First step into insulin therapy

1
First step into insulin therapy
(How to start insulin in a patient not controlled
on OADs)
By
Dr.Muhammad Tahir Chaudhry
B.Sc.M.BB.S(Pb).C.diabetology(USA)
2
The breakthrough Toronto 1921 Banting Best
3
(No Transcript)
4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
23
(No Transcript)
24
Fears concerns
about insulin therapy
25
(No Transcript)
26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
Normal physiologic patterns of glucose and
insulin secretion in our body
30
How Is Insulin Normally Secreted?
31

• The rapid early rise of insulin secretion in
  response to a meal is critical,
• because
• it ensures the prompt inhibition of endogenous
  glucose production by the liver
• disposal of the mealtime carbohydrate load, thus
  limiting postprandial glucose excursions.

32
(No Transcript)
33
(No Transcript)
34
Bolous insulins (Mealtime or prandial)
The time course of action of any insulin may vary
in different individuals, or at different times
in the same individual. Because of this
variation, time periods indicated here should be
considered general guidelines only.
35
Pre-mixed Insulins
NovoMix 30
Humolog Mix 25
(25 lispro75IAA)
Humolog Mix 50
(50 lispro 50IAA)
36
Basal insulins

• NPH
• Humulin N (Eli Lilly)
• Insulatard (Novo)
• (also available as insulatard Novolet pen)
• Dongsulin N (Highnoon)
• Insuget N (Getz)
• Analogs
• Glargine (Lantus)
• Lantus Solostar Pen (Sanofi Aventis)
• Detemir (Levimir) by Novo

37
Basal Insulins
The time course of action of any insulin may vary
in different individuals, or at different times
in the same individual. Because of this
variation, time periods indicated here should be
considered general guidelines only.
38
Bolous insulins (Mealtime or prandial)

• Human Regular
• Humulin R (Eli Lilly)
• Actrapid (Novo)
• (Also available as Actrapid novolet pen)
• Dongsulin R (Highnoon)
• Insuget R (Getz)
• Analogs
• Lispro (Humolog) by Eli Lilly
• Novorapid by Novo
• Aspart
• Glulisine (Apidra) by Sanofi Aventis

39
Bolous insulins (Mealtime or prandial)
The time course of action of any insulin may vary
in different individuals, or at different times
in the same individual. Because of this
variation, time periods indicated here should be
considered general guidelines only.
40

• Pre mixed
• 70/30 (70 N,30 R)
• Humulin 70/30 (Eli Lilly)
• Mixtard 30 (Novo)
• (Also available as Mixtard 30 Novolet Pen)
• Dongsulin 70/30 (Highnoon)
• Insuget 70/30 (Getz)
• Analogs
• Novomix 30 (Novo)
• Humolog Mix 25(Lilly)
• Humolog Mix 50(Lilly)

41
Types of Insulin

• 1. Rapid-acting
• 2. Short-acting
• 3. Intermediate-acting
• 4. Premixed
• 5. Long-acting
• 6. Extended long-acting

(Analogs)
(Regular)
(NPH)
(70/30)
(Lantus)
42
(No Transcript)
43
(No Transcript)
44
Proposed Algorithm of therapy for Type 2 Diabetes
Inadequate Non pharmacological therapy

• Severe symptoms
• Severe hyperglycaemia
• Ketosis
• pregnancy

2 oral agents
3 oral agents
1oral agent
Add Insulin Earlier in the Algorithm
45
First step intoInsulin therapy
46
What we have in our pockets?

• Basal Insulins (NPH,Lantus)
• Bolus Insulins(Human Regular)
• Premixed (Human 70/30)

47
The ADA Recommendations on the Use of Insulin
in Type 2 Diabetes
48
Touch Pad Question

• Currently, roughly ____ of my patients with type
  2 diabetes are taking some form of insulin.

1. gt80 2. 60-80 3. 40-60 4. 20-40 5. 0-20
49
Touch Pad Question

• When it comes to first-line insulin, I tend to
  prescribe

1. An intermediate-acting insulin with
fast-acting insulin as needed 2. A long-acting
or extended long-acting insulin with fast-acting
insulin as needed 3.A premixed insulin
50
Types of Insulin
51
Types of Insulin
52
Types of Insulin
53
Inhaled Insulin
Inhaled Insulin

• Approved in the U.S. in 2006 for the treatment of
  type 2 diabetes
• However, published studies to date have not
  demonstrated whether inhaled insulin can lower
  HbA1c to 7, either
• As monotherapy or
• In combination with an injection of long-acting
  insulin

Nathan DM et al. Diabetes Care 200629(8)1963-72.
54
Advantages of Insulin Therapy

• Oldest of the currently available medications,
  has the most clinical experience
• Most effective of the diabetes medications in
  lowering glycemia
• Can decrease any level of elevated HbA1c
• No maximum dose of insulin beyond which a
  therapeutic effect will not occur
• Beneficial effects on triglyceride and HDL
  cholesterol levels

Nathan DM et al. Diabetes Care 200629(8)1963-72.
55
Effect of Insulin on Triglyceride
and HDL-C Levels
0.34 mmol/l (30mg/dl) p0.07 n15
1.5
2
0.22 mmol/l (19.4mg/dl) p0.07 n15
1.85
1.4
1.8
1.39
1.3
1.6
Tryglyceride level (mmol/l)
HDL-C (mmol/L)
1.51
1.2
1.4
1.17
1.1
1.2
1
1
Baseline
Month 9
Baseline
Month 9
HDL-C
Triglycerides
Adapted from Nathan DM et al. Ann Int Med
1988108334-40.
56
Disadvantages of Insulin Therapy

• Weight gain 2-4 kg
• May adversely affect cardiovascular health
• Hypoglycemia
• However, rates of severe hypoglycemia in patients
  with type 2 diabetes are low
• Type 1 DM 61 events per 100 patient-years
• Type 2 DM 1-3 events per 100 patient-years

Nathan DM et al. Diabetes Care 200629(8)1963-72.
57
Balancing Good Glycemic Control with a
Low Risk of Hypoglycemia
Glycemic control
Hypoglycemia
58
Rates of Hypoglycemia for Premixed vs.
Long-Acting Insulin
plt0.05
plt0.05
3.5
45
3.4
43
40
3
35
2.5
30
2
25
of subjects
Episodes per patient-year
20
1.5
15
16
1
10
0.5
0.7
5
0
0
BIAsp 70/30 (n117)
Glargine (n116)
BIAsp 70/30 (n117)
Glargine (n116)
Adapted from Raskin P et al. Diabetes Care
200528(2)260-5.
59
HbA1c ?7 Without Hypoglycemia (Composite
Endpoint) in Two Treat-to-Target Studies
35
35
plt0.05
33.2
30
30
25
25
26.7
p0.008
26.0
20
20
Percentage of patients achieving HbA1c ?7
Percentage of patients achieving HbA1c ?7
15
15
16.0
10
10
5
5
0
0
Insulin glargine
NPH
NPH
Insulin detemir
Once-daily dosing1
Twice-daily dosing2
Hypoglycemia definition glucose levels 4
mmol/L (72 mg/dL) or requiring assistance
1. Riddle M et al. Diabetes Care
2003263080-6. 2. Hermansen K et al. Diabetes
Care 2006291269-74.
60
Rates of Hypoglycemia for Premixed vs.
Long-Acting Insulin OAD
Mean number of confirmed hypoglycemic events per
patient-year in a 28-week study
6
p0.0009
5.73
Premixed insulin Insulin glargine OADs
5
4
Events per patient-year
3
2.62
2
p0.0449
p0.0702
1
1.04
0.05
0.00
0.51
0
Symptomatic
Nocturnal
Severe
Adapted from Janka et al. Diabetes Care
200528254-9.
61
Rates of Hypoglycemia for Premixed vs.
Long-Acting Insulin OAD in Elderly Patients
12
Rate of event per patient-year
Premixed (n63) Glargine OAD (n69)
p0.01
10
p0.008
8
6
p0.06
4
2
0
All episodes of hypoglycemia
All confirmed episodes of hypoglycemia
Confirmed symptomatic hypoglycemia
Adapted from Janka HU et al. J Am Geriatr Soc
200755(2)182-8.
62
Rates of Nocturnal Hypoglycemia for NPH vs.
Long-Acting Insulin
HbA1c and rates of nocturnal hypoglycemia at Week
28
40
plt0.02 glargine vs. NPH
NPH (n259) Insulin glargine (n259)
30
4
Patients ()
20
3
plt0.01 for both treatments vs. baseline
2
10
Adjusted mean change from baseline
1
0
0
-1
-2
HbA1c ()
Nocturnal hypoglycemia (Month 2 to endpoint)
Adapted from Rosenstock J et al. Diabetes Care
200124(4)631-6.
63
The ADA Treatment Algorithm for
the Initiation and Adjustment of Insulin
64
Initiating and Adjusting Insulin
Hypoglycemia or FG gt3.89 mmol/l (70 mg/dl)
Reduce bedtime dose by 4 units (or 10 if dose
gt60 units)
Target range 3.89-7.22 mmol/L (70-130
mg/dL)
If HbA1c ?7...
If fasting BG in target range, check BG before
lunch, dinner, and bed. Depending on BG results,
add second injection (can usually begin with 4
units and adjust by 2 units every 3 days until BG
in range)
Continue regimen check HbA1c every 3 months
Recheck pre-meal BG levels and if out of range,
may need to add another injection if HbA1c
continues to be out of range, check 2-hr
postprandial levels and adjust preprandial
rapid-acting insulin
Continue regimen check HbA1c every 3 months
Nathan DM et al. Diabetes Care.
200629(8)1963-72.
65
Step One
Hypoglycemia or FG gt3.89 mmol/l (70 mg/dl)
Reduce bedtime dose by 4 units (or 10 if dose
gt60 units)
Target range 3.89-7.22 mmol/L (70-130
mg/dL)
If HbA1c ?7...
If fasting BG in target range, check BG before
lunch, dinner, and bed. Depending on BG results,
add second injection (can usually begin with 4
units and adjust by 2 units every 3 days until BG
in range)
Continue regimen check HbA1c every 3 months
Recheck pre-meal BG levels and if out of range,
may need to add another injection if HbA1c
continues to be out of range, check 2-hr
postprandial levels and adjust preprandial
rapid-acting insulin
Continue regimen check HbA1c every 3 months
Nathan DM et al. Diabetes Care.
200629(8)1963-72.
66
Step One Initiating Insulin

• Start with either
• Bedtime intermediate-acting insulin or
• Bedtime or morning long-acting insulin

Insulin regimens should be designed taking
lifestyle and meal schedules into account
Nathan DM et al. Diabetes Care 200629(8)1963-72.
67
Step One Initiating Insulin, contd

• Check fasting glucose and increase dose until in
  target range
• Target range 3.89-7.22 mmol/l (70-130 mg/dl)
• Typical dose increase is 2 units every 3 days,
  but if fasting glucose gt10 mmol/l (gt180 mg/dl),
  can increase by large increments (e.g., 4 units
  every 3 days)

Nathan DM et al. Diabetes Care 200629(8)1963-72.
68
Step One Initiating Insulin, contd

• If hypoglycemia occurs or if fasting glucose lt
  3.89 mmol/l (70 mg/dl)
• Reduce bedtime dose by 4 units or 10
  if dose gt60 units

Nathan DM et al. Diabetes Care 200629(8)1963-72.
While using basal insulin alone,never stop or
reduce ongoing oral therapy
69
After 2-3 Months

• If HbA1c is lt7...
• Continue regimen and check HbA1c every 3 months
• If HbA1c is 7...
• Move to Step Two

Nathan DM et al. Diabetes Care 200629(8)1963-72.
70
(No Transcript)
71
(No Transcript)
72
Step Two
Hypoglycemia or FG gt3.89 mmol/l (70 mg/dl)
Reduce bedtime dose by 4 units (or 10 if dose
gt60 units)
Target range 3.89-7.22 mmol/L (70-130
mg/dL)
If HbA1c ?7...
If fasting BG in target range, check BG before
lunch, dinner, and bed. Depending on BG results,
add second injection (can usually begin with 4
units and adjust by 2 units every 3 days until BG
in range)
Continue regimen check HbA1c every 3 months
Recheck pre-meal BG levels and if out of range,
may need to add another injection if HbA1c
continues to be out of range, check 2-hr
postprandial levels and adjust preprandial
rapid-acting insulin
Continue regimen check HbA1c every 3 months
Nathan DM et al. Diabetes Care.
200629(8)1963-72.
73
Step Two Intensifying Insulin

• If fasting blood glucose levels are in target
  range but HbA1c 7, check blood glucose before
  lunch, dinner, and bed and add a second
  injection
• If pre-lunch blood glucose is out of range,
• add rapid-acting insulin at breakfast
• If pre-dinner blood glucose is out of range,
• add NPH insulin at breakfast or rapid-acting
  insulin at lunch
• If pre-bed blood glucose is out of range,
• add rapid-acting insulin at dinner

Nathan DM et al. Diabetes Care 200629(8)1963-72.
74
Making Adjustments

• Can usually begin with 4 units and
  adjust by 2 units every 3 days until blood
  glucose is in range

When number of insulin Injections increase from
1-2..Stop or taper of insulin secretagogues
(sulfonylureas).
Nathan DM et al. Diabetes Care 200629(8)1963-72.
75
After 2-3 Months

• If HbA1c is lt7...
• Continue regimen and check HbA1c every
  3 months
• If HbA1c is 7...
• Move to Step Three

Nathan DM et al. Diabetes Care 200629(8)1963-72.
76
Step Three
Hypoglycemia or FG gt3.89 mmol/l (70 mg/dl)
Reduce bedtime dose by 4 units (or 10 if dose
gt60 units)
Target range 3.89-7.22 mmol/L (70-130
mg/dL)
If HbA1c ?7...
If fasting BG in target range, check BG before
lunch, dinner, and bed. Depending on BG results,
add second injection (can usually begin with 4
units and adjust by 2 units every 3 days until BG
in range)
Continue regimen check HbA1c every 3 months
Recheck pre-meal BG levels and if out of range,
may need to add another injection if HbA1c
continues to be out of range, check 2-hr
postprandial levels and adjust preprandial
rapid-acting insulin
Continue regimen check HbA1c every 3 months
Nathan DM et al. Diabetes Care.
200629(8)1963-72.
77
Step Three Further Intensifying Insulin

• Recheck pre-meal blood glucose and if out of
  range, may need to add a third injection
• If HbA1c is still 7
• Check 2-hr postprandial levels
• Adjust preprandial rapid-acting insulin

Nathan DM et al. Diabetes Care 200629(8)1963-72.
78
Premixed Insulin

• Not recommended during dose adjustment
• Can be used before breakfast and/or dinner if the
  proportion of rapid- and intermediate-acting
  insulin is similar to the fixed proportions
  available

Nathan DM et al. Diabetes Care 200629(8)1963-72.
79
Key Take-Home Messages

• Insulin is the oldest, most studied, and most
  effective antihyperglycemic agent, but can cause
  weight gain (2-4 kg) and
  hypoglycemia
• Insulin analogues with longer, non-peaking
  profiles may decrease the risk of hypoglycemia
  compared with NPH insulin
• Premixed insulin is not recommended during dose
  adjustment

80
Key Take-Home Messages, contd

• When initiating insulin, start with bedtime
  intermediate-acting insulin, or bedtime or
  morning long-acting insulin
• After 2-3 months, if FBG levels are in target
  range but HbA1c 7, check BG before lunch,
  dinner, and bed,and, depending on the results,
  add 2nd injection (stop sulfonylureas here)
• After 2-3 months, if pre-meal BG out of range,
  may need to add a 3rd injection
  if HbA1c is still 7 check 2-hr
  postprandial levels and adjust preprandial
  rapid-acting insulin.

81

• Regimen 2

82
First calculate total daily dose of insulin

• Body weight in kgs / 2
• e.g an 80 kg person will require roughly about
• 40 units / day.

83
Dose calculation..contd

• Split the total calculated dose into 4 (four)
  equal s/c injections.
• ¼ of total dose as regular insulin s/c half-hour
  ( ½ hr ) before the three main meals with 6 hrs
  gap in between.
• ¼ total calculated dose as NPH insulin s/c at
  1100 p.m. with no food to follow.

84
Dose calculation example

• For example in an 80-kg diabetic requiring 40
  units per day, start with
• 0800 a.m. --- 10 units regular insulin s/c ½ hr
  before breakfast.
• 0200 p.m. --- 10 units regular insulin s/c ½ hr
  before lunch.
• 0800 p.m. --- 10 units regular insulin s/c ½ hr
  before dinner.
• 1100 p.m. --- 10 units NPH/ lantus insulin s/c

85
Dose adjustment

• For adjustment of dosage, check fasting blood
  sugar the next day and adjust the dose of night
  time NPH Insulin accordingly i.e. keep on
  increasing the dose of NPH by approximately 2
  units daily until you achieve a normal fasting
  blood glucose level of 80-110 mg/dl.

86
Control BSF by adjusting the prior the dose of
NPH
87
Dose adjustment.contd.

• Remember that the BSL (Blood Sugar Level) at any
  given time reflects the insulin / meal taken
  before the reading, and therefore, a raised level
  of fasting blood sugar requires a change in the
  dose of previously administered night time
  insulin and will NOT be controlled by adjusting
  the next insulin injection.

88
Dose adjustmentcontd.

• Once the fasting blood glucose has been
  controlled, check 6-Point blood sugar as follows
  
• Fasting.
• 2 hours after breakfast.
• Before lunch (and noon insulin)
• 2 hours after lunch.
• Before dinner (AND EVENING INSULIN)
• 2 hours after dinner

89
Control random sugar level by adjusting the prior
dose of regular insulin
90
Dose adjustmentcontd.

• Now control any raised random reading by
  adjusting the dose of previously administered
  regular insulin.
• For example a high post lunch reading will NOT
  be controlled by increasing the dose of next
  insulin (as in sliding scale), rather adjustment
  of the pre-lunch regular insulin on the next day
  will bring down raised reading to the required
  levels.

91
Examples

• We need to increase the dose of NPH at night to
  bring down baseline sugar level (BSF) to around
  100 mg/dl after which the profile should
  automatically adjust as follows
• Blood sugar fasting 100 mg/dl
  
• Blood sugar 02 hrs after breakfast 170 mg/dl
• Blood sugar pre-lunch 110 mg/dl
  
• Blood sugar 2 hrs. after lunch 190 mg/dl
• Blood sugar pre-dinner 120 mg/dl
  
• Blood sugar 2 hrs. post dinner 180 mg/dl

• For the following profile
• Blood sugar fasting 180 mg/dl
  
• Blood sugar after breakfast 250 mg/dl.
• Blood sugar pre lunch 190 mg/dl
  
• Blood sugar post lunch 270 mg/dl
• Blood sugar pre dinner 200 mg/dl
  
• Blood sugar post dinner 260 mg/dl

92
Examplescontd.

• Blood sugar fasting 130 mg/dl
  
• Blood sugar after breakfast 160 mg/dl
• Blood sugar pre-lunch 130 mg/dl
  
• Blood sugar post lunch 240 mg/dl
• Blood sugar pre-dinner 180 mg/dl
  
• Blood sugar 2 hrs. post dinner 200 mg/dl
• This patient needs adjustment of pre-lunch
  regular Insulin which will bring down post lunch
  and pre dinner readings within normal limits.
• 2 hrs post dinner blood sugar(200 mg/dl) will be
  brought down by adjusting pre dinner regular
  insulin.

93
Combinations

• In types 2 subjects, once the blood sugar profile
  is normalized and the patient is not under any
  stress, the total daily dose (morning noon
  night NPH at 11 p.m) may be divided into two 12
  hourly injections of premixed Insulin

94
Examples.contd.

• e.g-1 If a patient is stabilized on
• 10U R 12U R 10U R 12U NPH
• then he may be shifted to
• 44/2 22 units of 70/30 Insulin 12 hourly s/c ½
  hr before meal.

• e.g-2 If the adjusted Insulin is
• 14U R16U R12U R8U NPH,
• then split the total dose
• 30 U 70/30 before breakfast and 20U 70/30
  before dinner to compensate for the high morning
  and lunch Insulin.

95
Combinationscontd.

• Problem Remember that BD dosing usually fails to
  cover lunch, especially if it is heavy. So
• Always check for post lunch hyperglycemia when
  using this regimen.
• Solution
• Patients can be advised to take their lunch
  (heavier meal) at breakfast and breakfast
  (lighter meal) at lunch.
• Adding Glucobay with lunch some times provides a
  reasonable control.
• An alternate combination to overcome the problem
  is regular insulin for morning and noon, with
  premixed insulin at night.

96
Example

• 10U R before breakfast 12U R before lunch 22U
  70/30 before dinner.
• Insulin will be injected exactly 6 hrs apart as
  in the QID regimen.

97
Choice of regimens

• R R R L
• R R R N
• R R premixed insulin
• BD premixed insulins

98

• Regimen 3
• (Pre mixed)

99
Adding basal insulin to oral agents is simple to
implement, well tolerated, and highly effective
-- particularly for patients with A1C levels
between 7.0 and 10.0
100
(No Transcript)
101
(No Transcript)
102
(No Transcript)
103
(No Transcript)
104
This should also be adjusted every 3-5 days to
target FBG.
105
(No Transcript)
106
(No Transcript)
107
(No Transcript)
108
(No Transcript)
109
The prandial insulins
110
(No Transcript)
111
(No Transcript)
112
(No Transcript)
113
How to add and titrate prandial insulins?
(Starting Insulin in Patients With A1C gt 10.0)
114
Regular insulin and Rapid acting analogues(Lispro)
115
1.Pre-meal plasma glucose levels and 2. meal
size (carbohydrate content)
prandial insulin dosing depends upon
116
A usual starting dosage for patients with type 2
diabetes is 1 U of rapid-acting insulin for every
10 g of carbohydrate eaten plus an additional 1 U
for every 30 mg/dL above the target
self-monitoring blood glucose level of 100
mg/dL. For example, a patient who had a
premeal self-monitoring blood glucose level of
160 mg/dL, and was planning to eat a meal
containing 30 g of carbohydrate, would take a
prandial insulin dose of 5 U .
117
If the patient is uncomfortable counting
carbohydrates, the physician can recommend a
range of insulin dosages empirically based on the
size of the meal I.e, 5 U of a rapid-acting
analog for a small meal and 8-10 U for a large
meal plus additional units of insulin, if
needed, based on the pre -meal self-monitoring
blood glucose level reading
118
A simple way to introduce prandial insulin is to
start with 1 dose at the main meal (ie, 5-10 U).
119
Titration of regular insulin and analogues
120
You can increase or decrease the dose of regular
insulin and analogues by 20 i.e
If the patients is using, 1-10 units./- 2
unit 11-20 units/- 4 units 21-30
units/- 6units 31-40 units/- 8
units..
121
How to start pre mixed (70/30) Insulin
122
For pre mixed insulins(70/30 preparations) Step1F
irst calculate the total daily starting
requirement of insulin body weight(kg)/2 eg,
For a 60kg patient,total daily dose 30
units Step 2Then devide this dose into 3 equal
parts 101010 Step 3Give 2 parts in the
morning and 1 part in the evening Morning20U
Evening10 U
123
Dose titration of Pre-mixed(70/30) preparations
124
You can increase or decrease the dose of
pre-mixed insulin by 10 i.e If the patients is
using, 1-10 units./- 1 unit 11-20
units/- 2 units 21-30 units/- 3
units 31-40 units/- 4 units..
125
Advantages and disadvantages of pre- mixed
insulins
126
AdvantagesEasy to administer for the
physician.Easy to fill and inject by the
patient.Provides both basal and bolus coverage
with fewer number of injections.
127
DisadvantageNo dose flexabilityIf u
increase/decrease the dose of one component ,the
dose of other component is also changed un
desirably
128
How to solve the problem of dosage flexibility
129
Regimen 4
130
(No Transcript)
131
Disadvantage of split- mixed regimen
132
How to solve the problem of nocturnal hypoglycemia
133
Somogyi phenomenon

• Due to
• excess dose of night time insulin, or
• Night insulin taken early
• Peaks at 300 a.m hypoglycemia
• Counter regulatory hormones released in excess
• Resulting in over correction of hypoglycemia
• Fasting hyperglycemia
• Solution
• Check BSL AT 3 00 a.m
• Give long acting at 1100 p.m so peak comes later
• Reduce dose of night time insulin

134
(No Transcript)
135
Dawn phenomenon

• Growth hormone surge at dawn raises insulin
  requirement.
• Night time insulin taken early, fades out before
  dawn.
• Fasting hyperglycemia
• Solution
• Give long acting insulin not before 11 00 p.m
• May need to increase dose of night time insulin

136
More physiologic regimens
137
(No Transcript)
138
(No Transcript)
139
(No Transcript)
140
(No Transcript)
141
(No Transcript)
142
Remember

• Insulin
• No miracle drug
• Has definite indications
• As delivery route follows reverse physiology
• Good control is achieved only if residual
  pancreatic function is preserved to a certain
  extent i-e
• Starting insulin on time is vital
• (Concept of early insulinization)

143
Pearls for practice

• Never try to control diabetes with oral
  hypoglycemic drugs / insulin without first
  ensuring strict diet control.
• Always bring fasting sugar to normal before
  trying to control post prandial / random blood
  sugar.
• Control any underlying infection/stressful
  condition vigorously.
• Keep meal timings regular with 6 hrs between the
  three meals.
• Do not inject NPH before 11 p.m.
• Keep number of calories during the meals same
  from day to day. The quantity and quality of diet
  should be same at same timings.
• Do not use sliding scale to calculate the dose of
  insulin.
• Use proper technique to inject s/c insulin.
• Ensure proper storage of insulin.

144
Common Problems
145
Problems can be avoided

• Adherence to time table is all that is required
  to avoid problems
• Regular meals
• Regular injections
• Regular excercise

146
Choosing an Insulin with a
Lower Risk of Hypoglycemia

• Insulin analogues with longer, non-peaking
  profiles may decrease the risk of hypoglycemia

Nathan DM et al. Diabetes Care 200629(8)1963-72.
147
Injection Techniques
148
Sites of injection

• Arms ?
• Legs ?
• Buttocks ?
• Abdomen ?

149
Sites of injection.contd.

• Preferred site of injection is the abdominal wall
  due to
• Easy access
• Ample subcutaneous tissue
• Absorption is not affected by exercise.

150
Injection technique
151
Technique

• Tight skin fold
• Spirit. X
• Appropriate needle size
• 90 degree angle
• Change site to avoid lipodystrophy

152
Injection technique.contd.
INSTRUCTIONS Keep the needle perpendicular to
skin in order to avoid variability in absorption
(fig-A) Insert needle upto the hilt
(fig-A) Distribute daily injections over a wide
area to avoid lipodystrophy and other local
complications (fig-B)
153
Storage

• Injections refrigerate
• Pens do not refrigerate

154
Shelf life

• One month once opened

155
(No Transcript)