Management of Type 2 Diabetes with Basal Bolus Treatment Strategies

1
Management of Type 2 Diabetes with Basal Bolus
Treatment Strategies

• Bruce W. Bode, MD, FACE
• Atlanta Diabetes Associates
• Atlanta, Georgia

2
Goals of Intensive Insulin Therapy

• Maintain near-normal glycemia
• Avoid short-term crisis
• Minimize long-term complications
• Improve quality of life

3
ACE/AACE Targets for Glycemic Control

• Fasting/preprandial glucose lt110 mg/dL
• Postprandial glucose lt140 mg/dL
• A1C lt6.5

ACE/AACE Consensus Conference August 2001
Washington, DC.
4
Type 2 DiabetesA Progressive Disease

• Over time, most patients will need insulin to
  control glucose

5
Mimicking Nature with Insulin Therapy

• Over time,
• most patients will need
• both basal and mealtime insulin
• to control glucose

6
The Basal/Bolus Insulin Concept

• Basal insulin
• Suppresses glucose production between meals and
  overnight
• 40 to 50 of daily needs
• Bolus insulin (mealtime)
• Limits hyperglycemia after meals
• Immediate rise and sharp peak at 1 hour
• 10 to 20 of total daily insulin requirement at
  each meal

7
Physiological Serum Insulin Secretion Profile
8
Basal/Bolus Treatment Program with Rapid-acting
and Long-acting Analogs
75
Breakfast
Lunch
Dinner
Aspart or Lispro
Aspart or Lispro
Aspart or Lispro
50
Plasma insulin (?U/mL)
Glargine or Detemir
25
400
1600
2000
2400
400
800
1200
800
Time
9
Novo Nordisk Devices in Diabetes Care

• First pen (NovoPen 1) launched in 1985
• Committed to developing 1 new insulin
  administration system per year

10
Lilly Insulin Pens
11
Novo FlexPen

• 3-mL prefilled disposable pen offers precise
  dosing

12
NovoLog FlexPen

• 82 of DNEs Preferred FlexPen

Source Diabetes Nurse Educators In-Depth
StudyReactions to FlexPen.
13
InDuoIntegration

• Feature
• Combined insulin doser and blood glucose monitor

14
InDuoDoser Memory

• Feature
• Remembers amount of insulin delivered and time
  since last dose
• Benefit
• Helps people inject the right amount of insulin
  at the right time

15
Starting MDI

• Starting insulin dose is based on weight
• 0.2 x wt in lb or 0.45 x wt in kg
• Bolus dose (aspart/lispro)
• 20 of starting dose at each meal
• Basal dose (glargine/NPH)
• 40 of starting dose at bedtime

MDImultiple dosage insulin.
16
Starting MDI in 180-lb Person

• Starting dose 0.2 x wt in lb
• 0.2 x 180 lb 36 U
• Bolus dose 20 of starting dose at each meal
• 20 of 36 U 7 U ac (TID)
• Basal dose 40 of starting dose at bedtime
• 40 of 36 U 14 U HS

17
Correction Bolus

• Must determine how much glucose is lowered by 1
  unit of short- or rapid-acting insulin
• This number is known as the correction factor
  (CF)
• Use the 1700 rule to estimate the CF
• CF 1700 divided by the total daily dose (TDD)
• Ex if TDD 36 U, then CF 1700/36 ?50,
  meaning 1 U will lower the blood glucose (BG) ?50
  mg/dL

18
Correction Bolus Formula
Current BG - Ideal BG Glucose CF

• Example
• Current BG 220 mg/dL
• Ideal BG 100 mg/dL
• Glucose CF 50 mg/dL

220 - 100 50
2.4 U
19
Case 1 DM 2 on SU with Infection

• 49-year-old white man
• DM 2 onset age 43, ht 70", wt 173 lb
• On glimepiride (Amaryl) 4 mg/d, A1C 7.3
  (intolerant to metformin)
• Infection in colostomy pouch (ulcerative colitis)
  glucose up to 300 mg/dL plus
• SBGM 3 times per day

SUsulfonylurea DMdiabetes mellitus SBGMself
blood-glucose monitoring.
20
Case 1 DM 2 on SU with Infection (contd)

• Started on MDI
• Did well, average BG 138 mg/dL at 1 month and
  117 mg/dL at 2 months post episode with A1C 6.1

21
Case 2 DM 2 on 70/30

• 60-year-old African American man
• DM 2 age 56, ht 69", wt 180 lb
• Failed oral agents
• On 70/30 BID 10 U AM and PM
• A1C 8.4,
• SMBG 144 on 0.8 tests/d
• Increased 70/30, tried 3x/d, still not at goal

22
Case 2 DM 2 on 70/30 (contd)

• Finally agrees to MDI
• Starting dose 0.2 x wt in lb (36 U)
• Bolus 20 pre-meal (7 U ac TID)
• Basal 40 bedtime or anytime (14 U HS)
• CF 1700 divided by TDD (50 mg/dL)
• Does greatA1C 6.4
• Current dose
• 4 U AM, 4 U noon, 10 U PM, 16 U Lantus HS

23
Options to MDI

• Simpler regimen
• Insulin pump
• Premixed BID (DM 2 only)

24
Variable Basal Rate CSII Program
75
Breakfast
Lunch
Dinner
50
Bolus
Bolus
Bolus
Plasma insulin (?U/mL)
25
Basal infusion
400
1600
2000
2400
400
800
1200
800
Time
CSIIcontinuous subcutaneous insulin infusion.
25
History of Pumps
26
(No Transcript)
27
Pump Infusion Sets
28
Metabolic Advantages with CSII

• Improved glycemic control
• Better pharmacokinetic delivery of insulin
• Less hypoglycemia
• Less insulin required
• Improved quality of life

29
CSII Factors Affecting A1C

• Monitoring
• A1C 8.3 - (0.21 x BG/d)
• Recording 7.4 vs 7.8
• Diet practiced
• CHO 7.2
• Fixed 7.5
• WAG 8.0
• Insulin type (Aspart)

Bode et al. Diabetes. 199948(suppl 1)264. Bode
et al. Diabetes Care. 200225439.
30
Self-Monitored Blood Glucose in CSII
NovoLog
Buffered Regular
Humalog

Blood Glucose (mg/dl)


Type 1 Diabetes
Bode, Diabetes 2001 50(S2)A106
31
Symptomatic or Confirmed Hypoglycemia
Plt0.05
Plt0.05
12
30 relative reduction
10
8

• Episodes/month/patient

6
4
2
0
Insulin aspart
Human insulin
Insulin lispro
Bode et al. Diabetes Care. March 2002.
32
DM 1 CSII PatientLispro to Aspart
Aspart Average 118 SD 73
Lispro Average 140 SD 118
Glucose (mg/dL)
33
Glycemic Control in Type 2 DM CSII vs MDI in
127 Patients

• A1C

Raskin et al. Diabetes. 200150(suppl 2)A128.
34
CSII vs MDI in DM 2 Patients
Raskin et al. Diabetes 200150 Suppl 2A128
35
DM 2 Study CSII vs MDI

• 93 in the CSII group preferred the pump to
  their prior regimen (insulin OHA)
• CSII group had fewer hyperglycemic episodes (3
  subjects, 6 episodes vs 11 subjects, 26 episodes
  in the MDI group)

Raskin et al. Diabetes. 200150(suppl 2)A128.
36
Case 3 DM 2 Poorly Controlled

• 58-year-old woman presented with a 12-year
  history of poorly controlled, insulin treated
  diabetes
• Ht 66", wt 174 lb, BMI 28, C-peptide 2.1
• A1C 10.4 on 165 U/d (70/30 BID)
• Added troglitazone, metformin, glimepiride to MDI
  insulin
• A1C range 7.7 to 12.6 over 3 years

37
Case 3 DM 2 Poorly Controlled (contd)

• Admitted twice for IV insulin and fasting with
  short-lived success (A1C to 7.6 but back up to
  12.6)
• Tried WeightWatchers and appetite
  suppressantsno help
• Decided to try CSII

38
Case 3 DM 2 on CSIIA1C Results

39
Case 3 DM 2 Poorly Controlled

• Patient loves the pump
• A1C remains normal as of 3/03 on 110 U/d
  consuming 2 meals/d (1.4 U/kg or 0.6 U/lb)
• Also on rosiglitazone 4 mg/d

40
Normalization of Lifestyle

• Liberalization of diettiming and amount
• Increased control with exercise
• Able to work shifts and through lunch
• Less hassle with traveltime zones
• Weight control
• Less anxiety in trying to keep on schedule

41
Current Continuation Rate CSII
Continued 97
Discontinued 3
N165. Average duration3.6 y. Average
discontinuation lt1/y. Bode BW, et al. Diabetes.
199847(suppl 1)392.
42
US Pump Usage Total Patients Using Insulin Pumps
250,000
200,000
200,000
157,000
150,000
Total no. of patients
120,000
100,000
81,000
60,000
35,000
26,500
43,000
20,000
50,000
15,000
11,400
8700
6600
0
'90
'91
'92
'93
'94
'95
'96
'97
'98
'99
'00
'01
'02
43
Current Pump Therapy Indications

• Diagnosed with diabetes (even new
  onset DM 1)
• Need to normalize BG
• A1C gt 6.5
• Glycemic excursions
• Hypoglycemia

44
Pump Therapy

• Basal Rate
• Continuous flow of insulin
• Takes the place of NPH or glargine insulin

• Meal Boluses
• Insulin needed premeal
• Premeal BG
• Carbohydrates in meal
• Activity level
• Correction bolus for high BG

45
If A1C Is Not at Goal

• Must look at
• SMBG frequency and recording
• Diet practiced
• Do they know what they are eating?
• Do they bolus for all food and snacks?

• Infusion-site areas
• Are they in areas of lipohypertrophy?
• Other factors
• Fear of low BG
• Overtreatment of low BG

46
If A1C Not at Goal and No Reason Identified

• Place on a continuous glucose monitoring system
  (CGMS by Medtronic MiniMed, GlucoWatch by
  Cygnus) to determine the cause

47
Summary

• Insulin remains the most powerful agent we have
  to control diabetes
• When used appropriately in a basal/bolus format,
  near-normal glycemia can be achieved
• Newer insulins and insulin delivery devices along
  with glucose sensors will revolutionize our care
  of diabetes

48
Conclusion

• Intensive therapy is the best way to treat
  patients with diabetes

49
Billing

• Get paid for what you do
• Use your codes and negotiate for coverage
• Detailed visit 99214
• Prolonged visit with contact plus above 99354 or
  99355 (insulin start or pump start)
• Prolonged visit w/o contact plus above 99358 or
  99359 (faxes, phone calls, e-mails)

50
Billing (contd)

• Bill faxes as prolonged visits without contact or
  negotiate a separate charge
• Bill meter download 99091
• Bill CGMS 95250
• Bill immediate A1C 83036

51
Questions

• For a copy or viewing of these slides, contact
  www.adaendo.com