Managing people with diabetes on insulin

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Managing people with diabetes on insulin

• Jacqui Troughton

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Aims of presentation

• To give you an overview of the insulin's
  available, their actions and potential insulin
  regimens
• Implications of insulin choice and treatment
  regimen on lifestyle advice

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Whos on insulin therapy?

• All people with Type 1 diabetes
• People with Type 2 diabetes on maximum tablets
• People with Type 2 diabetes with
  contraindications to OHA e.g renal failure, poor
  tolerance
• Gestational Diabetes
• Post acute MI (DIGAMI)
• Acute illness/ infection

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Normal Insulin Profiles
Basic Requirements
What happenswhen you eat
After a meal
Just to function normally
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Normal Insulin Profiles
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Types of insulin

• Short (Soluble)
• Rapid (Analogue)
• Intermediate (Isophane)
• Long (Lente)
• Long (Analogue)
• Mixtures (Biphasic)

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Short acting

• Human Actrapid (from Dec 2005, available only in
  vials)
• Humulin S
• Insuman Rapid

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Characteristics of short acting insulin

• Injected 15-30 minutes before food
• Onset of action within 30- 60 minutes
• Peak action 2-4 hours
• Duration of action 6-8 hours

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Action profile of a short acting insulin
insulin activity vs. time (h)
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Rapid acting

• Humalog Insulin Lispro
• Novo Rapid - Insulin Aspart

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Characteristics of rapid acting analogues

• Injected immediately before food, but may be
  given during or shortly after
• Onset of action within 15 minutes
• Peak action 30-45 minutes
• Duration of action 2-5 hours

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Action profile of a rapid acting analogue
insulin activity vs. time (h)
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Intermediate acting

• Human Insulatard (available in vial and
  cartridge but not flexpen or novolet)
• Humulin I
• Insuman Basal

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Characteristics of intermediate acting insulin

• Designed to mimic basal insulin
• Can be given once or twice daily in combination
  with short acting insulin
• Onset of action within 2-4 hours
• Peak action 6-8 hours
• Duration of action 12-18 hours

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Action profile of an intermediate acting insulin
insulin activity vs. time (h)
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Long acting analogues

• Insulin Glargine (Lantus)
• Insulin Detemir (Levemir )

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Characteristics of a long acting analogue

• Slow onset, long acting insulin
• Absorbed slowly but steadily
• A longer flatter profile of glucose lowering
  without apparent loss of efficacy
• Lantus is licensed for once daily administration
  at the same time of day, but may need twice daily
• Levemir is licensed for administration once or
  twice daily

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Mixtures

• Human Mixtard (10,20,30,40,50)
• Humulin (M3, M5)
• Insuman Comb (15, 25, 50)
• Humalog Mix 25, Mix 50
• NovoMix 30

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Characteristics of Pre Mixed Insulin

• Combination of a short or rapid acting insulin
  with an intermediate insulin to make a single
  formulation
• Characteristics of insulin mixture will depend on
  the percentage of quick/ rapid acting insulin
  present
• Usually given twice a day
• Convenient but not flexible

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Action profile of a premixed insulin
insulin activity vs. time (h)
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What factors might you consider when choosing an
insulin/ regimen?

Flexibility of regimen needed for
lifestyle Evidence base for efficacy of
product Weight HbA1c, fasting blood glucose,
symptoms Ability to self monitor blood/ urine
glucose Number of injections preferred Preferred
method of delivery/ device
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Insulin regimes

• For type 1
• BD Mixture
• Basal bolus
• Continuous Subcutaneous Insulin Infusion (CSII)
• For type 2
• Combination therapies (with metformin)
• OD Isophane or Lantus or levemir
• Basal bolus
• BD Mixture

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Regimens

Adapted from Heller (2001) Insulin Treatment in
type 2 diabetes in Insulin Made Easy
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Role of the Dietitian

• The DCCT research group found that the ability
  to adjust insulin dose with planned food
  variations seems crucial in maintaining
  normoglycaemia
• The relationship between diet and insulin MUST be
  taken into consideration to achieve optimal blood
  glucose control without unnecessary weight gain
  or hypo glycaemia
• For those on insulin with type 2 diabetes, weight
  management advice/support is vital

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Educational needs of person on insulin

• Weight gain/ weight loss
• Hypoglycemia
• People on insulin need to be given skills to
  adjust insulin to food eaten (if they want)
• Knowledge about insulin action
• Knowledge about which foods affect blood glucose
  levels e.g. CHO (qualitative/ quantitative), GI
  affect
• Snacks
• Alcohol
• Exercise
• Knowledge about self monitoring

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Professional Consensus Statement

• Suggested good practice for Dietitians involved
  in the dietetic management of adults, with type 1
  diabetes, treated with insulin analogues

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Guidelines

• The amount of CHO at meals and snacks has a
  greater influence on glycaemia than either source
  or type
• New insulin regimens in conjunction with more
  frequent monitoring enables people to vary amount
  of CHO at meals and timing by adjusting insulin
  dose/ physical activity or both
• Meal composition in elation to gastric emptying
  may need to be considered for those on insulin
  analogues
• Awareness of GI of foods useful for those on
  analogues

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• Generally bedtime snacks are not needed for those
  on new long acting analogues e.g. Lantus and
  Levemir
• The need for bedtime snacks can be based on a
  persons home testing
• Snacks may be needed for those who drink a large
  amount of alcohol in the evening
• Weight management advice is still key to those
  with type 2 diabetes on insulin

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• Thank you for listening