How I Introduce Insulin in Type 2 Diabetes Mellitus

1. How I Introduce Insulin in Type 2 Diabetes Mellitus Sheena Duffus Diabetes Specialist Nurse Norma Alexander Sister Diabetes Clinic

2. Points to ponder • Time of diagnosis to insulin therapy • Oral therapy at maximum combination tolerated by the patient • Patient compliance • Weight loss clinics? Metabolic syndrome drugs • Glitazones not licensed for use with insulin

3. Patients perspective • Patients resistance to insulin ‘v’ insulin resistance • Fear factor • Loss of employment / driving categories • Weight gain • Hypo’s (fear of) • ? Feel better

4. Who to target? • Persistent hyperglycaemia HbA1c > 7% despite maximum dose OHAs • Symptomatic • Severe inter-recurrent illness • Diabetes complications present • Weight loss due to hyperglycaemia • Ketosis?! Honk

5. Grampian Step 1 • Review the patient HbA1c , ? Symptomatic, ? Weight loss, Inter-recurrent illness or complication present Height / Weight BMI Waist circumference

6. Step 1 • Review the medication Compliant ? Dose increase possible Additional OHA Weight control clinic Metabolic insulin resistant drug

7. Step 1 • Knowledge of diabetes Start again ? – Have they had any formal diabetes education ?

8. Revisiting control Step 1 • Review lifestyle Exercise – Do they do any ? – What could they do ? • Smoking • Psychological issues – What else is happening in their life ? stress • Motivation – How do they see it ?

9. Step 2 • Commence home blood glucose monitoring – An essential tool ! • Refer patient to diabetes dietitian • Discuss with Consultant, DSN or GP

10. Step 3 • A. After 2 months if there is an improvement in HbA1c go back to Step 1 • B. Negotiate commencement of insulin with the patient.

11. Next step • Be positive but address their fear factor • Seeing the needle! • Dry run – Sticking the needle in! • Relief factor

12. Preparation • Consent • Discuss and agree change of treatment • Employment • Driving • Hypo’s • Lifestyle • Exercise • Sick day rules

13. Pre – mix and OHAs Novomix 30 via preloaded Flexpen or Novopen 3 Humalog 25 Mix via Humapen Luxura Basal insulin and OHAs Lantus (Glargine) via pre loaded Optiset pen * must use Penfine needles or Autopen 24 Insulin regime options

14. Step 4 • Discuss insulin regime options • Action of insulin - How insulin works • Choosing their pen device – dexterity – pen needle length

15. Step 4 • Start doses - titration rates • Give clear verbal and written instructions of any OHA to be discontinued! • Written instructions of insulin dosage and titration rate

16. Step 4 • Injection sites and rotation • Storage of insulin – expiry date • Sharps disposal • Repeat prescriptions

17. Start date and time • Venue – surgery – ward • Time – morning • Task – first injection – keep it simple • Injection site – where? – rotation • Praise – discuss fear & their technique • Oral medication – continue or stop – written instructions

18. Follow up support • Injections • Daily contact at surgery or phone • Who should initiate contact? • Dose adjust every few days with patient depending upon their BG results Titrate dose slowly to prevent severe hypo’s • Answer questions