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insulin Management in type 2 diabetes mellitus

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Title: insulin Management in type 2 diabetes mellitus


1
insulin Management in type 2 diabetes mellitus
Text
  • PRACTICAL POINTERS FOR CLINICAL PRACTICE

2
What is so frightening about diabetes???
3
Denial, myths, fear....
  • I cant have diabetes, I feel GREAATTTT!
  • Only fat people get diabetes, so if I keep my
    weight down, I wont get it.
  • My grandmother told me that diabetes comes from
    eating too much sugar.
  • I took my medication once or twice a week. I
    really dont think it helped, so I quit taking it.

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the diabetes epidemic
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MANAGE SMARTER AND MORE AGGRESSIVELY
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Indications for Insulin therapy
  • Adjunctive therapy - used when oral agents alone
    fail to achieve target glycemic goals
  • Basal insulin at bedtime decrease fasting blood
    sugars, oral agents control blood sugar during
    the day.
  • Replacement therapy - used when both basal and
    meal-time insulin are needed.
  • Glucose Toxicity - use Intensive Insulin Therapy
    (IIT) for 2-4 weeks at diagnosis which may
    improve endogenous insulin secretion and
    sensitivity.
  • Triggers for starting insulin
  • persistent glucose gt 250 mg/dl.
  • HbA1c gt 10
  • ketonuria
  • symptoms - polyuria, polydipsia, weight loss
  • IIT used early can resolve glycemic issues faster
    than oral agents.
  • Other - during hospitalization, pre-operatively,
    with steroid therapy, or at any time that
    glycemic control deteriorates

8
triggers for starting insulin
  • HbA1c gt 10
  • Symptoms of polyuria, polydipsia, weight loss
  • Failure of multiple oral medications
  • Acute situations e.g. infections, MI, stroke,
    trauma
  • Perioperative period
  • Pregnancy
  • Contraindications to oral medications
  • failure

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Insulin Products
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Insulin Regimens
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How to Start and intensify INsulin
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Starting insulin
  • Is a process
  • Generally takes a few weeks
  • Familiarize patient with insulin administration
  • Build patient confidence
  • Gradual improvement of glycemic control while
    avoiding hypoglycemic episodes
  • If available, consultation with CDE is invaluable

13
  • Start Simple
  • Long acting or immediate acting insulin
  • Add short acting with meals to reduce post-meal
    rises
  • Continue to use oral agents Metformin, TZDs,
    DPP-4s
  • Sulfonylureas - discontinue
  • May require 20-30 more insulin if oral agents
    are discontinued

14
Commercial for Certified Diabetes Educators
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Insulin Regimens
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basal regimen
  • Once daily injection of Glargine, Detemir, NPH
  • Given at bedtime to lower fasting blood glucose
  • Can be used alone or with oral agents
  • Detemir and NPH may need to be given twice daily
  • NPH associated with more hypoglycemia
  • Raising basal only can lead to lows at night
  • Glargine and Detemir are more costly than NPH

18
Intermediate and Short-Acting Regimen
? Add short-acting insulin if post-meal
blood sugars are high
Split-Mix consider that insulin
proportions are typically 2/3 in
morning and 1/3 in evening. Ratios of
long-acting/NPH to rapid/Regular of 21
in am and 11 in evening.
?
Split-mix often leads to hypoglycemia in
middle of night related to NPH peak at 6-8
hours after dinner injection.
?
19
Basal-Bolus Regimen
Ideal for replacement insulin therapy
Preferred for patients who have unpredictable
mealtime and activity schedules.
Basal insulin is 40-50 of total daily dose of
insulin
Bolus given pre-meal - should be 50-60
- may be adjusted according to carbohydrate
counting using insulin-to-carbohydrate
ratio
20
How to Figure Insulin to CArb Ratio (ICR)
Example 60gm 10 units 6 ICR is 16
To Figure ICR divide amount of carb person is
consuming by amount of insulin taken at meal
?
?
If person eats 75 gm carbs
75 mg 6 12 units
?
21
Sensitivity/Correction Factor
  • Used for patients with varying blood glucose
  • Corrects pre-meal highs or lows
  • Given only before meals
  • Ensures that the post-meal glucose will be in
    acceptable range
  • More commonly used in Type1 vs. Type 2

22
Calculation Sensitivity/Correction Factor
  • Divide 1500 by total daily dose (TDD) insulin -
    this determines the sensitivity ratio.
  • Example 1500 50 units/day 30
  • Correction Factor If patient blood sugar is 250
    mg/dl. and target blood glucose range is 100
    mg/dl. , figure 1 unit of insulin is needed for
    every 30 pts. above target range of 100 mg/dl.

23
Doing the Math
Target Glucose Range 100 mg/dl. ICR
16 Sensitivity Factor 130 Patient blood
glucose is 250 mg/dl.
Calculation SMBG Target 250
mg/dl. - 100mg/dl. 150 Sensitivity 130
15030 5 units ICR person eats 75 gms. at
lunch 12 units Meal Bolus 12 units PLUS 5
units correction 17 units
24
IIT IMPortant tips
In Intensive Insulin Therapy (IIT)
If person eats 3 meals/day and 3 carb snacks they
should bolus 6 times per day
Better managed with consistent carb intake at
meals rather than snacks - reduces of
injections to 3 per day
OR teach patient about non-carb snacks
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Self MOnitoring of Blood Glucose (SMBG)
  • Very important component of insulin management to
    assess and make appropriate and safe changes
  • Recommendations for testing vary as to patient
    and insulin type 1-2 times if on basal regimen
    only OR 2-4 times for combined regimen.
  • REMEMBER 4-8 testings provide only 4-8
    snapshots. Can lose alot of information in
    between at night

27
  • IMPORTANT Evaluate fasting and 2 hour
    postprandial blood glucose readings when chosing
    basal insulin only, mixed insulins, or
    basal-bolus regimens (IIT)
  • Target is a blood sugar lt 180 mg/dl. or A1c of 7
    or less.
  • Need to check postprandials at different meals to
    identify a pattern that may be ocurring

28
CONTINUOUS GLUCOSE MONITORING (CGMS)
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Medical Nutrition Therapy
  • Proper nutrition is essential to insulin
    management.
  • ADA recommends individualized MNT
  • Teaches carb counting and is individualized to
    patients level of understanding

Current Nutrition Recommendations 3 meals /
day 30-45 gms. carbs each With or Without 1-2
snacks in between meals - if each snack is lt 30
gms. no additional rapid-acting insulin needed
31
Focus of MNT
  • Lifestyle changes
  • Increased physical activity
  • Pt. may chose to eat 3 meals/day OR small meals
    with snacks

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CArbohydrates
  • Greatest impact on postprandial blood sugars
  • Patient should understand which foods contains
    carbs
  • Understand portion size number of servings per
    meal/snack
  • Total carb consumption vs. type of carb impacts
    blood sugar control
  • No evidence to support low vs. high glycemic
    index diets
  • Artificial sweeteners are FDA approved for DM

34
Protein
  • Is widely misunderstood in diabetes glycemic
    control
  • Does raise plasma glucose concentration - amt.
    produced is small and does not appear in general
    blood circulation
  • Protein has not been found to slow carbohydrate
    absorption
  • Does not treat hypoglycemia
  • Adequate intake is important to euglycemia

35
FAts
  • Intake should be limited
  • Saturated fat is the primary determinant of LDL
  • Trans fats increase LDL lower HDL - limit as
    much as possible

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Initial MNT guidelines
  • Consume 3 meals/day, not skip meals
  • Meals no more than 4-6 hrs. apart
  • Set maximum carbohydrate intake per meal
  • Avoid regular soda, fruit juice, sport drinks,
    choose water
  • Food label - focus on serving size total carbs
  • Men 60-70 gms carbs., Women 45-60 gms

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Barriers to insulin
  • Hypoglycemia
  • Weight gain
  • Psychological Barriers
  • Lipodystrophy
  • Allergic reactions
  • Glargine insulin associated with cancer risk

41
IN Summary
42
Insulin is very effective but underused in T2DM
?
Insulin can be used earlier in disease and as an
adjunct to oral medications
?
Transition to insulin should not be regarded as a
failure by patient or provider
?
Primary care providers should be familiar with
indications for insulin, insulin regimens used
side effects
?
Adequate support for patients is key to
transitioning and the success of treatment
?
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"Too often we underestimate the power of a touch,
a smile, a kind word, a listening ear, an honest
compliment, or the smallest act of caring, all of
which have the potential to turn a life
around." Leo Buscaglia
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