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Case studies for Insulin initiation consideration

Case studies for Insulin initiation consideration .

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Case studies for Insulin initiation consideration

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  1. Case studies for Insulin initiation consideration It is important to find the most suitable treatment option which will require individualised patient assessment and discussion. These case studies are an aid to discussions around clinical scenarios and will be conducted by experienced Diabetes Nurses. Any treatment choice should be based on multiple factors with the final decision being based on an assessment of the pros and cons of each treatment option in an individualised patient context.

  2. Diabetes Control Case Study 1 • Mrs Patel is 74y widow, lives with her son & his family • She is taking; Metformin, Amaryl® , Pioglitazone; all at maximum doses • HbA1c creeping up, last result 77mmol/mol (9.2%) • Symptomatic with poor vision, recurrent candida, neuropathic pain in her feet • BMI 26 • Hypertension • Hyperlipidaemia

  3. Diabetes Control Case Study 1 suggestions • Tablet concordance • Dietary review and advice • Needs insulin therapy ? OD with main meal • Bp/Cholesterol/Aspirin • Podiatry review • Education and support

  4. Diabetes Control Case Study 2 • Leo is 42y male shift worker in a supermarket • Intolerant to Metformin • On Glimepiride & Pioglitazone at maximum doses for last 9 months • HbA1c 74mmol/mol (8.9%), FBG 6-9 mmol/l • BP 145/90, cholesterol 6.1, BMI 30 • Heavy smoker since 16y • Attends Pilates x 2 /week • Eating sleeping patterns are erratic • He goes clubbing every week end when he is not working until at least 4 am & then sleeps the next day • Symptomatic; retinopathy, intermittent claudication & being investigated for angina

  5. Diabetes Control Case Study 2 suggestions • Smoking cessation advice • Bp control • Statin • Re-educate re diet, exercise, regular medication, lifestyle pattern • ? Non prescribed drug use • Routine bloods • ? Metformin MR • Aspirin • ? Start insulin with lifestyle changes • ? Explore use of gliptins or GLP-1 receptor agonist

  6. Diabetes Control Case Study 3 • Luther is 53y male psychiatric nursing auxiliary • Hypertensive • FH of diabetes. Diagnosed in 2000. • FBGs of 16, 11, 14mmols • Taking Metformin 1gm bd and Pioglitazone 30mgs od, Sitagliptin 100mg od • BMI 34, • HbA1c 70 mmol/mol (8.6%) • Cholesterol 5.6

  7. Diabetes Control Case Study 3 suggestions • Aspirin, beta blockers, statin, ACE • Refer for education sessions/Dietitian • Blood profile • Reinforce lifestyle changes, diet and exercise • Review in 1-2-3months (LFT, HbA1c, Cholesterol, Bp) • Assess need for additional treatment ? insulin or GLP-1 receptor agonist • Inform patient to contact DVLA and insurance

  8. Diabetes Control Case Study 4 • Maria is 59y grandmother who baby sits her grand daughter in the mornings • Diagnosed 12y ago • On maximal doses of OHAs • BMI 24 • HbA1c creeping up, last result 72 mmol/mol (8.7%) • Consistently high blood glucose readings, never below 10mmol/l • Sometimes has symptoms of hyperglycaemia • Evidence of retinal damage

  9. Diabetes Control Case Study 4 suggestions • Taking correct medication? Time/dose/regularly? • Review diet and exercise • Consider insulin therapy • Assess cardiovascular risk • ? Seen optician, if not needs review and referral

  10. Diabetes Control Case Study 5 • 42 year old female. • Agoraphobic. Previous IV drug abuser. • Poor sleeper, catnaps all day. Depressed. • BMI 32. HbA1c 119 mmol/mol (13%) • Previous gestational diabetes. Now Type 2 diabetes from June 06. • Has a puppy. Children unkempt. • Can’t tolerate OHAs. WANTS insulin. • Irregular eating pattern, doesn’t eat with the family

  11. Diabetes Control Case Study 5 suggestions • Screen for depression • Motivational interviewing • Diet and lifestyle • Consult multi disciplinary team colleagues • Discuss with previous practice • Discuss with Gp and Practice nurse • Refer to consultant • ? insulin therapy suitable

  12. Case Study References • Actos SPC. http://www.emc.medicines.org.uk/emc/assets/c/html/displaydoc.asp?documentid=4236 (accessed 2009). • Bergenstal RM, Kendall DM, Franz MJ, Rubenstein AH. Management of type 2 diabetes: a systematic approach to meeting the standards of care. II: Oral agents, insulin, and management of complications. In: Degroot LJ, Jameson J (eds). Endocrinology. Philadelphia: WB Saunders Co, 2001:821–35. • Diabetes UK. Driving and diabetes. http://www.diabetes.org.uk/Documents/Guide%20to%20diabetes/Driving_diabetes0505.pdf (accessed 2009). • Garber AJ, Wahlen J, Wahl T, Bressler P, Braceras R, Allen E, Jain R. Attainment of glycaemic goals in type 2 diabetes with once-, twice- or thrice-daily dosing with biphasic insulin aspart 70/30 (The 1-2-3 study). Diabetes Obes Metab 2006;8:58–66. • Heller S, Kozlovski P, Kurtzhals P. Insulin's 85th anniversary—An enduring medical miracle. Diabetes Res Clin Pract 2007;78(2);149–58. • Hirsch IB. Insulin analogues. N Engl J Med 2005;352:174–83. • Holman RR, Thorne KI, Farmer AJ, Davies MJ, Keenan JF, Paul S, Levy JC; 4-T Study Group. Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes. N Engl J Med 2007;357:1716–30. • Lindholm A. New insulins in the treatment of diabetes mellitus. Best Pract Res Clin Gastroenterol 2002;16:475–92.

  13. Case Study References • Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, Zinman B. Medical management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009;32:193–203 • NHS Trust West Suffolk. http://www.diabetesuffolk.com/ManagingDiabetes/Sick%20day%20rules.htm (accessed 2009). • The National Institute for Health and Clinical Excellence (NICE). NICE clinical guideline 87. Quick reference guide. Type 2 diabetes. The management of Type 2 diabetes. http://www.nice.org.uk/nicemedia/pdf/CG87QuickRefGuide.pdf (accessed 2009). • Royal College of Nursing. Starting insulin treatment in adults with type 2 diabetes. http://www.rcn.org.uk/__data/assets/pdf_file/0009/78606/002254.pdf (accessed 2009). • West Suffolk Diabetes Service. Sick Day Rules. http://www.diabetesuffolk.com/ManagingDiabetes/Sick%20day%20rules.htm (accessed 2009). • For full range of insulins and devices please refer to Diabetes Update – Insulin Pens Wall Chart or Transition Aid (UK/DB/0410/0065)

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