Kiss

KISS :KEEP INSULIN SAFE AND KISS :KEEP INSULIN SAFE AND SIMPLESIMPLE

Dr. RISHIKESAN K.V, Dr. RISHIKESAN K.V,

VENNIYIL MED.CENTRE, SHARJAHVENNIYIL MED.CENTRE, SHARJAH

Adapted from White, N et al, J Pediatr. 2001 Dec; 139(6): 804-12.

““ Less than optimal glycemic control Less than optimal glycemic control during the early years of diabetes has during the early years of diabetes has a lasting detrimental effect on the a lasting detrimental effect on the development and progression of development and progression of complications, even after better complications, even after better glycemic control is established later glycemic control is established later in the course of the disease.”in the course of the disease.”

DCCT/EDICDCCT/EDIC

METABOLIC MEMORYMETABOLIC MEMORY THE GOOD CONTROL THAT YOU HAVE THE GOOD CONTROL THAT YOU HAVE

FIVE OR SIX YEARS CREATES A FIVE OR SIX YEARS CREATES A METABOLIC MEMORY IN OUR PATIENTS , METABOLIC MEMORY IN OUR PATIENTS , AND THEY TEND TO HAVE LESS AND THEY TEND TO HAVE LESS MACROVASCULAR COMPLICTIONS MACROVASCULAR COMPLICTIONS LATER ON.LATER ON.

First commercial insulinFirst commercial insulin

BANTING-1891-1941 & BEST-1899-1978BANTING-1891-1941 & BEST-1899-1978

Orthopod who became a physiologist and died in air crash in Newfoundland while on wartime mission

Together they isolated insulin and Banting won the Nobel Prize in 1923 knighted in 1934

Initiating insulin in T2DMInitiating insulin in T2DM

Life style change and OAD ,will be initially Life style change and OAD ,will be initially effective.effective.

About 50% will require insulin within 6 yrs.of About 50% will require insulin within 6 yrs.of Dsis.Dsis.

Starting insulin is not hard,not risky, and does Starting insulin is not hard,not risky, and does work.work.

A simple six- step guide to initiate insulin A simple six- step guide to initiate insulin therapy.therapy.

STEP 1STEP 1

Is the pts.A1C on target?Is the pts.A1C on target? Higher the A1C, greater the microvascular riskHigher the A1C, greater the microvascular risk

[UKPDS].[UKPDS].

A1C above 7% and certainly above 8% should A1C above 7% and certainly above 8% should prompt consideration of insulin Therapy.prompt consideration of insulin Therapy.

A1C value reflects the overall avg.BGL(24H/dA1C value reflects the overall avg.BGL(24H/d

over several wks.)over several wks.)

A1C A1C

BGL( mmol/L) = 2A1C – 6 BGL( mmol/L) = 2A1C – 6 OR OR

BGL (mg% ) = (A1C X BGL (mg% ) = (A1C X 35.6 ) – 77.3.35.6 ) – 77.3.

Following this formula A1C Following this formula A1C 8% = BGL 10mmol/L.8% = BGL 10mmol/L.

Ideal/Target A1C < 6.5%.Ideal/Target A1C < 6.5%.

A1C = FBS+ PPBS.A1C = FBS+ PPBS.

Lower A1C level Reduces the Lower A1C level Reduces the Risk of ComplicationsRisk of Complications

DCCT * KUMAMOTO * UKPDSDCCT * KUMAMOTO * UKPDS

Each 1% fall in A1C results in 20-Each 1% fall in A1C results in 20-30% RRR in microvascular compln30% RRR in microvascular compln

Long-term Complications of Long-term Complications of Diabetes MellitusDiabetes Mellitus

Diffuse AtheroscleroisDiffuse Atherosclerois AMIAMI CVACVA PVDPVD

HypertensionHypertension Renal failureRenal failure Diabetic Diabetic

retinopathy/blindnessretinopathy/blindness GangreneGangrene

HbAHbA1c1c and Microvascular Complications and Microvascular Complications

Relative Relative RiskRisk

1515

1313

1111

99

77

55

33

11

HbAHbA1c1c,, % %77 88 99 1010 1111 1212

NeuropathyNeuropathy

NephropathyNephropathy

RetinopathyRetinopathy

6767

Every 1% HbAEvery 1% HbA1c1c Increase Above Increase Above

Goal Elevates the Risk of Diabetic Goal Elevates the Risk of Diabetic ComplicationsComplications

0

10

20

30

40

50

Increase in AnyDiabetes-Related

Endpoint

Increase in Riskof MyocardialInfarction (MI)

Increase in Riskof Stroke

Increase in Riskof MicrovascularComplications

Inci

den

ce o

f D

iab

etes

-R

elat

ed C

om

pli

cati

on

s (%

)

+21%

+37%

+12%+14%

Adapted from Stratton et al. BMJ. 2000;321:405-412.

Lower A1C level Reduces the Lower A1C level Reduces the Risk of ComplicationsRisk of Complications

DCCT * KUMAMOTO * UKPDSDCCT * KUMAMOTO * UKPDS

Each 1% fall in A1C results in 20-Each 1% fall in A1C results in 20-30% RRR in microvascular compln30% RRR in microvascular compln

DCCT Research Group. N Engl J Med. 1993;329:977-986. Ohkubo Y et al. Diabetes Res Clin

Pract. 1995;28:103-117. UKPDS 33: Lancet. 1998;352:837-853.

HbA1c

Retinopathy

Nephropathy

Neuropathy

Macrovascular disease

DCCT

9 7%

63%

54%

60%

41%*

Kumamoto

9 7%

69%

70%

–

–

UKPDS

8 7%

17-21%

24-33%

–

16%*

* not statistically significant* not statistically significant

Good Glycemic Control (Lower HbAGood Glycemic Control (Lower HbA1c1c) )

Reduces Incidence of ComplicationsReduces Incidence of Complications

Chris Rhodes Ph.D.PNRI, Seattle, WA.

TYPE 2 DIABETES – A QUESTION OF BALANCE

PERIPHERAL INSULIN RESISTANCE BETA CELL MASS AND FUNCTION

NON DIABETIC STATE

BETA CELL MASS AND FUNCTION

PERIPHERAL INSULIN RESISTANCEDIABETIC STATE

STEP 2STEP 2Co morbidity/Life style/Co Rx.Co morbidity/Life style/Co Rx.

CHECK life style; insulin Tx is not a CHECK life style; insulin Tx is not a substitute for healthy life style.substitute for healthy life style.

Overwt/obese/underactive/overeating Overwt/obese/underactive/overeating individuals likely to gain wt. and may not get individuals likely to gain wt. and may not get glycaemic control.glycaemic control.

Many pts.gain wt. because of the good control Many pts.gain wt. because of the good control of glycosuria with insulin.of glycosuria with insulin.

WALKING MORE BUT NOT WALKING MORE BUT NOT ENOUGHENOUGH

Many of us are busy all dayMany of us are busy all day Exhausted physically & mentally by eveningExhausted physically & mentally by evening Feel relaxed in front of TV with the remoteFeel relaxed in front of TV with the remote Majority of the adults are not engaging in Majority of the adults are not engaging in

regular physical activityregular physical activity We might find we had walked fewer than 3000 We might find we had walked fewer than 3000

steps during the daysteps during the day Walking suits most people and walking with a Walking suits most people and walking with a

companion makes it enjoyablecompanion makes it enjoyable

Lifestyle Lifestyle

The long term goal might be The long term goal might be 30- 40 minutes or 10000 steps 30- 40 minutes or 10000 steps

per dayper day

WALK MORE ,WALK EACH DAYWALK MORE ,WALK EACH DAY

AND WALK MORE EACH WEEKAND WALK MORE EACH WEEK

Lifestyle Lifestyle

WT.GAIN IN TYPE 2 DMWT.GAIN IN TYPE 2 DM

Improved glycaemic control >>> decreased Improved glycaemic control >>> decreased glycosuria ( 2kg / 1% decrease inA1C )glycosuria ( 2kg / 1% decrease inA1C )

Prandial boluses , independent of glycaemiaPrandial boluses , independent of glycaemia OADs – SUs /Glitazones & stopping OADs – SUs /Glitazones & stopping

metforminmetformin Premixed insulins – hypos caused by the short Premixed insulins – hypos caused by the short

acting components >>> wt. gainacting components >>> wt. gain Overuse of insulin >>> hypos >>> hunger Overuse of insulin >>> hypos >>> hunger

symptoms.symptoms.

The Wrong InsulinThe Wrong Insulin

Some docs hope ONE SIZE WILL FIT ALL Some docs hope ONE SIZE WILL FIT ALL and use premixed insulins .and use premixed insulins .

In clothing XL will fit all , but not comfortably In clothing XL will fit all , but not comfortably or elegantly.or elegantly.

A rational approach – to start with 10 units of A rational approach – to start with 10 units of basal insulin at night and continue OADbasal insulin at night and continue OAD

Eventually many require bolus insulin for Eventually many require bolus insulin for better glycaemic controlbetter glycaemic control

METFORMIN ADVANTAGEMETFORMIN ADVANTAGE

Improves insulin sensitivityImproves insulin sensitivity

Cardiovascular protection / demonstrated decrease in Cardiovascular protection / demonstrated decrease in coronary events.coronary events.

As monotherapy for 6 months >>> wt.loss of 2-3 kg.As monotherapy for 6 months >>> wt.loss of 2-3 kg.

Net wt. advantge of 4-6 kg.Net wt. advantge of 4-6 kg.

EAT LESS AND WALK MORE.EAT LESS AND WALK MORE. SECONDARY CAUSES FOR HIGH BLOOD SUGAR.SECONDARY CAUSES FOR HIGH BLOOD SUGAR. A. Medications –A. Medications – OCPOCP STEROIDSSTEROIDS THIAZIDESTHIAZIDES BETABLOCKERSBETABLOCKERS PHENYTOINPHENYTOIN ANTIPSYCHOTICSANTIPSYCHOTICS GLUCOSAMINEGLUCOSAMINE

SEC.CAUSES Conts….SEC.CAUSES Conts….

B. Med. ConditionsB. Med. Conditions

UTI/ ASYMPTOMATICUTI/ ASYMPTOMATIC

DENTAL INFECTIONSDENTAL INFECTIONS

HYPERTHYROIDISMHYPERTHYROIDISM

OCCULT MALIGNANCYOCCULT MALIGNANCY

DIABETES PROGRESSIONDIABETES PROGRESSION

With progression of disease capacity of beta With progression of disease capacity of beta cells to secrete insulin decreases.cells to secrete insulin decreases.

Body”s capacity to respond to insulin also Body”s capacity to respond to insulin also decreases.decreases.

When insulin resistance exceeds insulin When insulin resistance exceeds insulin secretory capacity PREDIABETES strts.secretory capacity PREDIABETES strts.

Diabetes progressively worsens with time,Diabetes progressively worsens with time,

INSULIN SECRETION FAILSINSULIN SECRETION FAILS

FIRST PHASE INSULIN FIRST PHASE INSULIN SECRETIONSECRETION

BETA CELL FUNCTIONBETA CELL FUNCTION

T2DM –NATURAL HISTORYT2DM –NATURAL HISTORY

FAILURE OF SU AND FAILURE OF SU AND SECRETAGOGUES.SECRETAGOGUES.

These agents – DAONIL, AMARYL, These agents – DAONIL, AMARYL, STARLIX, NOVONORM,DIAMICRON etc. STARLIX, NOVONORM,DIAMICRON etc. will not work if there is insufficient insulin.will not work if there is insufficient insulin.

Insulin sensitisers like GLITAZONE and Insulin sensitisers like GLITAZONE and METFORMIN may be effective.METFORMIN may be effective.

Glucophage/ Actos alone or in combinationGlucophage/ Actos alone or in combination

worthwhile.worthwhile.

STEP 3. WHICH BASAL INSULINSTEP 3. WHICH BASAL INSULIN

In general ONCE DAILY BASAL INSULINIn general ONCE DAILY BASAL INSULIN

plus continuing OAD is the preferred option plus continuing OAD is the preferred option because of good glycaemic control, less wt . because of good glycaemic control, less wt . gain and lesser hypoglycaemia .gain and lesser hypoglycaemia .

Basal Insulins - 2 typesBasal Insulins - 2 types

Intermediate actingIntermediate acting

Long actingLong acting

INTERMEDIATE ACTINGINTERMEDIATE ACTING

ISOPHANE INSULIN-ISOPHANE INSULIN-

12- 24 Hour s duration- human 12- 24 Hour s duration- human origin,cloudy .origin,cloudy .

Available as vials, cartridges and disposible pen Available as vials, cartridges and disposible pen injectors.injectors.

Brands – Humulin NPHBrands – Humulin NPH

Protaphane.Protaphane.

LONG ACTING INSULINLONG ACTING INSULIN

24- 36 Hrs. duration24- 36 Hrs. duration Analogue nsulin ,clear soln.available as pen Analogue nsulin ,clear soln.available as pen

injectors, cartridges and vials.injectors, cartridges and vials. Brands Brands

LEVEMIRLEVEMIR

LANTUSLANTUS

Insulin Glargine:21A-Gly 30Ba-L-Arg-30Bb-L-Arg-insulin

Metabolites:M1-21A-Gly-insulinM2-21A-Gly-des-30B-Thr-insulin

11 55 1010 1515 2020 AsnAsn

11 55 1010 1515 2020 2525 3030

Arg Arg

Substitution

Extension

GlyA-chain

B-chain

Insulin GlargineInsulin Glargine: Structure: Structure

BASAL INSULINS BASAL INSULINS

PROS AND CONS OF ANALOGUEPROS AND CONS OF ANALOGUE PROSPROS

consistent profileconsistent profile

often single daily doseoften single daily dose

lesser hyposlesser hypos

no mixing or resuspensionno mixing or resuspension

CONS analogueCONS analogue

*slower response to dose changes*slower response to dose changes

*may be confused with bolus insulin as both are clear *may be confused with bolus insulin as both are clear solutionsolution

*cannot mix with bolus insulin*cannot mix with bolus insulin

*glargine may sting when injected.*glargine may sting when injected.

New Long Acting Insulin New Long Acting Insulin (Glargine Insulin)(Glargine Insulin)

Lantus is a new Lantus is a new type of long type of long acting insulin acting insulin that has no that has no peaks peaks

Mimics Mimics physiological physiological insulin (basal)insulin (basal)

STEP 4. DOSE TITRATIONSTEP 4. DOSE TITRATION

START WITH 10 UNITSSTART WITH 10 UNITS ADJUST THE DOSE TWICE WEEKLY TO ADJUST THE DOSE TWICE WEEKLY TO

REACH THE TARGET FBS OF < 6 mmol/L REACH THE TARGET FBS OF < 6 mmol/L (110 mg%)(110 mg%)

When BGL is well above target, increase by When BGL is well above target, increase by larger amounts than when BGL is close to larger amounts than when BGL is close to target.target.

Adjust dose every 2-3 daysAdjust dose every 2-3 days

INITIATION&TITRATIONINITIATION&TITRATION

FESTINA LENTE- HASTEN FESTINA LENTE- HASTEN SLOWLYSLOWLY

Increasing the dose too fast may cause hypos Increasing the dose too fast may cause hypos and wt.gainand wt.gain

Adjusting the dose slowly could mean many Adjusting the dose slowly could mean many months to achieve optimal controlmonths to achieve optimal control

Once the fasting BGL is on target, check the Once the fasting BGL is on target, check the evening preprandial BGL.evening preprandial BGL.

If the second preprandial not on target add a If the second preprandial not on target add a second dose of basal insulin( 10 units)second dose of basal insulin( 10 units)

SWITCHING FROM ISOPHANE SWITCHING FROM ISOPHANE TO ANALOGUE BASAL INSULINTO ANALOGUE BASAL INSULIN

If switching from once daily isophane to QD If switching from once daily isophane to QD Basal use same unitsBasal use same units

If switching from BID isophane to QD Basal If switching from BID isophane to QD Basal start at 80%start at 80%

If a premix insulin is used, calculate the new If a premix insulin is used, calculate the new dose on the amount of isophane in the mixdose on the amount of isophane in the mix

Consider a 10% dose redn.in case of severe Consider a 10% dose redn.in case of severe hypos in the pasthypos in the past

STEP 5. SHOULD OAD BE STEP 5. SHOULD OAD BE STOPPED&/OR BOLUS INSULIN STOPPED&/OR BOLUS INSULIN

STARTEDSTARTED Should OAD be stopped – stopping OAD Should OAD be stopped – stopping OAD

means less number of tabs. but may also mean means less number of tabs. but may also mean more of insulin units OR a second dose of more of insulin units OR a second dose of insulin.insulin.

SUs MAY NO LONGER BE EFFECTIVESUs MAY NO LONGER BE EFFECTIVE INSULIN SENSITISERS WILL CONTINUE INSULIN SENSITISERS WILL CONTINUE

TO WORK .TO WORK . THE RISK OF SERIOUS ADV.EFFECTS THE RISK OF SERIOUS ADV.EFFECTS

INCREASES-lactic acidosis & fluid overloadINCREASES-lactic acidosis & fluid overload

What is the patient”s A1c? What is the patient”s A1c?

If any difference between avg.BGL and that If any difference between avg.BGL and that predicted by the A1C –predicted by the A1C –

1. inaccurate/inadequate measurements and 1. inaccurate/inadequate measurements and recording recording

2.occasionally pts. may not record high or 2.occasionally pts. may not record high or low values.low values.

HIDDEN HYPERGLYCAEMIAHIDDEN HYPERGLYCAEMIA

Avg.BGL and A1C accurate, Preprandial Avg.BGL and A1C accurate, Preprandial BGLs are on target and A1C off target , checkBGLs are on target and A1C off target , check

PPBGLs and during the night( eg. 3.00am), forPPBGLs and during the night( eg. 3.00am), for

hidden hyperglycaemia.hidden hyperglycaemia.

Check BGLS before lunch and before HS to Check BGLS before lunch and before HS to check for morning and evening post prandial check for morning and evening post prandial hyperglycaemia.hyperglycaemia.

MORNING HYPERGLYCAEMIAMORNING HYPERGLYCAEMIA

In both people with and In both people with and without diabetes BGL falls without diabetes BGL falls during the night and the during the night and the increase in the early hours increase in the early hours of morning – can be a of morning – can be a problem in diabetics problem in diabetics (DAWN PHENOMENON)(DAWN PHENOMENON)

There are three classic There are three classic patterns of morning patterns of morning hyperglycaemiahyperglycaemia

*** INSULIN RUN OUT*** INSULIN RUN OUT**** THE BOUNCE**** THE BOUNCE***** POOR CONTROL***** POOR CONTROL

HOW TO TACKLE POST HOW TO TACKLE POST PRANDIAL HIGHs?PRANDIAL HIGHs?

Review the glycaemic load of that particular meal.Review the glycaemic load of that particular meal. A dietitian will be able to advise on glycaemic load A dietitian will be able to advise on glycaemic load

and on strategies to reduce post prandial glycaemia.and on strategies to reduce post prandial glycaemia.

If changes in CHO intake are not needed, practical, or If changes in CHO intake are not needed, practical, or effective then add QUICK ACTING INULIN in effective then add QUICK ACTING INULIN in addition to BASAL INSULIN addition to BASAL INSULIN

Glycemic Index for FoodGlycemic Index for Food

FoodFood Glycemic Glycemic IndexIndex

GlucoseGlucose 100100

HoneyHoney 9191

Brown RiceBrown Rice 8888

Corn Flakes CerealCorn Flakes Cereal 8383

Wheat BreadWheat Bread 7272

Table SugarTable Sugar 6464

BananaBanana 6161

Sweet CornSweet Corn 5858

Oatmeal CookiesOatmeal Cookies 5757

Sweet PotatoSweet Potato 5050

Orange JuiceOrange Juice 4949

MacaroniMacaroni 4646

Ice CreamIce Cream 3838

MilkMilk 3434

PeanutsPeanuts 1010

Not all carbohydrates are created Not all carbohydrates are created equalequal when compared to their effects on when compared to their effects on plasma glucose.plasma glucose.

Glycemic IndexGlycemic Index is an attempt to is an attempt to measure the differences in the amount of measure the differences in the amount of glucose converted in the plasma from glucose converted in the plasma from various foods.various foods.

Glycemic IndexGlycemic Index ranks foods according ranks foods according to their ability to raise blood sugar.to their ability to raise blood sugar.

Low Glycemic IndexLow Glycemic Index foods release their foods release their glucose to the bloodstream slowly, over glucose to the bloodstream slowly, over a prolonged period of time.a prolonged period of time.

High Glycemic IndexHigh Glycemic Index foods release foods release theirs all at once.theirs all at once.

FOODS THAT MUST BE FOODS THAT MUST BE AVOIDEDAVOIDED

SWEETS , ICE CREAMS , FRUIT SWEETS , ICE CREAMS , FRUIT SUGARSUGAR

CAKES , PASTRIES , SWEET CAKES , PASTRIES , SWEET BISCUITSBISCUITS

CHOCOLATES, SOFT DRINKS CHOCOLATES, SOFT DRINKS CONDENSED MILK , CREAM AND CONDENSED MILK , CREAM AND

MOLASSESMOLASSES

Sweet food Sweet food

Sweet food Sweet food

Fat foodFat food

MeatMeat

FOODS TO BE CONSUMED IN FOODS TO BE CONSUMED IN LIMITED AMOUNTSLIMITED AMOUNTS

CUT DOWN YOUR INTAKE OF SALT, CUT DOWN YOUR INTAKE OF SALT, RED MEAT, POULTRY, EGGS, COFFEE RED MEAT, POULTRY, EGGS, COFFEE AND TEA AND TEA

THESE SHOULD BE ESPECIALLY THESE SHOULD BE ESPECIALLY AVOIDED WHEN YOU HAVE AN EMPTY AVOIDED WHEN YOU HAVE AN EMPTY STOMACHSTOMACH

OTHER EXAMPLES: PASTA,COCONUT, OTHER EXAMPLES: PASTA,COCONUT, HONEY,PALM SUGAR,YOGHURTHONEY,PALM SUGAR,YOGHURT

BENEFICIAL FOODSBENEFICIAL FOODS

FIGS, POMEGRANATES,CITRUS FRUITSFIGS, POMEGRANATES,CITRUS FRUITS VEGETABLES SUCH AS CABBAGE, VEGETABLES SUCH AS CABBAGE,

BROCCOLI, SPINACH, CARROTS, BEET BROCCOLI, SPINACH, CARROTS, BEET RADISH, GARLIC, ONION, CEREALS RADISH, GARLIC, ONION, CEREALS CUCUMBER, LETTUCE, TOMATO, CUCUMBER, LETTUCE, TOMATO, WHOLE GRAIN FOODS, SPROUTS AND WHOLE GRAIN FOODS, SPROUTS AND GRAINS SUCH AS BENGAL GRAM AND GRAINS SUCH AS BENGAL GRAM AND CHICK PEASCHICK PEAS

CerealsCereals

Vegetables Vegetables

VegetablesVegetables

Raw vegetablesRaw vegetables



FishFish

BOLUS INSULINSBOLUS INSULINS

A Quick acting bolus insulin in case of on A Quick acting bolus insulin in case of on target preprandial BGL, but off target A1C andtarget preprandial BGL, but off target A1C and

post prandial BGLpost prandial BGL

BOLUS INSULINSBOLUS INSULINS

Traditional andTraditional and

Analogues bolus insulinsAnalogues bolus insulins

CHARACTERISTICS OF BOLUS CHARACTERISTICS OF BOLUS INSULIN INSULIN

A. Rapid acting/very quick acting-A. Rapid acting/very quick acting-

#Onset 5- 15 min. Peak 30-90 min. Durn 4-6 hrs #Onset 5- 15 min. Peak 30-90 min. Durn 4-6 hrs 1. INSULIN ASPART(NOVORAPID) clear 1. INSULIN ASPART(NOVORAPID) clear soln. analogue insulin available as vials, soln. analogue insulin available as vials, cartridges and penscartridges and pens

2.INSULIN LISPRO(HUMALOG) available 2.INSULIN LISPRO(HUMALOG) available as vials and cartridges for use in pens.as vials and cartridges for use in pens.

BOLUS INSULIN conts…..BOLUS INSULIN conts…..

B.Short acting/Quick acting insulin-B.Short acting/Quick acting insulin-

#Onset 30-60 min. Peak 2-3 hrs. Durn 8-10 hrs#Onset 30-60 min. Peak 2-3 hrs. Durn 8-10 hrs

NEUT. INSULIN (ACTRAPID/ HUMULIN R)NEUT. INSULIN (ACTRAPID/ HUMULIN R)

#Human insulin ,clear soln.available as vials and #Human insulin ,clear soln.available as vials and cartridges for use in pen injectorscartridges for use in pen injectors

#Both analogue and Human insulins are clear #Both analogue and Human insulins are clear soln. but each has its pros and conssoln. but each has its pros and cons

Human Neutral Bolus InsulinHuman Neutral Bolus Insulin

May act too slowly to control post prandial May act too slowly to control post prandial HYPER and may act for so long so that HYPO HYPER and may act for so long so that HYPO before the next meal becomes a riskbefore the next meal becomes a risk

For pts. on analogue basal insulin , neutral For pts. on analogue basal insulin , neutral human bolus insulin may be better to control human bolus insulin may be better to control the blood glucose before the next meal esp.the blood glucose before the next meal esp.

if the next meal is more than 6 hrs.after the if the next meal is more than 6 hrs.after the bolus insulinbolus insulin

Analogue Bolus Insulin…Analogue Bolus Insulin…

Faster in starting and stopping and may control Faster in starting and stopping and may control post prandial HYPER with lesser risk of post prandial HYPER with lesser risk of HYPO.HYPO.

However the analogue may increase the risk of However the analogue may increase the risk of HYPO if the meal is not eaten promptly or if HYPO if the meal is not eaten promptly or if enough CHO is not eaten with meal( steak and enough CHO is not eaten with meal( steak and salads)salads)

Rapid acting insulin may RUN OUT before Rapid acting insulin may RUN OUT before next.meal causing preprandial HYPERnext.meal causing preprandial HYPER

Humalog/Novolog versus RegularHumalog/Novolog versus Regular

RapidRapid acting insulins: acting insulins: Start in 10min Start in 10min Peak in 1-2h Peak in 1-2h Gone in 3.5-4hGone in 3.5-4h

Regular insulin: Starts Regular insulin: Starts in 30min Peaks in 3-in 30min Peaks in 3-4h 4h Gone in 6-8h Gone in 6-8h

Isophane Basal and Quick acting Isophane Basal and Quick acting Bolus…….Bolus…….

Is a good choice for better control of next Is a good choice for better control of next preprandial HYPER and immediate post preprandial HYPER and immediate post prandial HYPER.prandial HYPER.

Eg. Humulin NPH at HS and Humalog OR Eg. Humulin NPH at HS and Humalog OR Novorapid as preprandial bolus insulinsNovorapid as preprandial bolus insulins

Anlogue Basal and short acting neutral insulinAnlogue Basal and short acting neutral insulin is also a rational choice.is also a rational choice.Eg. Lantus/ Levemir at HS and human actrapid Eg. Lantus/ Levemir at HS and human actrapid

as bolus insulinsas bolus insulins

What dose of Bolus insulin?What dose of Bolus insulin?

Choosing the initiating dose is easy.Choosing the initiating dose is easy. Use 1/3 of the corrresponding morning or Use 1/3 of the corrresponding morning or

evening basal insulin doseevening basal insulin dose The usual recipe is 2/3 basal and 1/3 bolus.The usual recipe is 2/3 basal and 1/3 bolus. Adjust the starting dose according to the BGL Adjust the starting dose according to the BGL

profileprofile FESTINA LENTE-not too slow and not too FESTINA LENTE-not too slow and not too

fast. GET IT JUST RIGHTfast. GET IT JUST RIGHT

BOLUS INSULIN TITRATIONBOLUS INSULIN TITRATION

Increase the dose by 20% if BGL are well off Increase the dose by 20% if BGL are well off target and by 10%when they are closer to target and by 10%when they are closer to target.target.

Don’t aim too lowDon’t aim too low The major side effect of quick acting insulin The major side effect of quick acting insulin

is HYPOS and WT.GAIN ( wt.gain because of is HYPOS and WT.GAIN ( wt.gain because of assoc. hunger symptoms)assoc. hunger symptoms)

Hypos less likely in T2DM than in IDDM pt.Hypos less likely in T2DM than in IDDM pt.

BGL POFILE ON BASAL PLUS BGL POFILE ON BASAL PLUS BOLUS INSULIN SCHEDULEBOLUS INSULIN SCHEDULE

INSULIN INJECTIONINSULIN INJECTION

1.Morning Basal1.Morning Basal

2.Morning Bolus2.Morning Bolus

3.Evening Bolus3.Evening Bolus

4.Bed time Basal4.Bed time Basal

ON TARGET BGLON TARGET BGL

Evening preprandial(pre Evening preprandial(pre dinner)dinner)

Mid-day preprandial Mid-day preprandial (prelunch)(prelunch)

Pre bed timePre bed time

Fasting (pre brakefast)Fasting (pre brakefast)

INSULIN Rx PROGRAMINSULIN Rx PROGRAM

TROUBLE SHOOTING INSULIN TROUBLE SHOOTING INSULIN PROBLEMSPROBLEMS

FIRST FIX THE FASTING – Is BED TIME FIRST FIX THE FASTING – Is BED TIME insulin needed?insulin needed?

THEN TACKLE THE TEA – Is BRAKE THEN TACKLE THE TEA – Is BRAKE FAST insulin needed?FAST insulin needed?

FIND THE HIDDEN HYPERS- Is a PRE FIND THE HIDDEN HYPERS- Is a PRE MEAL bolus needed?MEAL bolus needed?

AND CHECK THE A1C – Is the A1C on AND CHECK THE A1C – Is the A1C on target ?target ?

STEP 6. ARE PROBLEMS WITH STEP 6. ARE PROBLEMS WITH INSULIN LIKELY?INSULIN LIKELY?

Two classes of potential problems-Two classes of potential problems-

1.MEDICAL1.MEDICAL

coping with injn. and monitoring techniques coping with injn. and monitoring techniques (both pts.& doctors) AND risk of hypos and (both pts.& doctors) AND risk of hypos and wt.gain (pts)wt.gain (pts)

2. PSYCHOLOGICAL ( both the pts.&doctors)2. PSYCHOLOGICAL ( both the pts.&doctors)

MEDICAL PROBLEMSMEDICAL PROBLEMS

Any pts.except a very few can manage to Any pts.except a very few can manage to administer their own insulin or monitor their administer their own insulin or monitor their BGL using injectors/pens and glucometers.BGL using injectors/pens and glucometers.

For these few a relative ,carer or visiting nurse For these few a relative ,carer or visiting nurse could help.could help.

BASAL INSULIN injn.& PREPRANDIAL BASAL INSULIN injn.& PREPRANDIAL BGL measuremnts are the most important BGL measuremnts are the most important daily activitiesdaily activities

PSYCHOLOGICAL PROBLEMSPSYCHOLOGICAL PROBLEMS?Causes?Causes

PATIENTSPATIENTS *insulin therapy will be painful and difficult*insulin therapy will be painful and difficult

*fear of wt. gain and hypoglycaemia*fear of wt. gain and hypoglycaemia

* end of the road , diabetes worse* end of the road , diabetes worse

*employment/dependency*employment/dependency

PSYCHOL.INSULIN PSYCHOL.INSULIN RESISTANCE -? CausesRESISTANCE -? Causes

DOCTORSDOCTORS *pts do not want insulin therapy*pts do not want insulin therapy

* difficult, extra time needed* difficult, extra time needed

* pts need referrals* pts need referrals

* hypos and wt gain* hypos and wt gain

* insulin therapy will not work and costly* insulin therapy will not work and costly

PSYCHOLOGICL INSULIN PSYCHOLOGICL INSULIN RESISTANCERESISTANCE

Many doc and their pts prefer to delay insulin Many doc and their pts prefer to delay insulin therapy until it is ABSOLUTELY therapy until it is ABSOLUTELY ESSENTIAL.ESSENTIAL.

Neither wants to take the bold step; the Neither wants to take the bold step; the problems of starting insulin are immediate and problems of starting insulin are immediate and obvious to both. The problems of not starting obvious to both. The problems of not starting are more remote and less obviousare more remote and less obvious

HOW TO RESOLVE THE HOW TO RESOLVE THE CONCERNS?CONCERNS?

@To demonstrate that inj. are virtually painless@To demonstrate that inj. are virtually painless

with a DRY injwith a DRY inj

@Introduce the person to a successful pt@Introduce the person to a successful pt

@Explain that the risk of hypo is remote(1/20@Explain that the risk of hypo is remote(1/20 thth

that in type1)that in type1)

@Explain that eating less and walking more will @Explain that eating less and walking more will limit or prevent wt. gain limit or prevent wt. gain

EMPLOYMENT AND EMPLOYMENT AND INSURANCEINSURANCE

Some concerns are less easy to resolve :Some concerns are less easy to resolve :

some employers /insurance do discriminatesome employers /insurance do discriminate against people with diabetes and access to against people with diabetes and access to

some jobs is more difficult.some jobs is more difficult.

Overall ,though ,insulin doesn’t limit Overall ,though ,insulin doesn’t limit opportunityopportunity

muchmuch

CONCLUSIONSCONCLUSIONS

WHY INITIATE INSULIN THERAPYWHY INITIATE INSULIN THERAPY *maintain near normal glycaemia when oral *maintain near normal glycaemia when oral

agents cannotagents cannot *reduce strain on beta cell*reduce strain on beta cell * improve insulin resistance and correct * improve insulin resistance and correct

glucotoxicityglucotoxicity * minimize long term complications-* minimize long term complications-

microvascular/macrovascularmicrovascular/macrovascular *improve QOL*improve QOL

INSULIN IS NOT……INSULIN IS NOT……

Initiate insulin therapy sooner Initiate insulin therapy sooner rather than later, and treat to targetrather than later, and treat to target

Insulin worksInsulin works

Insulin is goodInsulin is good

Insulin is your friendInsulin is your friend

KISS approach really worksKISS approach really works

A PATIENT MIGHT SAYA PATIENT MIGHT SAY

I FEEL GREAT. I FEEL GREAT.

I DON’T NEED DAYTIME NAPSI DON’T NEED DAYTIME NAPS

IF I HAD KNOWN HOW EASY IT WAS TOIF I HAD KNOWN HOW EASY IT WAS TO

START INSULIN ,I WOULD HAVE DONE ITSTART INSULIN ,I WOULD HAVE DONE IT

YEARS AGO YEARS AGO

THANK YOUTHANK YOU

THANK YOUTHANK YOU

VERY MUCHVERY MUCH

Health & Medicine

Kiss