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INTENSIVE INSULIN THERAPY

INTENSIVE INSULIN THERAPY. J. Robin Conway M.D. Diabetes Clinic, Smiths Falls, ON 1-800-717-0145. Objectives. Optimize diabetes management Assist you in initiating insulin in your office When to start insulin therapy? Insulins, doses, delivery options Patient training.

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INTENSIVE INSULIN THERAPY

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  1. INTENSIVE INSULIN THERAPY J. Robin Conway M.D. Diabetes Clinic, Smiths Falls, ON 1-800-717-0145 www.diabetesclinic.ca

  2. Objectives • Optimize diabetes management • Assist you in initiating insulin in your office • When to start insulin therapy? • Insulins, doses, delivery options • Patient training www.diabetesclinic.ca

  3. Challenges in Initiating Insulin? 1. Patient attitudes • Fear of needles • Insulin viewed as a threat by patient & physician • Hypoglycemia 2. Physician Attitudes • Discomfort with insulin • Lack of knowledge and experience • Fear of needles www.diabetesclinic.ca

  4. Type 1 Diabetes: • Impaired or absent ß cell function: • insulin secretion • Normal insulin action: • insulin sensitivity • The insulin deficiency results in unacceptable blood glucose control www.diabetesclinic.ca

  5. Type 2 Diabetes: Double Impairment • Impaired ß cell function: • insulin secretion • Impaired insulin action: • insulin resistance • Results in unacceptable blood glucose control www.diabetesclinic.ca

  6. Type 1 & 2 Diabetes: Key Concepts • Minimizing the complications of diabetes requires: • Early diagnosis and treatment of diabetes • Maintaining HbA1C level < 7% • Achieving HbA1C < 7% requires control of post-prandial and fasting hyperglycemia www.diabetesclinic.ca

  7. CDA Guidelines (for glycemic control) Normal Optimal A1C level (0.04-0.06) (< 0.07) Preprandial 3.5-6.1 4-7 glycemia (mmol/L) Postprandial glycemia 4.4-7.8 7-11 ( mmol/L) Haars s et al.,CMAJ 2003; 159 (Suppl.): S1-29. Gerstein, H.C. et al. CDA views on the UKPDS and revision of the guidelines affected by the results of this study. www.diabetesclinic.ca

  8. Steps to Glycemic Control • Establish glycemic objectives • Target fasting and post-prandial glycemia • Diet counseling with exercise component • Diabetes education for every patient • Pharmacological treatment; oral and insulin www.diabetesclinic.ca

  9. Patient Counselling Topics A.Review symptoms and treatment of hypoglycemia B.Proper training and correct use of glucose monitor C.Target desired glycemic levels for each patient www.diabetesclinic.ca

  10. A. Hypoglycemia • Definition: Glycemia < 3.8 mmol • Patients may experience hypoglycemia at different glycemic levels www.diabetesclinic.ca

  11. Mild < 3.3 mmol/L Neurovegetative symptoms Sweating Trembling Palpitations Anxiety Tingling Pallor Hunger Moderate to Severe < 2.8 mmol/L Symptoms of glucopenia Confusion Visual disturbances Weakness Speech disorder Behavioural disorder Drowsiness Coma Convulsions Symptoms of Hypoglycemia www.diabetesclinic.ca

  12. Preventing Hypoglycemia • Check BG 4-6 times per day • Carry glucose tablets • Have Glucagon Kit available www.diabetesclinic.ca

  13. Preventing Hypoglycemia • Test before driving and ideally 1 hour later (target: over 5.5 mmol/L) • Perform two SMBG 30 minutes apart prior to bedtime (confirming rising or falling BG) • When drinking alcohol, perform SMBG hourly • With exercise, perform SMBG pre- and post-exercise • If hypoglycemia episodes persist, raise target glucose levels www.diabetesclinic.ca

  14. Hypoglycemia Treatment Guidelines The Rule of 15 • If BG is 4 mmol/L or below • Treat with 15 grams of carbohydrates (glucose tabs) • Check BG in 15 minutes, and if not above 4 mmol/L, repeat treatment Glucagon • Current emergency kit readily available and knowledgeable person trained to administer www.diabetesclinic.ca

  15. PreventingHyperglycemia and DKA • Monitor BG 4-6 times per day • Use Correction Boluses when appropriate www.diabetesclinic.ca

  16. Hyperglycemia Treatment GuidelinesThe Key to Preventing DKA 1st BG over 14 mmol/L: • Take a correction bolus, check again in 1 hour • Call physician immediately or go to ER if nausea and vomiting are present www.diabetesclinic.ca

  17. B. Patient Training • Training by a multidisciplinary team at DEC is IDEAL for: • Diet counseling • Education on the injection sites • Education on the various injection devices • Evaluation of the patient’s support network • Other resources may exist for training, i.e. retail pharmacy www.diabetesclinic.ca

  18. C. Blood Glucose Monitoring • To adjust the insulin treatment • To detect or confirm hypoglycemia or severe hyperglycemia • To adjust treatment to the circumstances of daily life using an insulin scale prescribed by the attending physician • To improve patient safety and increase motivation to comply with treatment www.diabetesclinic.ca

  19. Ideal Testing Frequency • Stable type 2 • 1-2 readings/day • Type 1 or Unstable type 2 • 3-8 readings/day • Important to stress the need to vary testing times • AC, PC, h.s. and prn during the night www.diabetesclinic.ca

  20. Durable delivery devices Novolin-Pen® 3 Novolin-Pen® Junior InDuo® Innovo® HumaPen® Insulin pumps Syringes Disposable: multidose, prefilled (3.0 mL) NovolinSet® (NPH, Toronto, 30/70 ) Humulin® N Injection Tools and Options www.diabetesclinic.ca

  21. Advancing Insulin Therapy Through Device Innovation www.diabetesclinic.ca

  22. Goal of Insulin Therapy We are trying to duplicate how the pancreas works in releasing insulin for someone who doesn’t have diabetes www.diabetesclinic.ca

  23. Non-diabetic Insulin and Glucose Profiles Breakfast Lunch Supper 75 Insulin 50 Insulin (µU/mL) 25 Basal insulin 0 9.0 Glucose 6.0 Glucose (mmo/L) 3.0 Basal glucose 0 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 a.m. p.m. Time of Day www.diabetesclinic.ca

  24. Rapid-acting Vial and cartridge Aspart (NovoRapid®) Lispro (Humalog®) Start < 15 min. Short-acting (regular) Vial and cartridge Novolin®ge Toronto Humulin® R Start 30-60 min. Peak 4 hr IntermediateVial and cartridge Novolin®ge NPH Humulin® N Start 1.5 hrs Peak 7 hr Prolonged action Humulin® U vial only Lantus (Glargine) vial only Levemir (Detemir) cartridge Start 3-4 hrs. Peakless Insulin Preparations www.diabetesclinic.ca

  25. Insulin PreMixes • Regular + intermediate • Novolin® 10/90, 20/80, 30/70, 40/60, 50/50 • Humulin® 30/70, 20/80 • Analogue Pre-Mix • Humalog® 25/75 (insulin lispro protamine suspension) • NovoMix 30* (protaminated insulin aspart) * Not available www.diabetesclinic.ca

  26. Normal Blood Glucose Levels Blood Glucose (mmols) 10- 8- 6- 4- 2- 0 8am noon 6pm 2am 4am 8am Time www.diabetesclinic.ca

  27. Normal Blood Glucose Levels Blood Glucose (mmols) 10- 8- 6- 4- 2- 0 8am noon 6pm 2am 4am 8am Time www.diabetesclinic.ca

  28. Blood Glucose (mmols) 10- 8- 6- 4- 2- 0 Two injections/day R or H + N in AM R or H + N at Supper 8am noon 6pm 2am 4am 8am Time www.diabetesclinic.ca

  29. Blood Glucose (mmols) 10- 8- 6- 4- 2- 0 Three injections/day R or H + N in AM R or H at Supper N before bed 8am noon 6pm 2am 4am 8am Time www.diabetesclinic.ca

  30. Blood Glucose (mmols) 10- 8- 6- 4- 2- 0 Four injections/day R or H at every meal N or U once or twice/day 8am noon 6pm 2am 4am 8am Time www.diabetesclinic.ca

  31. Blood Glucose (mmols) 10- 8- 6- 4- 2- 0 Continuous Infusion 8am noon 6pm 2am 4am 8am Time www.diabetesclinic.ca

  32. Limitations of Regular Human Insulin • Slow onset of activity • Should be given 30 to 45 minutes before meal • Inconvenient for patients • Long duration of activity • Lasts up to 12 hours • Potential for late postprandial hypoglycaemia (4-6 hours) • Need for additional snack www.diabetesclinic.ca

  33. 30–45 min 15–30 min 0–15 min 0–15 min Meal B e f o r e After Adherence to Injection Recommendation (Canada) "When do you inject your insulin?" 100 42% % of Respondents 32% 22% 4% 0 www.diabetesclinic.ca 1998 Roper Starch Canada, Premix Insulin Using Respondents.

  34. Dissociation of Regular Human Insulin Regular Human Insulin peak time2-4 hr 10-3 M 10-3 M 10-5 M 10-8 M Û Û Û formulation hexamers dimers monomers capillary membrane www.diabetesclinic.ca

  35. Objectives for the Development of Short-Acting Insulin Analogues • Modify time action to address • Postprandial hyperglycemia • Hypoglycemia • Improve safety and convenience www.diabetesclinic.ca

  36. Whats’ new in type 1 diabetes treatment? • Insulin analogues. • Physiological insulin replacement • Aggressive “intensive” management • 4 injections per day • Insulin infusion pumps • Continuous glucose monitoring systems • Integrated technologies for monitoring control www.diabetesclinic.ca

  37. Non-diabetic Insulin and Glucose Profiles Breakfast Lunch Supper 75 Insulin 50 Insulin (µU/mL) 25 Basal insulin 0 9.0 Glucose 6.0 Glucose (mmo/L) 3.0 Basal glucose 0 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 a.m. p.m. Time of Day www.diabetesclinic.ca

  38. 0 2 4 6 8 10 12 14 16 18 20 22 24 NovoRapid® (insulin aspart) Time-Action Profile NovoRapid® Rapid-acting insulin analogue Onset: 10-20 minutes Maximum effect: 1-3 hours Duration: 3-5 hours www.diabetesclinic.ca

  39. Goal of Insulin Therapy We are trying to duplicate how the pancreas works in releasing insulin for someone who doesn’t have diabetes www.diabetesclinic.ca

  40. Insulin Therapy Options • MDI therapy • 0.5 units/kg = total daily dose • 4x/day 40% NPH @ hs and 60% rapid acting analogue ac meals • For patients with significant complications (i.e. renal failure, foot infections, CVD, etc…) www.diabetesclinic.ca

  41. Basal Insulin In someone without diabetes, the pancreas delivers a small amount of insulin continuously to cover the body’s non-food related insulin needs. www.diabetesclinic.ca

  42. Bolus Insulin The amount of insulin required to cover the food you eat. Fast-acting or Short-acting (clear) insulin works as a Bolus Insulin www.diabetesclinic.ca

  43. Why count carbs? • More precise way of measuring the impact of a meal on blood sugar • Lets you decide how much insulin is needed to “cover” the meal • Greater flexibility -eat what you want, when you want to eat it www.diabetesclinic.ca

  44. Fine Tuning: Bolus Doses • Carbohydrate counting or pre-determined meal portion • Individualized insulin to carbohydrate dose or insulin to meal dose • Adjust bolus based on post-meal BGs or next pre-meal BG www.diabetesclinic.ca

  45. Fine Tuning: Basal Rate • Monitor BG pre-meal, post-meal, bedtime, 12am, and 2-4am • Test fasting BG with skipped meals • Adjust nighttime basal based on 2-4am and pre-breakfast BG • Adjust basal by 0.1 u/hr to avoid over-correction www.diabetesclinic.ca

  46. Novolin®ge 30/70 Time-Action Profile Premixed insulin Onset: 0.5 hour Maximum effect: 2-12 hours Duration: 24 hours www.diabetesclinic.ca

  47. 30/70 - Twice/day www.diabetesclinic.ca

  48. 30/70 Dose Calculation • Weight = 80 kg • 80 kg x 0.3 U/kg = 24 U • 2/3 in the AM = 16 Units • 1/3 at supper = 8 Units www.diabetesclinic.ca

  49. Dosage Changes • Change insulin dose so that peak of action corresponds to most abnormal value (pre-meal) • If all values are abnormal - start with fasting glycemia followed by lunch, supper and bedtime • Change the dose by increments of 1-4 U • Not more than twice/week • Monitor for PATTERNS in hypoglycemia www.diabetesclinic.ca

  50. 0 2 4 6 8 10 12 14 16 18 20 22 24 Full Range of Novo Nordisk Insulins NovoRapid® Penfill® Rapid-acting human insulin analogue (insulin aspart) Onset: 10-20 minutes Maximum effect: 1-3 hours Duration: 3-5 hours Novolin®ge Toronto Penfill® Short-acting insulin (insulin injection, human biosynthetic) Onset: 0.5 hour Maximum effect: 1-3 hours Duration: 8 hours Novolin®ge NPH Penfill® Intermediate-acting Insulin (insulin injection, human biosynthetic) Onset: 1.5 hours Maximum effect: 4-12 hours Duration: 24 hours www.diabetesclinic.ca

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