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Intensifying Insulin Therapy in Type 2 Diabetes: Strategies for Family Medicine

Intensifying Insulin Therapy in Type 2 Diabetes: Strategies for Family Medicine. Amy Aronovitz, MD Endocrinologist, Northshore University HealthSystem Chicago, IL David Trachtenbarg, MD Medical Director, Diabetes Care Center, Methodist Medical Center

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Intensifying Insulin Therapy in Type 2 Diabetes: Strategies for Family Medicine

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  1. Intensifying Insulin Therapy in Type 2 Diabetes: Strategies for Family Medicine Amy Aronovitz, MD Endocrinologist, Northshore University HealthSystem Chicago, IL David Trachtenbarg, MD Medical Director, Diabetes Care Center, Methodist Medical Center Clinical Professor, University of Illinois College of Medicine at Peoria, Peoria, IL

  2. The evidence-based recommendations in this presentation are from the American Diabetes Association. Source: Standards of Medical Care in Diabetes—2010. Diabetes Care 2010;33(Suppl 1):S11-S61. Website:http://care.diabetesjournals.org/content/33/Supplement_ 1/S11.full.pdf+html Strength of Evidence is indicated following each recommendation. For a description of evidence levels, see Evidence-based Recommendations on the resources page. Evidence-based Recommendations

  3. Module 1 Case 1: Initiating Premeal Insulin

  4. Beta Cell Function and Insulin Resistance in Type 2 Diabetes β-cell function Insulin resistance Percentage Hermans MP. Diabetes Vasc Dis Res 2007;4(suppl 2):S7-S11.

  5. Normal Insulin Secretion 50 40 30 20 10 0 Lunch Breakfast Dinner Serum insulin (mU/L) 0 2 4 6 8 10 12 14 16 18 20 22 24 Time (hours) Bergenstal R. EndocrPract 2000;6:93-7.

  6. Uses of Insulin • Basal • Long-acting insulin • Keeps blood glucose stable when patient doesn’t eat • Meal bolus • Rapid-acting insulin • Covers carbohydrates in meals • Correction scale • Brings glucose to target if high

  7. Basal Insulin Replacement Profiles NPH (12–20 hours) Detemir (16–20 hours) Glargine (20–24 hours) Plasma insulin levels (µU/mL) 0 24 16 20 4 10 Time (hours) Goldstein BJ, et al. Textbook of Type 2 Diabetes. London: Informa; 2003:131-54. Plank J, et al. Diabetes Care 2005;28:1107-12.

  8. Bolus Insulin Replacement Profiles Aspart, lispro, glulisine (4–6 hours) Regular (6–10 hours) Plasma insulin levels (µU/mL) 4 0 10 24 16 20 Time (hours) Goldstein BJ, et al. Textbook of Type 2 Diabetes. London: Informa; 2003:131-54. Plank J, et al. Diabetes Care 2005;28:1107-12.

  9. Basal/Bolus Treatment Regimen Lunch Dinner Breakfast Insulin action 4 8 12 16 20 24 28 32 Time (hours) Leahy J, et al. InsulinTherapy. New York, NY: Marcel Dekker; 2002:87-112. Nathan DM. N Engl J Med 2002;347:1342-9.

  10. Basal/Bolus Treatment Regimen Lunch Dinner Breakfast Insulin action Glargine or detemir 4 8 12 16 20 24 28 32 Time (hours) Leahy J, et al. InsulinTherapy. New York, NY: Marcel Dekker; 2002:87-112. Nathan DM. N Engl J Med 2002;347:1342-9.

  11. Basal/Bolus Treatment Regimen Lunch Dinner Breakfast Insulin action Aspart, lispro, or glulisine Glargine or detemir 4 8 12 16 20 24 28 32 Time (hours) Leahy J, et al. InsulinTherapy. New York, NY: Marcel Dekker; 2002:87-112. Nathan DM. N Engl J Med 2002;347:1342-9.

  12. Recommended Blood Glucose Goals* • A1C: <7% • Preprandial: 70 mg/dL-130 mg/dL • 2-hour postprandial: <140 mg/dL-180 mg/dL • Bedtime: Individualized to patient *No predisposition for hypoglycemia. American Diabetes Association. Checking your blood glucose. Available at: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/checking-your-blood-glucose.html. Accessed January 6, 2011.

  13. Case 1: Profile • 45-year-old woman with 15-year history of T2DM • Also has HTN and hyperlipidemia • BMI: 39 • Current regimen • Metformin: 1,000 mg bid • Repaglinide: 4 mg per meal • Sitagliptin: 100 mg qd • Glargine: 48 U at night • Concerned because of high A1C (8.5%) over past 6 months despite compliance with therapy

  14. Polling Question Results (N=100)

  15. Polling Question Results (N=100)

  16. Case 1: BG Log BS Value (mg/dL) AC = before.

  17. Initiating Insulin: Rules of Thumb • Weight-based calculation: 0.4 U/kg • Titrate slowly; most patients will need 0.7 U/kg-1.0 U/kg • Split dose: 50% basal, 50% bolus • Bolus dosing options • Dose divided by 3; take meal size into consideration • If patient is resistant to multiple injections, one shot with largest meal may be an option

  18. Case 1: New Regimen • New regimen • Continue metformin, 1,000 mg bid • Discontinue sitagliptin and repaglinide • Decrease glargine to 21 U q 24 hours • Add aspart, 7 U before meals • Patient to keep blood glucose log, testing before each meal and at bedtime, and return in 2 weeks

  19. Case 1: Follow-up Visits

  20. Visit 2: BG Log Regimen Metformin: 1,000 mg bid Glargine: 21 U q 24 hours Aspart: 7 U AC meals AC = before.

  21. Change in Regimen • New regimen: • Metformin: 1,000 mg bid • Glargine: 21 U q 24 hours • Aspart: • 9 U before breakfast • 7 U before lunch • 7 U before dinner

  22. Visit 3: BG on Bolus/Basal Regimen Regimen Metformin: 1,000 mg bid Glargine: 21 U at bedtime Aspart: 9 U AC breakfast, 7 U AC lunch, 7 U AC dinner AC = before.

  23. Change in Regimen • Metformin: 1,000 mg bid • Glargine: 18 U q 24 hours • Aspart: • 9 U before breakfast • 7 U before lunch • 9 U before dinner

  24. Visit 4: BG on Bolus/Basal Regimen Regimen Metformin: 1,000 mg bid Glargine: 18 U at bedtime Aspart: 9 U AC breakfast, 7 U AC lunch, 9 U AC dinner AC = before.

  25. Change in Regimen • Metformin: 1,000 mg bid • Glargine: 18 U q 24 hours • Aspart: • 9 U before breakfast • 5 U before lunch • 9 U before dinner

  26. Module 1: Summary Points • Due to progressive decline in beta cell function, most patients with type 2 diabetes will require basal/bolus insulin to maintain optimal glucose control. • A blood glucose log is an important tool and can help guide adjustments in treatment. • Frequent follow-up is necessary when initiating bolus insulin to fine-tune the regimen.

  27. Self-Monitoring of Blood Glucose (SMBG) Recommendation #1: SMBG should be carried out three or more times daily for patients using multiple insulin injections or insulin pump therapy. (A) To achieve postprandial glucose targets, postprandial SMBG may be appropriate. (E) When prescribing SMBG, ensure that patients receive initial instruction in, and routine follow-up evaluation of, SMBG technique and using data to adjust therapy. (E) Evidence-based Recommendation ADA. Standards of Medical Care in Diabetes—2010. Diabetes Care 2010;33(Suppl 1):S11-S61.

  28. Glycemic Goal Recommendation #2: Lowering A1C to below or around 7% has been shown to reduce microvascular and neuropathic complications of type 1 and type 2 diabetes. Therefore, for microvascular disease prevention, the A1C goal for nonpregnant adults in general is 7%. (A) Less-stringent A1C goals than the general goal of <7% may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, and extensive comorbid conditions, and those with longstanding diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents, including insulin. (C) Evidence-based Recommendation ADA. Standards of Medical Care in Diabetes—2010. Diabetes Care 2010;33(Suppl 1):S11-S61.

  29. Module 2 Initiating Premeal Insulin: Video Vignette

  30. Sample Meal and Correction Scale

  31. Insulin Pumps Ping OmniPod Paradigm Revel

  32. Module 2: Summary Points • It’s essential that patients receive instruction on how to administer mealtime insulin when they start a basal/bolus regimen. Also need to address treatment of hypoglycemia. • It’s also a good time to review need for consistency in timing and content of meals, and the importance of SMBG.

  33. Module 2: Summary Points (cont) • Education can help address patient concerns and barriers to compliance. • Future visits can be geared toward more advanced topics such as carb counting, glycemic index, exercise and insulin pumps.

  34. Diabetes Self-Management Education Recommendation #3: People with diabetes should receive diabetes self-management education according to national standards when their diabetes is diagnosed, and as needed thereafter. (B) Evidence-based Recommendation ADA. Standards of Medical Care in Diabetes—2010. Diabetes Care 2010;33(Suppl 1):S11-S61.

  35. Medical Nutrition Therapy Recommendation #4: Individuals with diabetes should receive individualized medical nutrition therapy (MNT) as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with components of diabetes MNT. (A) Evidence-based Recommendation ADA. Standards of Medical Care in Diabetes—2010. Diabetes Care 2010;33(Suppl 1):S11-S61.

  36. Hypoglycemia Recommendation #5: Glucose (15 g-20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. If, after 15 minutes, SMBG shows continued hypoglycemia, treatment should be repeated. (E) Evidence-based Recommendation ADA. Standards of Medical Care in Diabetes—2010. Diabetes Care 2010;33(Suppl 1):S11-S61.

  37. Module 3 Troubleshooting Common Challenges With Basal/Bolus Regimens

  38. Case 2: High A1C on Fixed-Dose Insulin

  39. Case 2: Profile 62-year-old man with 25-year history of T2DM Complicated by nephropathy, neuropathy, HTN and hyperlipidemia On insulin for 10 years: 70/30 55 U in morning and 45 U in evening Previous physician told him this regimen would allow him to avoid insulin injections at work

  40. Case 2: Profile (cont) • On further questioning, patient reports: • Erratic work schedule; often misses lunch break • Several hypoglycemic episodes in early afternoon, so frequently omits dose with breakfast • Eats dinner at variable times; thought he was supposed to take 70/30 at bedtime, not dinner • Last A1C was 9.4%

  41. BID “Split-Mix” Premixed Insulin Lunch Breakfast Dinner Bedtime Regular Regular Insulineffect NPH NPH Afternoon Morning Evening Night

  42. Pitfalls of Premixed Insulin • Does not mimic normal physiology • Risk of inadequate insulin titration • Requires consistency in meals and snacks • Higher risk of hypoglycemia

  43. Basal/BolusPrescription • Patient receiving total of 100 U • 80% of 100 U is 80 U • 80 U divided in half is 40 U • 40 U divided for three meals, largest dose at dinner: • 12 U before breakfast • 12 U before lunch • 16 U before dinner

  44. Case 3: Use of Correction Scale

  45. Case 3: Profile • 68-year-old man with 20-year history of T2DM • Complicated by CAD (CABG), HTN and hyperlipidemia • Reports starting detemir 6 months ago due to rising A1C • Dose titrated to 30 U qhs • Recently started lispro correction scale: • 1 U/50 mg/dL above 150 mg/dL at meals and bedtime • Takes no insulin if BG <150 mg/dL • BG readings now 200-300 during the day

  46. Case 3: BG Log AC = before.

  47. Review: Uses of Insulin

  48. Approaches to Initiate Correction Scale • 1 U-2 U per 50 mg/dL above 150 mg/dL OR • “1500 rule” • Correction factor: 1500 / total daily insulin dose • 1 U of insulin will lower glucose by correction factor • Similar to “1800 rule” for T1DM

  49. Case 3: Change in Regimen • Detemir: 24 U qhs • Lispro: 8 U before each meal • Correction scale 1 U/ 30 mg/dL above 140 mg/dL

  50. SampleCorrection Scale

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