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Management of Type 2 Diabetes INSULIN

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Management of Type 2 Diabetes INSULIN – PowerPoint PPT presentation

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Title: Management of Type 2 Diabetes INSULIN


1
Management of Type 2 DiabetesINSULIN
2
Pathogenesis of Type 2 Diabetes
3
Insulin secretion profiles in Type 2 diabetic
patients and healthy persons
4
Insulin secretion in Type 2 diabetic patients
  • Amount of insulin released over 24 hours similar
    to control levels
  • Irregular pulses of lower amplitude
  • Slow increase after meal
  • No return to basal levels between meals

5
Secondary Failure
6
Glycaemic Control Type 2
  • United Kingdom Prospective Diabetes Study (UKPDS)
  • 3867 patients 20 year follow up
  • Endpoints evaluated
  • Would intensive pharmacological control of blood
    glucose improve outcome?
  • Was outcome affected by treatment choice?

7
UKPDS - Glycaemic control
Conventional policy
Intensive policy
11
9
10
8
9
Median HbA1c ()
Median FPG (mM)
8
7
7
6
0
0
15
12
9
6
3
0
15
12
9
6
3
0
Time from randomisation (years)
UKPDS Group Lancet 1998352837
8
UKPDS - Conventional vs Intensive Therapy
  • Over first 10 years from diagnosis
  • FPG and HbA1c increased in both groups due to
    deterioration of beta cell function
  • But 11 reduction in HbA1c on intensive policy vs
    conventional policy (median 7.0 vs 7.9
    plt0.0001)

9
Correlation between HbA1c Plasma Glucose
HbA1c Mean plasma glucose 6 7.5 7 9.
5 8 11.5 9 13.5 10 15.5 11 17.5 12
19.5
10
UKPDS key outcome results
Any diabetes- related endpoint
Risk reduction, intensive versus conventional
treatment groups.
Microvascular endpoint
Cataract extraction
Retinopathy (12 years)
Myocardial infarction
Albuminuria (12 years)
0
10

Risk reduction ()
p lt 0.05 p lt 0.01
20



30

11
UKPDS Conclusions
  • Reducing the risk of microvascular complications
    in Type 2 diabetes is a realistic goal !
  • Intensive blood glucose control reduces risk of
    complications

12
Treatment Type 2 Diabetes
13
Type 2 diabetes is a progressive disease
  • Progressive loss of beta cell function is
    observed during the natural course of the disease
  • Many patients need combination therapy
  • 5-10 of the patients treated with oral agents
    will start insulin every year
  • At 6 years 50 of patients in the UKPDS were
    receiving insulin to maintain good glycaemic
    control

14
Stages to reach and maintain the targets
  • Diet and exercise
  • Oral hypoglycaemic agents monotherapy
  • Oral hypoglycaemic agents combination therapy
  • OHA s Nocte Insulin therapy
  • OHAs (IS) Insulin Therapy

15
Begin an oral agent when
  • An adequate trial of life-style intervention/
    education has been given
  • either (usually) HbA1c gt 6.5, venous FPG
    gt 6.0 mmol/L (gt110 mg/dl)
  • or (occasionally) if the patient is thin and
    there are no other arterial factors HbA1c gt
    7.5,
  • venous FPG gt 7.0 mmol/L (gt 125 mg/dl)

A Desktop Guide to Type 2 Diabetes Mellitus,
European Diabetes Policy Group 1999
16
OADs 5 classifications
Sulphonylureas (SU)
Insulin Secretagogues
Prandial Glucose Regulators (PGRs)

Biguanides
Insulin Sensitisers
Thiazolidinediones (TZDs)
a-Glucosidase Inhibitors
17
Maximum Dose Guide for OADs
4 Refer to MIMS Annual for information on
these and other OADs
18
Monotherapy and Combination Therapy

19
Guidelines for Starting Insulin
Insulin therapy is indicated if the following
measures fail to achieve glycaemic targets
  • Maximum tolerated dose of Oral Hypoglycaemic
    Agents (OHA)
  • Failure to reach glycaemic targets (6/12)
  • Remediable factors considered (e.g. food and
    exercise plan, intercurrent problems)

20
Targets for glycaemic control in Type 2 diabetes
  • Fasting/preprandial BG lt 6.0 mmol/L
  • Postprandial BG lt 7.7 mmol/L
  • HbA1c lt 7.0

Self-monitored blood glucose
A Desktop Guide to Type 2 Diabetes Mellitus,
European Diabetes Policy Group 1999
21
Insulin therapy in Type 2 diabetes maxing out
on oral therapy
  • Begin insulin therapy when HbA1c gt 8.0 after
    maximum attention to dietary control and oral
    glucose lowering therapy
  • Review diet before starting insulin
  • Review (or start) self-monitoring of blood
    glucose before starting insulin therapy
  • Continue therapy with metformin/insulin
    secretagogues/ PPAR - agonists

A Desktop Guide to Type 2 Diabetes Mellitus,
European Diabetes Policy Group 1999
22
Treatment Options
  • Bedtime Insulin and Daytime OHA
  • Replacement Insulin Therapy twice daily insulin
  • Intensive therapy QID (rarely indicated)

23
Combination Therapy
  • Maintain sulfonylurea and metformin doses
  • Add evening Protaphane dose

24
How to START insulin therapy
25
Bedtime Insulin Daytime Oral Agents
OADs during the day
Protaphane InnoLet at bedtime
26
  • If more than 30-36 IU of insulin necessary to
    obtain good metabolic control, consider stopping
    insulin secretagogues and continue on same total
    dose of insulin metformin or actos
  • Divide the dose into 2 daily injections
  • 2/3 before breakfast
  • 1/3 at bedtime

27
Start insulin twice a day
28
Replacement Therapy- Twice Daily Insulin
2/3 Daily dose given in the morning
1/3 Daily dose given in the evening
29
Points to Consider
  • Education regarding
  • Diet and exercise
  • Blood glucose monitoring
  • Hypoglycaemia
  • Improved control may result in
  • Weight gain

30
Additional tips
  • Do not alter insulin doses frequently
  • Go slowly
  • Adjust every few days based on a pattern
  • Diet/ education/ activity critical
  • If you get stuck call us at DCAS if CVR gt15 in
    next 5 years

31
Summary
  • Early and aggressive treatment of Type 2 diabetes
    to improve glycaemic control decreases the risk
    of long-term complications
  • Type 2 diabetes is a progressive disease
    progressive loss of beta cell function is
    observed during the natural course of the disease
  • Insulin treatment should be initiated when near
    normalization of blood glucose cannot be achieved
    with OHAs

32
DIABETES An epidemic!!!
33
The role of the GP
  • Sheer necessity
  • Frequent follow-up
  • Better patient familiarity
  • Consultant back-up can be supportive and
    occasional specify.
  • Complex cases and type I diabetes need to have
    interactive endocrinologist care.

34
?
35
STENO-2 STUDY
160 patients with T2D and the metabolic syndrome,
including microalbuminuria, randomised to either
conventional therapy at their GPs, or intensive
care at Steno Diabetes Centre.
P. Gaede, P. Verdel, N. Larsen, et al. N Engl J
Med. 2003348383-393
36
  • Individualised risk assessment
  • Ambitious goal setting
  • More drugs/higher doses
  • Continued patient education/motivation

Drug treatment stepwise and target driven
Hyperglycaemia Metformin - Gliclazide Insulin
per charts Dyslipidaemia Statins
Fibrates Hypertension ACE Inhibitors -
Angiotensin II blockers Diuretics - Calcium
antagonists - Beta-blockers Albuminuria ACE
Inhibitors Other CVD prevention Aspirin
37
STENO-2 Follow up at 8 yrs
Intensive
Conventional
  • HbA1C () 9.0 7.9
  • Systolic BP (mmHg) 146 131
  • Diastolic BP (mmHg) 78 73
  • Total chol (mM) 5.6 4.1
  • LDL chol (mM) 3.3 2.1
  • Triglycerides (mM) 3.0 1.7

38
Steno-2 Microvascular complications after 8 years
Nephropathy
0.39
Relative Risk
0.42
Retinopathy
Auton Neuropathy
0.37
Periph Neuropathy
1.09
1.0
1.5
2.0
2.5
0
0.5
In favour of intensive
In favour of conventional
39
Steno-2 Cardiovascular endpoints after 8 years
65 CVD events in 35 conventional patients
(44) 33 CVD events in 19 intensive patients
(24)
Probability for primary endpoint
0.6
Conventional
0.5
0.4
0.3
Intensive
0.2
0.1
0
0
12
24
36
48
60
72
84
96
Months of follow-up
40
Fundamental message
  • Diabetes management - aggressive
  • Lifestyle is critical in ALL
  • Target all CVRF
  • Manage Hyperglycaemia
  • Screen for and manage complications
  • We do not do a good job of reaching targets in
    this condition
  • Challenge

41
We can do this as a team
  • Feasible
  • Sustainable
  • Affordable
  • Effective
  • Model of diabetes care for Australia
  • Centered around self efficacy and GP based care
    with expert support

42
Questions
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