Title: Management of Type 2 Diabetes Mellitus: Initiating Insulin Therapy
1Management of Type 2 Diabetes Mellitus
Initiating Insulin Therapy
- Med-Peds Continuity Clinic
- Baylor College of Medicine
- Anoop Agrawal, M.D.
2Case One
- 50 yo male with diagnosed with Type 2 diabetes
three months ago. He has been on Metformin
1000mg bid since diagnosis. A1C was 8.7 at time
of diagnosis. - Today Hgb A1c is 7.3 with a FBS of 165 mg/dl
- You are confident he has been compliant with his
therapy. What is your next step?
3Case One
- A. No change in therapy, recheck A1c in 3 months
- B. Start Glyburide 5mg bid
- C. Start Actos 30mg daily
- D. Start NPH 10 units qhs
4Case One
- A. No change in therapy, recheck A1c in 3 months
- B. Start Glyburide 5mg bid
- C. Start Actos 30mg daily
- D. Start NPH 10 units qhs
B, C or D - all acceptable choices
5ADA Diabetes Algorithm
Diabetes Care, Vol 6, Number 8, August 2006
6Case One - Clinician Inertia
- Initiate therapy with metformin and reevaluate
A1c after 3 months. If goal of 7 not met, then
advance therapy. - It is not necessary to titrate a medication to
maximal dosage before adding another agent. - Going above half the max recommended dosage of a
sulfonylurea provides little additional benefit.
(i.e. glyburide 5mg bid is sufficient) - Similarly, increasing metformin from 2000mg to
max of 2550 does little to benefit.
7Case One - Clinical Inertia
- A study out of Kaiser Permanente in California
looked at how many patients moved to next level
of treatment when A1C was over 8 - On sulfonlyurea - 35
- On metformin - 44
- On two oral agents - 18
- In general, patients spent 5 years with A1C over
8 before decision was made to add insulin!
8Barriers to Starting Insulin Patient Driven
- Fear of needles/injections and pain
- Fear of hypoglycemia
- Belief that once one starts insulin, they will
soon die - Belief that starting insulin means the disease
has won - Fear of insulin induced by the provider
- if you dont start doing X, Im going to have to
put you on insulin
9Barriers to Starting Insulin Provider Driven
- Unsure how to start and how to adjust
- Fear of promoting vascular complications
- Belief that patient compliance will be adversely
affected - Fear of patient rejection
- Concern for inducing side effects (hypoglycemia,
weight gain)
10Decline in ß-cell function UKPDS
25-30 initial non-responders to OHA 5-20 fail
each year by 10-15 yrs, 100 OHA failure
11Oral Hypoglycemic Agents MOA and Efficacy
Agent MOA ? A1c
Sulfonylureas increase insulin production from ß cells 1 to 2
Biguanides inhibits hepatic glucose production increases insulin sensitivity up to 2
Thiazolidinediones increase insulin sensitivity 0.8 to 1
Alpha-glucosidase inhibitors inhibit glucose absorption 0.5 to 1
12Oral Agents
- Sulfonylurea efficacy declines with the
progressive diminishing ß-cell function. - Metformin and Glitazones continue to provide some
benefit throughout the course of the disease
especially those with insulin resistance. - In order to adhere to ADA and ACE treatment
goals, physicians should consider initiating
insulin therapy at the first sign of poor
response to oral agents. - In general, patients with A1c gt10 need to be on
insulin.
13Insulins and Duration of Action
14Patient is on glucovance 2.5/500 2 tabs po bid.
He has had DM II for 5 years. What is your next
course of action?
Initiate insulin therapy with BIDS therapy -
daytime sulfonylurea and nighttime NPH insulin
15Case Two
- 45 yo female with Type 2 diabetes for the past 5
years. - Current medications Glipizide 10mg daily and
Metformin 1000mg bid - Today Hgb A1c is 8.5 with a FBS of 150-220 mg/dl
over past 2 months in her log book. - What is your next step?
16Case Two
- A. Add on a TZD agent (i.e. Actos)
- B. Add on a DPP IV agent (i.e. Januvia)
- C. Add on a long acting insulin at bedtime
- D. Stop oral drugs and start insulin basal-bolus
therapy
17Case Two
- A. Add on a TZD agent (i.e. Actos)
- B. Add on a DPP IV agent (i.e. Januvia)
- C. Add on a long acting insulin at bedtime
- D. Stop oral drugs and start insulin basal-bolus
therapy
18Case Two
- Add basal insulin!! Do not add a third oral
antidiabetic agent! - Why?
- Understand the natural course of diabetes, i.e.
the progressive decline of insulin production
with time (beta-cell loss) - Understand the relationship between insulin and
hepatic glucose production, and its effect on
fasting glucose.
19Bedtime insulin/Daytime Sulfonylurea (BIDS)
General rules of thumb Start with 10 units NPH
qhs Administration is usually between 10 pm and
midnight.
20Case Two
- First, focus on getting fasting plasma glucose to
70-130 mg/dl. - QHS insulin will suppress hepatic glucose
production at overnight, reducing FPG. - In the Treat-to-Target Trial, the addition of
nighttime basal insulin to oral agents lowered
A1C from 8.6 to 7 in 10 weeks. - The study also compared NPH vs. glargine and
found no difference between NPH and glargine in
achieving A1C reduction.
21Case Two - QHS insulin
- In general, the starting dose at bedtime is less
important than having a titration algorithm. - Typically, start at 10 units qhs or 0.1 to 0.2
units per kg. - Most patients will end up needing 0.5 to 1.0
units per kg. - Titration can be done every 2-3 days by the
patient until FPG reaches near 100-120 mg/dl.
22Titration of bedtime insulin
FPG values in preceding 2 days increase in insulin dosage (U/day)
180 mg/dl 6
140-180 mg/dl 4
120-140 mg/dl 2
100-120 mg/dl 0
23Initiating Basal Insulin Algorithm
- Once FPG at 70-130 mg/dl and A1c still gt7 then
start assessing pre-meal sugars. - Pre-lunch high add Reg at breakfast
- Pre-dinner high add NPH at breakfast
- Pre-bed high add Reg at dinner
Text
Diabetes Care, Vol 6, Number 8, August 2006
24Insulin Oral Agents
- Pros
- Decreased insulin dose
- Potential for less hypoglycemia
- Less intensive insulin regimens
- Cons
- Increased number of meds decreased compliance
- Potential for drug interactions
- Potentially more costly
25Case Three A 56 yo male with glyburide 5mg
daily, metformin 1gm bid and NPH insulin 35 units
qHS. His A1C is 8. Below is his blood sugar
log.
What is your next course of action?
26Case Three
- A. Add Actos 45mg daily
- B. Add NPH in the AM and continue qHS
- C. Start regular insulin qam and qpm, along with
NPH qam and qpm stop glyburide - D. Start Lantus once daily, stop NPH continue
oral medications.
27Case Three
- A. Add Actos 45mg daily
- B. Add NPH in the AM and continue qHS
- C. Start regular insulin qam and qpm, along with
NPH qam and qpm stop glyburide - D. Start Lantus once daily, stop NPH continue
oral medications.
28Case Three
- As A1c approaches target levels (lt8-8.5),
postprandial glucose contributes more than 50 to
value of the A1c. - Use basal insulin to achieve rapid reduction in
A1cs greater than 8.5 - However, to achieve goal of 6.5-7 may require
the addition of prandial insulin.
29ADA Diabetes Algorithm
Diabetes Care, Vol 6, Number 8, August 2006
30Options in basal insulin
- Insulin Glargine in place of NPH
- Pros
- ease of use (once daily)
- 35 lower incidence of hypoglycemia
- Cons
- formulary restrictions/cost
- NPH equally effective in compliant patients
31Starting Insulin Only
- Normal daily insulin secretion is 0.5 to 0.7
u/kg/day - Hence, starting insulin doses range from 0.3 to
1.0 u/kg/day, with the average being 0.5 to 0.8
u/kg/day. - Factors in choosing 24 hour insulin needs
physical activity level, weight, renal failure,
coexisting illness, eating habits
32Calculating 24-hour insulin needs
Physical Activity Level Normal Weight Obese
High 0.3 U/kg 0.5 U/kg
Moderate 0.4 U/kg 0.6 U/kg
Low 0.5 U/kg 0.8 U/kg
Coexisting Illness (CKD) Subtract 0.2 U/kg Subtract 0.2 U/kg
Big eater eating habits Add 0.1 U/kg Add 0.1 U/kg
33Insulin Adjustments
- Ms. Smith is on NPH 40u/Reg 14u qam, Reg 10u
before dinner and NPH 30u qhs. She has reported
multiple daytime and nighttime episodes of
hypoglycemia. You decide to change NPH to
glargine. How do you convert NPH to glargine? - 80 of NPH dose initial glargine dose
34Other goals for insulin therapy
- Patients who no longer have ß-cell function
require a Basal-Bolus Insulin Regimen, i.e. NPH
bid/glargine qd combined with short acting
insulin premeals. - Premix insulins (70/30, 75/25) are more difficult
to adjust and hence less popular. Serves as a
good option for patients resistant to more than
two injections of insulin a day.
35Common Questions
- How often should blood sugar be checked?
- At least as often as an injection of insulin is
given - Can insulins be mixed (in same syringe)?
- NOT with Glargine
- Always draw up Short Acting Insulin before
intermediate acting - Remember First draw up clear, then cloudy -
short acting insulins are clear, long acting are
cloudy (except glargine - is clear)
36Common Questions
- What to do with insulin dose when NPO?
- Continue glargine at same dose
- Skip Short Acting Insulin
- FBG level should not vary if the glargine dose
is correct. - If using NPH pt should take 50 of dose
- Skip SAI
37New Insulin Therapies
- Exubera - inhaled insulin
- no advantage over injectable insulin
- will require monitoring with PFTs
- Now off the market due to lack of use
- New fast acting agents glulisine (Apidra)
- New intermediate to long acting (basal) insulin
detemir (Levemir)
38Summary
- Oral agents have limited efficacy which will wane
over a period of time. - Insulin initiation should be considered in any
patient on two oral agents at maximum doses and
A1C over 7. - Combination therapy of an oral agent with insulin
is safe and effective. - Choosing and dosing an insulin formulation should
take into account the patients profile and
lifestyle.
39References
- Nathan, DM. et al. Management of Hyperglycemia
in Type 2 Diabetes A Consensus Algorithm for the
Initiation and Adjustment of Therapy. Diabetes
Care Aug 2006291963-1972. - Nelson SE, Palumbo PJ. Addition of Insulin to
Oral Therapy in Patients with Type 2 Diabetes.
The American Journal of Medical Sciences May
2006331257-63. - McMahon G, Dluhy RG. Intention to Treat -
Initiating Insulin and the 4-T Study. New
England Journal of Medicine Oct 073571759-1761. - Hirsch IB. Insulin Analogues. New England
Journal of Medicine Jan 05352174-83.