insulin Management in type 2 diabetes mellitus

1. Text insulin Management in type 2 diabetes mellitus • PRACTICAL POINTERS FOR CLINICAL PRACTICE

2. What is so frightening about diabetes???

3. Denial, myths, fear.... • I can’t have diabetes, I feel GREAATTTT! • Only fat people get diabetes, so if I keep my weight down, I won’t get it. • My grandmother told me that diabetes comes from eating too much sugar. • I took my medication once or twice a week. I really don’t think it helped, so I quit taking it.

5. the diabetes epidemic

6. MANAGE SMARTER AND MORE AGGRESSIVELY

7. Indications for Insulin therapy • Adjunctive therapy - used when oral agents alone fail to achieve target glycemic goals • Basal insulin at bedtime decrease fasting blood sugars, oral agents control blood sugar during the day. • Replacement therapy - used when both basal and meal-time insulin are needed. • Glucose Toxicity - use Intensive Insulin Therapy (IIT) for 2-4 weeks at diagnosis which may improve endogenous insulin secretion and sensitivity. • Triggers for starting insulin: • persistent glucose > 250 mg/dl. • HbA1c > 10% • ketonuria • symptoms - polyuria, polydipsia, weight loss • IIT used early can resolve glycemic issues faster than oral agents. • Other - during hospitalization, pre-operatively, with steroid therapy, or at any time that glycemic control deteriorates

8. triggers for starting insulin • HbA1c > 10% • Symptoms of polyuria, polydipsia, weight loss • Failure of multiple oral medications • Acute situations; e.g. infections, MI, stroke, trauma • Perioperative period • Pregnancy • Contraindications to oral medications • failure

9. Insulin Products

10. Insulin Regimens

11. How to Start and intensify INsulin

12. Starting insulin • Is a process • Generally takes a few weeks • Familiarize patient with insulin administration • Build patient confidence • Gradual improvement of glycemic control while avoiding hypoglycemic episodes • If available, consultation with CDE is invaluable

13. Start Simple • Long acting or immediate acting insulin • Add short acting with meals to reduce post-meal rises • Continue to use oral agents; Metformin, TZDs, DPP-4’s • Sulfonylureas - discontinue • May require 20-30% more insulin if oral agents are discontinued

14. Commercial for Certified Diabetes Educators

15. Insulin Regimens

17. basal regimen • Once daily injection of Glargine, Detemir, NPH • Given at bedtime to lower fasting blood glucose • Can be used alone or with oral agents • Detemir and NPH may need to be given twice daily • NPH associated with more hypoglycemia • Raising basal only can lead to lows at night • Glargine and Detemir are more costly than NPH

18. Intermediate and Short-Acting Regimen ✰ Add short-acting insulin if post-meal blood sugars are high Split-Mix: consider that insulin proportions are typically 2/3 in morning and 1/3 in evening. Ratios of long-acting/NPH to rapid/Regular of 2:1 in am and 1:1 in evening. ✰ ✰ Split-mix often leads to hypoglycemia in middle of night related to NPH peak at 6-8 hours after dinner injection.

19. Basal-Bolus Regimen Ideal for replacement insulin therapy Preferred for patients who have unpredictable mealtime and activity schedules. Basal insulin is 40-50% of total daily dose of insulin Bolus given pre-meal - should be 50-60% - may be adjusted according to carbohydrate counting using insulin-to-carbohydrate ratio

20. How to Figure Insulin to CArb Ratio (I:CR) Example: 60gm ÷ 10 units = 6 I:CR is 1:6 To Figure I:CR divide amount of carb person is consuming by amount of insulin taken at meal ☞ ☟ If person eats 75 gm carbs 75 mg ÷ 6 = 12 units ☞

21. Sensitivity/Correction Factor • Used for patients with varying blood glucose • Corrects pre-meal highs or lows • Given only before meals • Ensures that the post-meal glucose will be in acceptable range • More commonly used in Type1 vs. Type 2

22. Calculation: Sensitivity/Correction Factor • Divide 1500 by total daily dose (TDD) insulin - this determines the sensitivity ratio. • Example: 1500 ÷ 50 units/day = 30 • Correction Factor: If patient blood sugar is 250 mg/dl. and target blood glucose range is 100 mg/dl. , figure 1 unit of insulin is needed for every 30 pts. above target range of 100 mg/dl.

23. Doing the Math Target Glucose Range: 100 mg/dl. I:CR 1:6 Sensitivity Factor: 1:30 Patient blood glucose is: 250 mg/dl. Calculation: SMBG Target 250 mg/dl. - 100mg/dl. = 150 Sensitivity: 1:30 150÷30 = 5 units I:CR person eats 75 gms. at lunch = 12 units Meal Bolus =12 units PLUS 5 units correction = 17 units

24. IIT IMPortant tips In Intensive Insulin Therapy (IIT) If person eats 3 meals/day and 3 carb snacks they should bolus 6 times per day Better managed with consistent carb intake at meals rather than snacks - reduces # of injections to 3 per day OR teach patient about non-carb snacks

26. Self MOnitoring of Blood Glucose (SMBG) • Very important component of insulin management to assess and make appropriate and safe changes • Recommendations for testing vary as to patient and insulin type : 1-2 times if on basal regimen only OR 2-4 times for combined regimen. • REMEMBER: 4-8 testings provide only 4-8 “snapshots.” Can lose alot of information in between & at night

27. IMPORTANT: Evaluate fasting and 2 hour postprandial blood glucose readings when chosing basal insulin only, mixed insulins, or basal-bolus regimens (IIT) • Target is a blood sugar < 180 mg/dl. or A1c of 7% or less. • Need to check postprandials at different meals to identify a pattern that may be ocurring

28. CONTINUOUS GLUCOSE MONITORING (CGMS)

30. Medical Nutrition Therapy • Proper nutrition is essential to insulin management. • ADA recommends individualized MNT • Teaches carb counting and is individualized to patient’s level of understanding Current Nutrition Recommendations: 3 meals / day; 30-45 gms. carbs each With or Without 1-2 snacks in between meals - if each snack is < 30 gms. no additional rapid-acting insulin needed

31. Focus of MNT • Lifestyle changes • Increased physical activity • Pt. may chose to eat 3 meals/day OR small meals with snacks

33. CArbohydrates • Greatest impact on postprandial blood sugars • Patient should understand which foods contains carbs • Understand portion size & number of servings per meal/snack • Total carb consumption vs. type of carb impacts blood sugar control • No evidence to support low vs. high glycemic index diets • Artificial sweeteners are FDA approved for DM

34. Protein • Is widely misunderstood in diabetes glycemic control • Does raise plasma glucose concentration - amt. produced is small and does not appear in general blood circulation • Protein has not been found to slow carbohydrate absorption • Does not treat hypoglycemia • Adequate intake is important to euglycemia

35. FAts • Intake should be limited • Saturated fat is the primary determinant of LDL • Trans fats increase LDL & lower HDL - limit as much as possible

37. Initial MNT guidelines • Consume 3 meals/day, not skip meals • Meals no more than 4-6 hrs. apart • Set maximum carbohydrate intake per meal • Avoid regular soda, fruit juice, sport drinks, choose water • Food label - focus on serving size & total carbs • Men: 60-70 gms carbs., Women: 45-60 gms

40. Barriers to insulin • Hypoglycemia • Weight gain • Psychological Barriers • Lipodystrophy • Allergic reactions • Glargine insulin associated with cancer risk

41. IN Summary

42. Insulin is very effective but underused in T2DM ☤ Insulin can be used earlier in disease and as an adjunct to oral medications ☤ Transition to insulin should not be regarded as a failure by patient or provider ☤ Primary care providers should be familiar with indications for insulin, insulin regimens used & side effects ☤ Adequate support for patients is key to transitioning and the success of treatment ☤

43. ♡ ♡ ♡ ♡ ♡ "Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around." ~ Leo Buscaglia ~