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How I Introduce Insulin in Type 2 Diabetes Mellitus. Sheena Duffus Diabetes Specialist Nurse Norma Alexander Sister Diabetes Clinic. Points to ponder. Time of diagnosis to insulin therapy Oral therapy at maximum combination tolerated by the patient Patient compliance

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how i introduce insulin in type 2 diabetes mellitus

How I Introduce Insulin in Type 2 Diabetes Mellitus

Sheena Duffus

Diabetes Specialist Nurse

Norma Alexander

Sister Diabetes Clinic

points to ponder
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
patients perspective
Patients perspective
  • Patients resistance to insulin ‘v’ insulin resistance
  • Fear factor
  • Loss of employment / driving categories
  • Weight gain
  • Hypo’s (fear of)
  • ? Feel better
who to target
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
grampian step 1
Grampian Step 1
  • Review the patient HbA1c , ? Symptomatic, ? Weight loss, Inter-recurrent illness or complication present Height / Weight BMI Waist circumference
step 1
Step 1
  • Review the medication Compliant ? Dose increase possible Additional OHA Weight control clinic Metabolic insulin resistant drug
step 11
Step 1
  • Knowledge of diabetes Start again ? – Have they had any formal diabetes education ?
revisiting control step 1
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 ?
step 2
Step 2
  • Commence home blood glucose monitoring – An essential tool !
  • Refer patient to diabetes dietitian
  • Discuss with Consultant, DSN or GP
step 3
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.
next step
Next step
  • Be positive but address their fear factor
  • Seeing the needle!
  • Dry run – Sticking the needle in!
  • Relief factor
preparation
Preparation
  • Consent
  • Discuss and agree change of treatment
  • Employment
  • Driving
  • Hypo’s
  • Lifestyle
  • Exercise
  • Sick day rules
insulin regime options
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
step 4
Step 4
  • Discuss insulin regime options
  • Action of insulin - How insulin works
  • Choosing their pen device – dexterity – pen needle length
step 41
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
step 42
Step 4
  • Injection sites and rotation
  • Storage of insulin – expiry date
  • Sharps disposal
  • Repeat prescriptions
start date and time
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
follow up support
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
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