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Managing the patient on insulin. A Practical Approach Neum Conference October 24, 2008 John A Geddes MD

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Managing the patient on insulin. A Practical Approach Neum Conference October 24, 2008 John A Geddes MD. “Менаџмент “ код пацијента који је на инсулину Практични приступ Проф.Џон Гедис Октобра, 2008. у Неуму. Managing the patient on insulin.

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slide1

Managing the patient on insulin.

A Practical Approach

Neum Conference

October 24, 2008

John A Geddes MD

slide2

“Менаџмент “ код пацијента који је на инсулину

  • Практични приступ
  • Проф.Џон Гедис
  • Октобра, 2008. у Неуму
slide3

Managing the patient on insulin

B.N je 57 godina stara žena kojoj je diagnosticiran diabetes prošle godina kada je bila u bolnici zbog oboljenja koronarnih arterija. Ona koristi Metformin 500mg tri puta dnevno i insulin koristi ujutro. Ona posjećuje endokrinologa svakih 4 mjeseca. Ona dolazi po ramapril (BP je 146/92) i tablete za spavanje. Ona ima problema sa spavanjem, budi se dva puta u toku noći da ide na toalet i onda više ne može zaspati.

slide4

Managing the patient on insulin

Posljednji put kad ste je vidjeli naručili ste neke krvne nalaze da uradi. Njena glukoza na tašte je bila 12,4. Neće vidjeti endokrinologa u sljedećih dva mjeseca.

Last time you saw her you ordered some blood work. Her fasting blood glucose was 10.8. She doesn’t see the endocrinologist for another two months.

slide5

Managing the patient on insulin

Šta vi trebate da znate o ovom pacijentu u cilju postizanja zadovoljavajuće kontrole glukoze?

What do you need to know about this patient in order to manage her insulin to achieve satisfactory glycemic control?

slide6

Managing the patient on insulin

Diet/Nutrition

Exercise

Insulin

slide14

Managing the patient on insulin

Diet/Nutrition

Kinds of food consumed

Frequency of meals

Ability to count calories/carbohydrates?

Availability of nutritional counselling?

slide15

Managing the patient on insulin

Exercise

Type

Frequency

Impediments to exercising

slide17

Managing the patient on insulin

Insulin

Type

Mode of administration

Dose

Frequency of administration

slide18

Managing the patient on insulin

Insulin

Type

Regular, NPH, Lente, Ultra Lente

Insulin Analogues

Lispro/aspart (Rapid Acting)‏

Glargine (Lantis)‏

Detemir

slide20

Action Profiles of Various Insulin Types

lispro/aspart 4–6 hours

  • BOLUS INSULINS
  • BASAL INSULINS

regular 6-10 hours

NPH 12–20 hours

Plasma Insulin levels

glargine ~ 20-26 hours

Hours

Note: action curves are approximations for illustrative purposes. Actual patient response will vary.

Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491

Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

slide21

Action Profiles of Mixed Insulin Types

regular 6-10 hours

NPH 12–20 hours

Plasma Insulin levels

Hours

Note: action curves are approximations for illustrative purposes. Actual patient response will vary.

Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491

Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

slide22

Action Profiles of Various Insulin Types

lispro/aspart 4–6 hours

  • BOLUS INSULINS
  • BASAL INSULINS

NPH 12–20 hours

Plasma Insulin levels

Hours

Note: action curves are approximations for illustrative purposes. Actual patient response will vary.

Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491

Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

slide23

Action Profiles of Various Insulin Types

lispro/aspart 4–6 hours

  • BOLUS INSULINS
  • BASAL INSULINS

Plasma Insulin levels

glargine ~ 20-26 hours

detemir – 20-24 hrs

Hours

Note: action curves are approximations for illustrative purposes. Actual patient response will vary.

Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491

Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

slide24

Managing the patient on insulin

Mode of Administration

Syringe

Pen

CSII – Continuous Subcutaneous Insulin Infusion - INSULIN PUMP

Inhaled

slide27

Morate razmotriti i tip inzulina koji se

koristi. broj jedinica koje koristi I

vrijemeadministracije u svezi sa

vrijednostima glukoze u toku dana,

dijete i navike vježbanja pacijenta.

You will need to consider the type of insulin used, the number of units taken and the time of administration in conjunction with the glucose readings over the day, the diet and exercise habits of the patient.

slide28

What are the goals of intensive glycemic management?

Near-Normal Glycemia

Avoid short term crisis

Hypoglycemia

Hyperglycemia

Diabetic Ketoacidosis

Avoid long term complications

Improve quality of life

ADA. Clinical Practice Recommendations. 2001.

targets for glycemic control
Targets for Glycemic Control

Hgb A1c < 7%

Preprandial glucose – 4.0-7.0 mmol/l

Postpradial glucose – 5.0 – 10.0 mmol/l

(5.0 – 8.0 if HgbA1c target

not met)‏

Canadian Diabetes Association Guidelines 22008

Canadian Diabetes Guidelines - 2008

targets for glycemic control30
Targets for Glycemic Control

Hgb A1c < 7%

Preprandial glucose – 4.0-7.0 mmol/l

Postpradial glucose – 5.0 – 10.0 mmol/l

(5.0 – 8.0 if HgbA1c target

not met)‏

Canadian Diabetes Association Guidelines 22008

Canadian Diabetes Guidelines - 2008

targets for glycemic control31
Targets for Glycemic Control

Hgb A1c < 7%

Preprandial glucose – 4.0-7.0 mmol/l

Postpradial glucose – 5.0 – 10.0 mmol/l

(5.0 – 8.0 if HgbA1c target

not met)‏

Canadian Diabetes Association Guidelines 22008

Canadian Diabetes Guidelines - 2008

targets for glycemic control32
Targets for Glycemic Control

Hgb A1c < 7%

Preprandial glucose – 4.0-7.0 mmol/l

Postpradial glucose – 5.0 – 10.0 mmol/l

(5.0 – 8.0 if HgbA1c target

not met)‏

Canadian Diabetes Association Guidelines 22008

Canadian Diabetes Guidelines - 2008

slide33

What are the goals of intensive glycemic management?

Near-Normal Glycemia

Avoid short term crisis

Hypoglycemia

Hyperglycemia

Diabetic Ketoacidosis

Avoid long term complications

Improve quality of life

ADA. Clinical Practice Recommendations. 2001.

slide35

Return to the patient:

Otkrivate da B.N. koristi 32 jedinice M3 inzulina ujutro. NjenHgbA1Cje9,6 %. Njenaglukozanatašteje12,2.

You discover that B.N. is taking 32 units of M3 insulin in the morning. Her Hgb A1C is 9.6%. Her fasting blood sugar is 12.2.

slide36

Vi znate da ona treba više inzulina (ili više vježbanja ili manje hrane). Ona vam govori da joj je jedanput ranije doktor povećao insulin za 4 jedinice I da se osjećala užasno poslijepodne I da je morala uzeti meda. Ona se plaši da poveća njen insulin ponovo.

  • Šta joj savjetujete?
          • You know that she needs more insulin (or more exercise or less food). She tells you that once before a doctor had increased her insulin by 4 units and she ended up feeling terrible in the afternoon and had to eat honey. She is afraid to increase her insulin again.
  • What will you advise?
slide37

Tokom sljedeće sedmice pacijent je koristio glukometar da provjerava vrijednosti njene glukoze u različito vrijeme u toku dana I dobila je sljedeće rezultate:

ujutro- 14,1

podne-11,1

4 pm-5.3

veče- 13.8

Takođe ste shvatili da ona uzima kafu, sir I pecivo za doručak, supu I voće za ručak I da je njen glavni obrok u 5 I 30 kada joj muz dođe s posla.

slide38

Blood Glucose HGBA1c - 9.6

AM 14,1 noon 11,1 4pm 5,3 hs 13,8

Plasma Insulin levels

Hours

Note: action curves are approximations for illustrative purposes. Actual patient response will vary.

Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491

Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

slide39

Teoretski… ova pacijentica treba više inzulina I treba bolju distribuciju inzulina tokom dana. Ovo se najbolje može postići time da se podijeli doza inzulina I das a upotrebom multiplih injekcija NPH ili upotrebom nekog od novijih dugodjelujućih insulin analoga kao bazalnog inzulina, I ako je potrebno dodaju se bolus ili pred obrok brzodjelujući insulin uz obrok.

In theory....this patient needs MORE insulin and needs it better distributed over the day. This is best accomplished by dividing the insulin doses and by either using multiple injections of NPH or by using one of thenewer long acting insulin analogues as a basal insulin and, if necessary, adding bolus or prandial rapid acting insulin with meals.

slide40

Možete pokušati povećati njen UKUPNI insulin za 10% (3-4 jedinice) I podijeliti ih tako da dobije 2/3 ujutro 2/3 prije njene večere.

(M3 inzulin -22 jedinice ujutro,

14 jedinica prije večere)‏

(Self monitoring with a glucometer will help to adjust the insulin requirements.)‏

slide41

Action Profiles of Various Insulin Types

Plasma Insulin levels

Hours

Note: action curves are approximations for illustrative purposes. Actual patient response will vary.

Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491

Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

slide42

Action Profiles of Various Insulin Types

lispro/aspart 4–6 hours

Plasma Insulin levels

glargine ~ 20-26 hours

detemir – 20-24 hrs

Hours

Note: action curves are approximations for illustrative purposes. Actual patient response will vary.

Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491

Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

slide43

Managing the patient on insulin

Patient concerns

Hypoglycemic episodes

Cost

Use of needles

Ability to comply (vision, Understanding)‏

Availability of Diabetes Education.

slide44

Educate the patient. (AND YOURSELF)‏

Glucose monitoring

Diet and insulin needs

Hypoglycemia

Adjust the insulin (dose, type, time)‏

according to the response to therapy.

Try for good glycemic control – all day

Consider other factors (vision, exercise, age, intellect)‏

Basal/bolus therapy is now considered to be the management of choice.

h

slide45

Edukovati pacijenta. (I sami sebe)

  • Glukoza nadzor.
  • Dijeta i potrebe inzulina.
  • Hipoglikemija.
  • Prilagodite inzulin (doza, vrsta, vrijeme)
  • prema odgovoru na terapiju. Pokušajte dobre kontrole glikemije - cijeli dan Razmislite o drugim faktorima (vid, vježbe, dobi, intelekt) Bazalna terapija je sada smatrana kao izbor za
  • upravljanje dijabetesom.
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