Insulin Conundrums Veronica Green
Risk reduction Risk reduction for each 1% reduction in HbA1c in type 2 diabetes Amputation or death due to peripheral vascular disease Any diabetes- related endpoint Microvascular complications Myocardial infarction Cataract extraction Heart failure 0 21% 37% 14% 19% 16% 43% -10 * ** Risk reduction (%) associated with a 1% lower HbA1c -20 * * *p < 0.0001 **p = 0.021 -30 * -40 * Epidemiological extrapolation showing benefit of a 1% reduction in mean HbA1c with a mean duration of diabetes of 10 years • Stratton IM et al. BMJ 2000; 321: 405–412.
Standard approach to the management of Type 2 diabetes LifestyleChanges Oral Combination+glipins + Oral Monotherapy Treatment intensification Insulin Oral + exenatide / + Diet and Exercise V Green Byetta workshop 2
NICE • Hba1c >7.5% • Use NPH od/bd • Or long acting analogue if • Hypoglycaemia • Can’t do it themselves • Otherwise would need BD basal+orals • Hba1c >9% • Use BD biphasic • Use analogue mix if • Marked post prandial raise • Need to inject immediately pre-meals • hypos NICE 2009
Or Not • NPH ½ price of analogue long acting insulin but • 20% variability in absorption with each injection • iFriedburg SJ, Lam YWF, Blum JJ, Gregerman RI. 2006. Insulin absorption: a major factor in apparent insulin resistance and the control of type 2 diabetes. Metabolism. 55(5) 614-619
Doctor’s Fears Will I do my patient any good? Will their complications worsen? Will it make a difference to the blood glucose levels? Will they put on more weight?
Nurse’s Fears Can this person learn to inject? Is it going to make a difference? What insulin to use? Am I able and competent to do this? What if something goes wrong?
Patient’s Fears Will this make me a drug addict? What about my lifestyle? Fear of hypos My diabetes mild, I don’t need insulin Needle phobia
Effect on Lifestyle • Find out about work, social life BEFORE deciding on a regime • Adapt the regime about the life not the other way round.
Rapid Acting Analogues • Work almost straight away • Last 3-5 hours • Used pre/post prandially • NovoRapid , Humalog, Apidra
Short Acting Insulins • Act 30 minutes post injection • Last 6-8 hours • Given pre prandially • Actrapid or Humulin S
Intermediate Acting Insulins • Act after 1-2 hours • Last 12-14 hours • Given morning/evening or bedtime • Insulatard or Humulin I
Pre Mixed Insulins • Act after 30 minutes, last 12-14 hours • Given morning and evening pre meal • Mixtard, Humulin M • Mixed analogues – NovoMix 30, Humalog Mix 25, 50
Long Acting Analogues • Act immediately • Last 18-24 hours • Given am or pm • Lantus or Levemir
Classification • Mild – can be treated by the person themselves without help • Moderate – Need help in treating, but are conscious • Severe – Pt unable to help themselves, need of hospital care
Neuro-glycopenic Confusion Drowsiness Speech difficulty Poor coordination Atypical behaviour Diplopia Autonomic Sweating / pale Palpitations Shaking (tremor) Hunger Symptoms
Other signs • Malaise • Headache • Hemiplegia (particularly in the elderly) • Person may have individual signs e.g. numb lips
Nocturnal hypoglycaemia 1 • Effects 30-40% of all diabetics • Can be slept through • The person may only be aware the next morning that they have had a hypo
Nocturnal hypos 2 • Nightmares / vivid dreams • Waking up unrested • Waking up with a headache • High fasting sugar (often alternating with OK ones)
Hypo Unawareness • Loss of bodily warning signs • Can cause severe hypos • Caused by • Running very tightly • Frequent hypos • Duration of diabetes
Physiology BG<3 Neuroglycopenic symptoms Autonomic symptoms Treat with glucose Release of glucagon, + stress hormones Glucogenolysis, gluconeogenesis (liver/kidney) Raise in BG
Treatment • 20g glucose • Back up long acting carbohydrate • Find the cause • Adjust medication if required
Causes • Too much insulin / OHA • Too little food • Timing of injection in relation to food • Alcohol • Exercise • Injection site problems • Hot weather