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Insulin Dose Adjustment : What’s new for 2015 and Patient Self-Adjustment of Insulin Survey Findings
Carrie Haggett RN, BScN, CDE DCPNS Diabetes Consultant
Conflict of Interest
• In the past 12 months, I have received speaker honoraria from – BD Medical
• I am an employee of the NS Health Authority, Central Zone and the DCPNS
Presentation Overview
• Discuss the need for the revision of the Insulin Dose Adjustment Policies and Guidelines Manual, 2012. Section 4-NEW
• Discuss the findings from the Patient Self- Adjustment of Insulin survey (Sept 2014).
• Discuss how the findings impact the need for change. • Formation of a working group.
Revision 2012 DCPNS Insulin Dose Adjustment Polices and Guidelines Manual • Formal agreements in place with PEI and NB, with
agreements in the works for NL—Eastern and Western Regions (use our guidelines, processes, and exams)
• CDA guidelines released 2013 • Growing list of new and emerging therapies. • Potential formulary differences across Atlantic Provinces
Revision Process
• Engage specialist physicians for review of sections. • Invite review from partnering provinces. • Develop a new section on insulin and non insulin therapies.
New Section includes use with pregnancy and paediatrics. • Aiming to have revisions completed by the end of April
2015. (March 31,2015)
Dates Carrie’s Timeline Reality
Jan 19,2015 Meet with sec3on authors Mee3ngs went well. All on board.
Feb 2,2015 Return first dra@s to Barb. First dra@s in to Barb.
Feb 17,2015 Out to Atlan3c Provinces Third dra@s in…Barb can be bribed with Tootsie pops!
March 2,2015 Out to Medical Advisors Fi@h dra@s in …Need more Tootsie pops for Barb.
March 17,2015 All sec3ons returned. To be reviewed by educator reviewers.
No Luck of the Irish here. Sec3ons are s3ll in dra@ mode. Start physician Engagement for completed sec3ons.
March 30,2015 Send to print. Feels like the 50th dra@. Tootsie rolls are not effec3ve.
April 2,2015 Comple3on May ,2015 S3ll in dra@ mode…..
Section work Insulin Dose Adjustment
Policies and Guidelines Manual Sec<ons
Sec<on Authors Physician Reviewers From the Atlan<c Provinces
Sec3on 1 and 2-‐ Travel and Shi@ Work
Carrie HaggeY RN BScN CDE ✔
Sec3on 2 –Illness & Physical Ac3vity/Exercise
Catherine Splane RN BComm CDE ✔
Sec3on 3 -‐Pregnancy Lois Ferguson RN CDE ✔
Sec3on 3 –Children/ Adolescents
Sheilagh Crowley RN BN CDE ✔
Sec3on 3-‐ Pump Therapy Shawna Boudreau BScN RN CDE ✔ Sec3on 4 – Formulary Coverage of Insulin therapy(1A), non-‐insulin therapy (1B) and considera3ons for use (2A).
Kim Kelly BSc.Pharm (Drug Evalua3on Unit of Nova Sco3a) Peggy Dunbar MEd PDt CDE Carrie HaggeY RN BScN CDE
✔
Sec3on Overviewers Bev Harris PDt CDE Peggy Dunbar MEd PDt CDE Carrie HaggeY RN BScN CDE
✔
Draft DCPNS April 2, 2015
DRAFT Table 1B: Formulary Coverage of Non-Insulin Therapies (oral and injectable) and Indications for Use in Various Populations Formulary Coverage Indication for use with:
Other Therapeutic Considerations
NON-INSULIN THERAPIES
NS
NB
NL
PE
ADULTS×
PEDIATRICS×
PREGNANCY
LACTATION€
ORAL ANTIHYPERGLYCEMIC AGENTS
Alpha-glucosidase inhibitor Safety not established. ¥
No data, probably compatible
• Acarbose (Glucobay®)
! ! "1 ! Type 2 Not for use < 18
Insulin Secretagogues Glyburide may be considered through the first trimester (under care of a specialist) until insulin is initiated - Diabetes Care Program Nova Scotia (DCPNS)
Sulfonylureas: • Gliclazide (Diamicron®, Diamicron® MR) ! ! ! ! Safety not established. § No data
• Glimepiride (Amaryl®) # ! ! ! Type 2 Not for use <18 Safety not established. ¥ No data, probably hazardous
• Glyburide (Diabeta®, Euglucon®) ! ! ! ! Human data suggest low risk¥
No data, probably compatible
• Chlorpropamide # ! ! ! Type 2 Safety, efficacy not
established Human data suggest risk in 3rd trimester. ¥
No data, probably compatible
• Tolbutamide ! ! ! ! Type 2 Safety, efficacy not established
Human data suggest risk in 3rd trimester. ¥
Limited data, probably compatible
Meglitinides: • Nateglinide (Starlix®) # # # # Type 2
Not for use <18 Safety not established¥ No data, probably
compatible • Repaglinide (Gluconorm®)
# "2 "3 # Type 2 Not for use <18 Safety not established¥ No data, probably
hazardous
Biguanides Use in Polycystic Ovarian Syndrome (PCOS). Use in the first trimester until insulin initiated. Increasing use in GDM and type 2 DM in pregnancy.
• Metformin (generics Glucophage®, Glumetza® once-daily formulation)
! ! ! ! Type 2 Safety & efficacy not established
Human data suggest low risk¥
Limited data, compatible
DPP-4 Inhibitor • Sitagliptin (Januvia®) "4 "5 "6 # Safety not established ¥ No data, probably
compatible • Saxagliptin (Onglyza®) # # # # Type 2 Not for use <18 Safety not established ¥ No data
• Linagliptin (Trajenta®) "6 "6 "6 # Safety not established ¥ No data, probably compatible
• Alogliptin (Nesina®)
# # # # Safety not established ¥ No data
Patient Self- Adjustment of Insulin. Is it actually happening?
What the DCPNS Registry tells us?
• Using data from calendar year 2013, the DCPNS Registry shows us: – 12% of follow-up patients (not newly diagnosed) have A1C values
≥ 9% with another 6% between 8.5% and 8.99%. Total of 18% with A1Cs ≥ 8.5%
– Of those using insulin therapy (alone or in combination), 34% have A1Cs ≥ 8.5% (24% ≥ 9%)
– For those age 19-39 years, 35% have values ≥ 8.5% (27% ≥ 9%)
• The DHW Target Setting Initiative (2011-2013) selected A1C ≥ 9% as a key indicator. A specific target was set to reduce the proportion, for those ages 19-39 yrs., from 29.5% to 20 % by 2020. …We are moving in the right direction, but there is more to do…
Nova Scotia 2013 A1C by Treatment Type
0%
20%
40%
60%
80%
100% Li
fest
yle
Onl
y
Insu
lin
OA
A
In/O
AA
Tota
l
≥ 9% 8.5- 8.99% 7-8.49% < 7%
Source: DCPNS Registry. Follow-up Indicator Report. October 2014
Nova Scotia 2013 A1C by Age Group (N = 10,432)
0%
20%
40%
60%
80%
100% 19
-39
40-4
9
50-5
9
60-6
9
70-7
9
≥ 80
Tota
l
≥ 9% 8.5- 8.99% 7-8.49% < 7%
Source: DCPNS Registry. Follow-up Indicator Report. October 2014
Why This Work?
• With these numbers in hand, we needed to find out if
patients are being taught how to self-adjust insulin on their own.
• We know people are being started on insulin in Diabetes Centers, Pharmacies and Doctor’s offices.
• We started with a survey of Diabetes Educators …with the intent of working with other groups FPNs, Pharmacists as we move forward.
Patient Self-Adjustment of Insulin Survey Overall Survey Results from:
Registered Nurses Registered Dietitians
22 15
We reached out to educators across the province with varying degrees of experience
SSH=4 SWH=2 AVH=6 CEDHA=1 CHA=2
PCHA=2 GASHA=4 CBDHA=3 CDHA=8 IWK=5
<2 years 2-‐4.9 5-‐9.9 10-‐14.9 15 or more
1 6 7 5 18
Sample of Survey Questions Yes No
1. Do you currently adjust insulin for your patients (by phone and/or in person)?
30 = 86% 5 = 14%
2. Do you teach your patients how to self-adjust their insulin doses?
30 = 86% 5 = 14%
3. Do your patients self-adjust their insulin dose? 10 = 26% Some 28 = 74%
6. Do you currently use tools or instruments that you have adapted for patient self-adjustment of insulin?
14 = 42% 19 = 58%
8. Within your practice do you have a defined approach to teaching patient self-adjustment of insulin?
17 = 46% 20 = 54%
9. Do you offer a patient education groups for insulin dose adjustment?
14 = 39% 22 = 61%
14. Would it be beneficial to have a standardized approach?
29 = 85% 5 = 15%
15. Would you be interested in working on a provincial approach to patient self-adjustment of insulin and/or the development of the supporting tools?
18 = 53% 16 = 47%
Survey Findings
Patient Self-Adjustment of Insulin Traits that……Hinder… • Poor cognition (10) • Lack confidence ,
motivation or unwilling (10) • Fear of hypoglycemia(6) “Lack of good easy to understand tools. Low literacy levels. Fear.”
…Allow… • Motivated , willing (5) • Basic knowledge (6) • Confidence (4)
“Acceptance of uncontrolled diabetes, readiness for change”
What tools are currently being used to teach self-adjustment of insulin? • CDA education tools (11) • DCPNS Insulin Dose Adjustment Policies and Guideline
manual(15) -checklist and insulin dose adjustment guidelines
• Other (11)- insulin company tools, homemade tools. “Writing instructions in logbooks”
Would it be beneficial to have a standardized approach to patient self-adjustment of insulin?
Yes No No Response
28 5 4
“Yes. So all educators are comfortable with following the same protocol.” “Yes. It would be great to have standard tools which have been tested with patients.” “No. Important to be flexible in approaches to meet the needs.”
Plan 1. Form a working group and approach review group. 2. Find a tool that could be used to assess the patients
cognitive level prior to starting them on insulin.* 3. Consider tools to address fear of hypoglycemia. 4. Tools to address confidence. 5. Consider other HCPs who could benefit from use of this
standardized tool. *Dr.L.Mallery, Dr.P.Moorehouse, Heather Moffatt BSc BA
Approach • The approach will take into consideration the patients level
of cognition. • Develop a standardized approach that can be used to
assist with insulin adjustment. • Offer this approach to other HCP who start patients on
insulin. • Create a self-adjustment insulin tool for patients that also
takes into consideration- cognition, readiness to change and fear of hypoglycaemia.
Thank You
Questions?