Helping people with type 2 diabetes to continue insulin therapy; Case studies

1. Helping people with type 2 diabetes to continue insulin therapy; Case studies 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 change in insulin will require careful consideration, particularly when changing from a human to an analogue insulin due to the different time action profiles. 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. Supporting patients during the early stages of insulin therapy I’m struggling with injecting. What should I do?

3. Case Study 1 for Injection Problems • Mrs Brown is 76 yrs of age and has had Type 2 DM for 12 yrs, treated with Metformin® 500 mg tds and Insulatard® 22 units od, given with a syringe and vial. She has always injected into her legs. • She lives alone but is fiercely independent, even though she now has failing eyesight and limited mobility because of arthritis. • Although not tightly controlled, her HbA1c has always been around 64 mmol/mol (8%) but has gradually increased over the last year. • At her last clinic appointment she confessed that it was all getting too much for her. She often has nocturnal hypos and is scared to go to bed on a reading of less than 12mmols/l. Sometimes she misses her injections completely if her BGL is lower than this. She tests before breakfast and bed every day. • Her daughter has worried her even further by telling her that she should have a district nurse to give the insulin now, because she feels her mother is not able to manage it anymore. • What advice would you give?

4. Change insulin regimen – which one, ?dose Analogues less likely to cause hypos ?Using needle/syringe Visual/dexterity problems - ?pen device – reason for choice Check for lipodystrophy – 4% insulin users will develop lipos Pre-bed levels high – what should they be? ?Missing injections which leads to erratic profile Vary times of testing to assess BG profile HbA1c >8% - what levels to aim for? Fear of hypos is a problem – never underestimate this fear Independence should be encouraged Encourage bringing a family member to next appt for reassurance Other issues to consider Allergies to insulin/latex/lanolin on needle Some insulins can sting, especially if used straight from fridge Occasional capillary bleeding or bruising – check if on aspirin, warfarin etc Injecting in public can be in issue – could result in mistimed injection or possibly omitted altogether!! Is correct dose being given Re-assess injection technique Effect of insulin on BGL depends entirely on how its given – poor technique/timing/site can result on poor control Injections - Issues to Consider

5. Injection problems Case Study 2 • Ester is 82y female • Lives with husband in a bungalow • Fiercely independent, still do their own gardening • She had a minor CVA several weeks ago • She has weakness in right hand, bilateral cataracts • Metformin® 500mg TDS, NPH 24 units OD via syringe • Husband is able to inject her but also has mild visual trouble • They are refusing a carer • HbA1c 69 mmol/mol (8.5%), asymptomatic, no hypos • BMI 22

6. Injection problem Case Study 2 suggestions • Secondary prevention? Aspirin,statin, Bp • Refer for cataracts • Assess use with syringe, safety and ease • ? Use an Innolet® device • Assess impact of weakness on self care • Under weight. Refer to Dietitian. • Accept HbA1c around 8%? • Educate husband on injection technique • Check concordance • ? District nurse support

7. Supporting patients during the early stages of insulin therapy I’m suffering frequent episodes of hypoglycaemia. What should I do?

8. Case Study 1 for Hypoglycaemia • Mr Black is a 68 yr old, BMI 24 retired factory manager. • He has had Type 2 DM for 9 yrs and is currently on Humulin M3® , 32+32 units. Last HbA1c was 44 mmol/mol (6.2%) • Since his retirement, he and his wife have enjoyed several trips away in their touring caravan. • However, this has now stopped as he recently had a hypo whilst driving, resulting in a minor accident. • Although no-one was injured, both Mr and Mrs Black have now lost confidence in his driving ability. • Very worried about this situation, they have asked to see you for advice. • Mr Black admits that he often has hypos but has never, until now, taken them seriously. Hypo awareness has diminished. • What would you advise?

9. HbA1c too good – room to increase slightly HbA1c possibly not accurate – frequent hypos will skew results Loss of hypo awareness so must be having frequent hypos Why? Missing meals Dose too high ? recent weight loss ? More active now as retired Correct injection technique? Rotation of sites – lipodystrophy Timing of injections Correct re-suspension of insulin warm weather at the caravan site! Run BGL higher for a few weeks to regain some awareness Check knowledge of appropriate hypo management Advise carrying glucose at all times Could lose driving licence! Make sure he is aware of DVLA notification Test more frequently, certainly before driving and every 2 hours Hypos should not be accepted as inevitable consequence of insulin therapy or diabetes Consider other causes of hypos warm bath / showers Other diseases eg thyroid problem, and infections which can impact on BGL Interaction of other medication with insulin metabolism Hypos - Issues to Consider

10. Hypo case study 2 • Type 2 diabetes or 10 years (now 55yrs) • Currently using Humulin S ® (with meals) and Humulin I ® at bedtime. • Erratic blood glucose results • Monitoring 4 times a day pre meal due to hypos • Very active. Stressful job. • Lipohypertrophy to abdomen. • Very frustrated with diabetes control. • HbA1c 73 mmol/mol (8.8%)

11. Hypo case study 2. Suggestions • Update education and patient knowledge • ?CHO counting course or dietetic advice. ?alcohol intake • Stress management • ?review insulin and explore using newer insulins as a possibility, ?devices. • Explore aim of treatment regimen, current insulin action and limitations • May have hypo unawareness • Over treating hypos? • May need review of meter, update • Review of blood glucose results and timing of testing • Moving of injection sites, discuss and explore other sites • Needle size appropriate and needle use? • If moving injection site, may need initial reduction of dose for safety • Explore frustrations and develop plan. Goal setting

12. Hypo Case Study 3 • Stan is 66y male • Retired, dances x 2/week • Frequent attendee at local pub where he smokes cigars & drinks beer while playing darts • Metformin ® 500mg OD, NovoMix 30 ® BD (60 units + 60 units) • He does not dose adjust • Problematic hypos, often nocturnal, regularly in the evenings • BMI 32, waist 42cm • HbA1c 57 mmol/mol (7.4%), other bloods normal • FBG 3-5 mmol/l • Does not often check blood sugars

13. Hypo Case Study 3 suggestions • Blood glucose profile • Advise on dose adjustment, seeking help • Hypos after dancing? Need to reduce insulin dose on these evenings? • ? Can tolerate more metformin, if not Glucophage SR® . Will need insulin dose reducing • Alcohol intake? • Smoking cessation • Lifestyle advice, recover • Cardiovascular risk

14. Hypo case study 4 • Type 2 lady. 60 years old. • Cleaner. • HbA1c 97 mmol/mol (11%) • Severe hypos on previous insulin regimen, but still runs higher blood glucose to avoid hypos. • Concerned that improved control will caused weight gain and return of hypos • Using Novorapid® and Lantus® • 12 mm needles

15. Hypo case study 4. Suggestions • ?how long has she had diabetes • Education update • ?Hypo unawareness, explore hypo history- treatment, symptoms, experiences • Poor control. Giving all doses? Reducing doses? Chasing results? • Look at current regimen and any limitations. Happy on basal bolus? • Explore treatment regimen and possibilities • Pen devices review • Dietitian review and update. ? needs CHO counting advice. • Review injection sites, needle size and use. • Hypos can cause weight gain

16. Supporting patients during the early stages of insulin therapy I’m gaining weight. What can I do?

17. Case Study 1 for Weight Gain • Mrs Pink is a 57yr old lady who has arthritis of the hips and is awaiting a total hip replacement. • She used to have a very active lifestyle but now finds it very painful to mobilise and walks with the aid of sticks. She has had to give up her employment. • Because of this she tends to stay at home most of the time, usually sat in her armchair. She appears quite depressed. • She admits that she takes consolation in food and that her diet is not as good as it should be. • She has gained 5kg to 90kg BMI 40; BP 175/80; HbA1c 85 mmol/mol(9.9%) • She has had Type 2 DM for 4 yrs and is using Lantus ® 74units od plus maximum doses of Gliclazide ® and Metformin ®. • She hopes to have her operation soon but you are aware that she will need to improve her clinical status in order to have a successful outcome from this. • What would you advise?

18. Encourage healthy diet and exercise Encourage increasing activity May need change of insulin regimen Consider what change and dose Some analogue insulins are weight neutral On maximum doses of OHA – would you keep these or remove on changing regimen BP needs reduction – weight loss will help May not be able to have hip op if weight and BP too high ?Treat for depression. May be generally depressed as weight gain in image conscious society can be seen as cosmetically unappealing and can, in itself, lead to depression Treat any pain which may be preventing full mobility Natural insulin enhances lipogenesis and is anabolic, therefore encourages laying down fat and muscle mass Some people will gain weight through fear of hypos (snacking) Weight gain increases risk of long term complications and will increase insulin resistance Blaming weight gain on insulin will sometimes cause people to omit insulin doses this resulting in erratic BGL Weight Gain – Issues to Consider

19. Weight gain case study 2 • Walter has type 2 diabetes and has been on insulin for 1 year. He started on a once daily regimen of Glargine® 20 units. • He is now taking 80 units at night and 20 units tds of Apidra. • He states that he feels constantly bloated and has put a stone on in weight. His control remains poor even since starting insulin. • He does not like giving 4 injections of insulin daily. • He has a sedentary lifestyle and gives all his insulin doses at the same time everyday. • He is too scared to make changes to his insulin dose as he is not sure what to do. • He does not want to check his blood glucose levels as it hurts too much.

20. Weight gain case study 2 suggestions • Lifestyle advice. • Referral to Dietitian • Metformin ® introduction? • Review insulin doses, technique, needle use • ?Change regimen- ?BD or TDS? • Has a more predictable lifestyle • Meter review and BG monitoring. Alternative site testing • Cardiovascular risk • Support and re-education

21. Supporting patients during the early stages of insulin therapy I want to start a new exercise. Is it OK for me to do so?

22. Case Study for Exercise • Mr White is a 57 yr old gentleman BMI 35 who has recently had an inferior MI. • He has had Type 2 DM for 8 yrs which was poorly controlled Hba1c 86 mmol/mol (10%) and treated with Mixtard 30® 70 units bd and Metformin ®. • During his hospital admission following the MI, he has had his regimen changed to a basal bolus of Lantus® and Novorapid® . Metformin ® has been discontinued. • He is now keen to improve his health by making changes to his previously sedentary lifestyle, and plans to start swimming sessions on Saturday morning and Wednesday evening each week. • The hospital cardiac rehabilitation nurse has advised him to seek advice from you as to how this will affect his insulin management. • What advice would you give him?

23. Needs to lose weight – beneficial for cardiovascular status and diabetes control Swimming good for exercise and should be encouraged Metformin® can be re-instated as soon as out of heart failure Discuss when Metformin can and cannot be used (Renal failure or renal dysfunction (creatinine clearance < 60 mL/min) heart failure, stop 48 hrs before Xray / procedure requiring IV contrast dye) Note different total amount of insulin required per 24 hrs since hospital admission – why could that be? Different exercise regimens will affect metabolism to different extents. Vigorous exercise will require substantial alterations to dose and food intake Would advise this man to reduce his insulin doses before swimming. Which dose and by how much? May also need to have extra carbohydrate before sessions if they become lengthy and very energetic N.B. Extra carbs may cause weight gain! Should always test BGL before and after exercise. What should BGL be before exercise? Remember that BGL can be affected several hours following exercise May need to reduce daily insulin if he loses weight Starting Exercise – Issues to Consider

24. Supporting patients during the early stages of insulin therapy I’m going on holiday. What precautions do I need to take?

25. Case Study for Travelling • Mr Green is 65 yrs old, BMI 27 and has had Type 2 DM for 11 yrs. • He is about to retire later this year and he and his wife are planning a holiday in Australiato celebrate. • His diabetes is reasonably well controlled with Humalog Mix 25® bd plus Metformin ®. (Last HbA1c was 57 mmol/mol (7.4%)). He is in good general health. • He comes to you for advice about his insulin requirements whilst on this holiday. • What advice would you give him?

26. Adjust insulin dose going out and coming back If gaining hours and therefore eating an extra meal during flight, give small amount of extra insulin. If losing time, give less insulin with each meal on journey May help to keep watch on UK time Different food and routines may require more frequent testing. May be more active – may be less so Take extra supplies Take CHO foods in case of delays etc with flight Keep supplies in hand luggage – insulin will be denatured if frozen in aircraft hold Be aware of hot weather and affect on BGL Keep insulin in cool place if in hot weather. Keep next to body if in cold weather Do not dehydrate. N.B. Alcohol intake and it’s effect on BGL Carry ID ? Learn to say “I have diabetes” in other languages Have a great time! Finally, this gent is soon to retire, so different lifestyle and routines may change insulin requirements. Would advise he comes back to see you after his holiday! Will need a letter from GP Take a cool bag if going to a hot country Travel – Issues to Consider

27. Case study references • Carver C. Insulin treatment and the problem of weight gain in type 2 diabetes. Diabetes Educ 2006;32:910–7. • Chowdhury TA, Escudier V. Poor glycaemic control caused by insulin induced lipohypertrophy. BMJ 2003;327:383–4. • Diabetes UK. Alcohol and diabetes. http://www.diabetes.org.uk/Guide-to-diabetes/Food_and_recipes/Alcohol_and_diabetes/ (accessed 2009). • Diabetes UK. Driving and diabetes. http://www.diabetes.org.uk/Documents/Guide%20to%20diabetes/Driving_diabetes0505.pdf (accessed 2009). • Diabetes UK. Keeping active. http://www.diabetes.org.uk/Guide-to-diabetes/Treatment__your_health/Keeping_active/ (accessed 2009). • Diabetes UK. Travelling with diabetes. http://www.diabetes.org.uk/Guide-to-diabetes/Living_with_diabetes/Everyday_life/Travelling_with_diabetes/Things_to_check_out_before_you_go/ (accessed 2009). • DVLA. For medical practitioners. At a glance guide to the current medical standards of fitness to drive. http://www.dvla.gov.uk/media/pdf/medical/aagv1.pdf (accessed 2009). • Heller SR, Colagiuri S, Vaaler S, Wolffenbuttel BHR, Kolendorf K, Friberg HH, Windfeld K, Lindholm A. Hypoglycemia with insulin aspart: a double-blind, randomised, crossover trial in subjects with type 1 diabetes. Diabet Med 2004;21:769–75

28. Case study references • Makimattila S, Nikkila K, Yki-Jarvinen H. Causes of weight gain during insulin therapy with and without metformin in patients with type II diabetes mellitus. Diabetologia 1999;42:406–12. • Nutrition Subcommittee of the Diabetes Care Advisory Committee of Diabetes UK. The implementation of nutritional advice for people with diabetes. Diabet Med 2003;20:786–807. • Peirce NS. Diabetes and exercise. Br J Sports Med 1999;33:161–72. • Polonsky WH, Fisher L, Guzman S, Villa-Caballero L, Edelman SV. Psychological insulin resistance in patients with type 2 diabetes: the scope of the problem. Diabetes Care 2005;28:2543–5. • 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). • For full range of insulins and devices please refer to Diabetes Update – Insulin Pens Wall Chart or Transition Aid (UK/DB/0410/0065)