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Insulin Conundrums . Veronica Green. Risk reduction. Risk reduction for each 1% reduction in HbA1c in type 2 diabetes. Amputation or death due to peripheral vascular disease. Any diabetes- related endpoint. Microvascular complications. Myocardial infarction. Cataract extraction.

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insulin conundrums

Insulin Conundrums

Veronica Green

slide2

Risk reduction

Risk reduction for each 1% reduction in HbA1c in type 2 diabetes

Amputation or death due to peripheral vascular disease

Any diabetes- related

endpoint

Microvascular complications

Myocardial infarction

Cataract extraction

Heart failure

0

21%

37%

14%

19%

16%

43%

-10

*

**

Risk reduction (%) associated with a 1% lower HbA1c

-20

*

*

*p < 0.0001

**p = 0.021

-30

*

-40

*

Epidemiological extrapolation showing benefit of a 1% reduction in mean HbA1c with a mean duration of diabetes of 10 years

  • Stratton IM et al. BMJ 2000; 321: 405–412.
standard approach to the management of type 2 diabetes
Standard approach to the management of Type 2 diabetes

LifestyleChanges

Oral Combination+glipins

+

Oral Monotherapy

Treatment intensification

Insulin

Oral + exenatide /

+

Diet and Exercise

V Green Byetta workshop 2

slide5
NICE
  • Hba1c >7.5%
  • Use NPH od/bd
  • Or long acting analogue if
    • Hypoglycaemia
    • Can’t do it themselves
    • Otherwise would need BD basal+orals
  • Hba1c >9%
  • Use BD biphasic
  • Use analogue mix if
    • Marked post prandial raise
    • Need to inject immediately pre-meals
    • hypos

NICE 2009

or not
Or Not
  • NPH ½ price of analogue long acting insulin but
  • 20% variability in absorption with each injection
  • iFriedburg SJ, Lam YWF, Blum JJ, Gregerman RI. 2006. Insulin absorption: a major factor in apparent insulin resistance and the control of type 2 diabetes. Metabolism. 55(5) 614-619
doctor s fears
Doctor’s Fears

Will I do my patient any good?

Will their complications worsen?

Will it make a difference to the blood glucose levels?

Will they put on more weight?

nurse s fears
Nurse’s Fears

Can this person learn to inject?

Is it going to make a difference?

What insulin to use?

Am I able and competent to do this?

What if something goes wrong?

patient s fears
Patient’s Fears

Will this make me a drug addict?

What about my lifestyle?

Fear of hypos

My diabetes mild, I don’t need insulin

Needle phobia

effect on lifestyle
Effect on Lifestyle
  • Find out about work, social life BEFORE deciding on a regime
  • Adapt the regime about the life not the other way round.
rapid acting analogues
Rapid Acting Analogues
  • Work almost straight away
  • Last 3-5 hours
  • Used pre/post prandially
  • NovoRapid , Humalog, Apidra
short acting insulins
Short Acting Insulins
  • Act 30 minutes post injection
  • Last 6-8 hours
  • Given pre prandially
  • Actrapid or Humulin S
intermediate acting insulins
Intermediate Acting Insulins
  • Act after 1-2 hours
  • Last 12-14 hours
  • Given morning/evening or bedtime
  • Insulatard or Humulin I
pre mixed insulins
Pre Mixed Insulins
  • Act after 30 minutes, last 12-14 hours
  • Given morning and evening pre meal
  • Mixtard, Humulin M
  • Mixed analogues – NovoMix 30, Humalog Mix 25, 50
long acting analogues
Long Acting Analogues
  • Act immediately
  • Last 18-24 hours
  • Given am or pm
  • Lantus or Levemir
classification
Classification
  • Mild – can be treated by the person themselves without help
  • Moderate – Need help in treating, but are conscious
  • Severe – Pt unable to help themselves, need of hospital care
symptoms
Neuro-glycopenic

Confusion

Drowsiness

Speech difficulty

Poor coordination

Atypical behaviour

Diplopia

Autonomic

Sweating / pale

Palpitations

Shaking (tremor)

Hunger

Symptoms
other signs
Other signs
  • Malaise
  • Headache
  • Hemiplegia (particularly in the elderly)
  • Person may have individual signs e.g. numb lips
nocturnal hypoglycaemia 1
Nocturnal hypoglycaemia 1
  • Effects 30-40% of all diabetics
  • Can be slept through
  • The person may only be aware the next morning that they have had a hypo
nocturnal hypos 2
Nocturnal hypos 2
  • Nightmares / vivid dreams
  • Waking up unrested
  • Waking up with a headache
  • High fasting sugar (often alternating with OK ones)
hypo unawareness
Hypo Unawareness
  • Loss of bodily warning signs
  • Can cause severe hypos
  • Caused by
    • Running very tightly
    • Frequent hypos
    • Duration of diabetes
physiology
Physiology

BG<3

Neuroglycopenic symptoms

Autonomic symptoms

Treat with glucose

Release of glucagon, + stress hormones

Glucogenolysis, gluconeogenesis (liver/kidney)

Raise in BG

treatment
Treatment
  • 20g glucose
  • Back up long acting carbohydrate
  • Find the cause
  • Adjust medication if required
causes
Causes
  • Too much insulin / OHA
  • Too little food
  • Timing of injection in relation to food
  • Alcohol
  • Exercise
  • Injection site problems
  • Hot weather