity at a nuclear level on peroxisome proliferator-activated receptor γ(PPARγ) • HbA1c reduction of 0.5 - 1.4% • Several controversies thus use is declining • Increased CV death rates • Increased fracture rates • Increased rates of macular oedema Nissen SE NEJM 2007;356(24):2457-2471 Loke Y et al In press Ryan EH et al Retina 2006; 26(5):562-70

  21. GLP-1 and DPP-IV GLP-1 secreted upon the ingestion of food 5.Brain: Promotes satiety and reduces appetite 2.α-cell: Suppresses postprandialglucagon secretion 3.Liver:reduces hepatic glucose output 1.-cell:Enhances glucose-dependent insulin secretion in the pancreas 4.Stomach: slows the rate of gastric emptying Nauck MA et al. Diabetologia 1993;36:741–744; Larsson H et al. Acta Physiol Scand 1997;160:413–422; Nauck MA et al. Diabetologia 1996;39:1546–1553; Flint A et al. J Clin Invest 1998;101:515–520; Zander et al. Lancet 2002;359:824–830.

  22. Their Effects Are Additive HbA1C Time

  23. The Goalposts Are Changing • HbA1C targets are coming down • The tighter the control, the likelihood of developing complications reduces – to a point

  24. –21% –14% –37% –43% Lessons from UKPDS:Better Control Means Fewer Complications EVERY 1% reduction in HbA1c REDUCED RISK* 1% Deaths from diabetes Heart attacks Microvascular complications Peripheral vascular disorders *p<0.0001 UKPDS 35. BMJ 2000;321:405–12

  25. How Many Guidelines? • EASD / ADA • Nathan et al Diabetes care 22/10/08 epub ahead of publication http://care.diabetesjournals.org/misc/dv08-9025.pdf • NICE • http://www.nice.org.uk/nicemedia/pdf/CG66diabetesfullguideline.pdf • Royal College of Physicians • http://www.rcplondon.ac.uk/pubs/contents/14f051f1-8fa4-4d0b-9385-9f2e77edc2ca.pdf

  26. Recent ADA / EASD Guidelines Nathan DM et al Diabetes Care 22/10/08 epub online

  27. NICE Advice http://www.nice.org.uk/nicemedia/pdf/CG66diabetesfullguideline.pdf Accessed 9th November 2008

  28. RCP Management of Type 2 diabetes – May 2008 Accessed 9.11.08 http://www.rcplondon.ac.uk/pubs/contents/14f051f1-8fa4-4d0b-9385-9f2e77edc2ca.pdf

  29. Tighter Control • This means that oral agents alone may not be sufficient and that insulin needs to be added

  30. Consider the Following Scenarios • 60 year old, CVA, blind, dense hemiplegia, lives in a nursing home, fully dependent • 80 year old, plays golf daily, travels the world extensively with their 60 year old partner looking for ‘excitement’ • QOF is not ‘situation specific’

  31. Insulin • Should be started when the HbA1C is ≥ 7.5% on maximal oral hypoglycaemics • Pregnancy • Steroids • Intercurrent illness

  32. Now You’ve made Your Decision • A few questions • Which insulin? • What dose? • What regime? • What do I do with the tablets? • Should I address their weight first??

  33. Insulins • Soluble (short acting) • NPH (intermediate) • Once daily • Mixtures • Insulin analogues – ultra short, long and mixtures

  34. EASD / ADA Recommendations • Start with once daily basal insulin • Which type of insulin depends on when BG levels are highest • If there are no contraindications – stay on night time insulin, with day time metformin or SU’s • Keep regularly increasing the dose until the fasting blood glucose is less than 7.0 mmol/L Holman RR et al N Engl J Med 2007;357:1716-1730 Bretzel RG et al Lancet 2008;371:1073-1084; Nathan DM et al Diabetes Care 22/10/2008; epub Riddle MC Endocrine and Metabolic Clinics of North America 2005;34:77-98; Pala L et al Diabetes Res Clin Pract 2007;78:132-135

  35. Other Options • Twice daily mixtures are commonly used but may be associated with greater weight gain than once daily injections • Three times daily mixtures are also common on the continent • In people who have unpredictable lifestyles, a basal bolus regime may be appropriate

  36. ADA/EASD Insulin Initiation Guidelines Nathan DM et al Diabetes Care 22/10/08 epub online

  37. There are Other Algorithms • At:Lantus – starting at 10 IU / day Davies M et al Diabetes Care 2005;28:1282-1288

  38. Potential Implications • Driving • Insurance

  39. Recent Data • ACCORD (Action to Control Cardiovascular Risk in Diabetes) • ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation) • VADT (Veteran’s Administration Diabetes Trial) NEJM 2008;358(24):2545-2559 NEJM 2008;358(24):2560-2572 Duckworth WC et al Diabetes Care 2001;24:942-945

  40. Tighter Glycaemic Control Does NOT Influence Outcomes • Getting HbA1C to less that 7.0% added no benefit • In ACCORD it lead to a higher mortality rate • Lots of reasons – including better risk factor management

  41. Increased Use of Adjunctive Agents Charlton J et al Diabetes Care 2008;31(8):1761-1766

  42. Things That Make the Most Difference • Smoking OR 2.87 • Raised ApoB/ApoA1 ratio OR 3.25 • History of hypertension OR 1.91 • Diabetes OR 2.37 • Abdominal obesity OR 1.12 • Psychosocial factors OR 2.67 • Daily fruit and veg intake OR 0.7 • Regular alcohol consumption OR 0.9 • Regular physical activity OR 0.86 Yusuf et al Lancet 2004 364:937-952

  43. In Summary • There are a lot of medications to try first • Weight loss is a cornerstone to delaying insulin • To ensure the best outcomes for your patients with diabetes • Be Aggressive! • Treat Early! • Being on insulin is not ‘failure’

  44. Thank you for your attention

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