intensive insulin therapy

www.diabetesclinic.c a 1 INTENSIVE INSULIN THERAPY J. Robin Conway M.D. Diabetes Clinic, Smiths Falls, ON 1-800-717-0145 www.diabetesclinic.c a 2 Objectives • Optimize diabetes management • Assist you in initiating insulin in your office – When to start insulin therapy? – Insulins, doses, delivery options – Patient training www.diabetesclinic.c a 3 Challenges in Initiating Insulin? 1. Patient attitudes Patient attitudes – Fear of needles – Insulin viewed as a threat by patient & physician – Hypoglycemia 2. Physician Attitudes Physician Attitudes – Discomfort with insulin • Lack of knowledge and experience – Fear of needles www.diabetesclinic.c a 4 Type 1 Diabetes: • Impaired or absent ß cell function:  ↓ insulin secretion • Normal insulin action:  ↑ insulin sensitivity • The insulin deficiency results in unacceptable blood glucose control www.diabetesclinic.c a 5 Type 2 Diabetes: Double Impairment • Impaired ß cell function:  ↓ insulin secretion • Impaired insulin action:  ↑ insulin resistance • Results in unacceptable blood glucose control www.diabetesclinic.c a 6 Type 1 & 2 Diabetes: Key Concepts • Minimizing the complications of diabetes requires: – Early diagnosis and treatment of diabetes – Maintaining HbA 1C level < 7% • Achieving HbA 1C < 7% requires control of post-prandial and fasting hyperglycemia www.diabetesclinic.c a 7 CDA Guidelines (for glycemic control) Normal Optimal A 1C level (0.04-0.06) (< 0.07) Preprandial glycemia (mmol/L) 3.5-6.1 4-7 Postprandial glycemia (mmol/L) 4.4-7.8 7-11 Haars s et al., CMAJ 2003; 159 (Suppl.): S1-29. Gerstein, H.C. et al. CDA views on the UKPDS and revision of the guidelines affected by the results of this study. www.diabetesclinic.c a 8 Steps to Glycemic Control • Establish glycemic objectives – Target fasting and post-prandial glycemia • Diet counseling with exercise component • Diabetes education for every patient • Pharmacological treatment; oral and insulin www.diabetesclinic.c a 9 Patient Counselling Topics A.Review symptoms and treatment of hypoglycemia B.Proper training and correct use of glucose monitor C.Target desired glycemic levels for each patient www.diabetesclinic.c a 10 A. Hypoglycemia • Definition: Glycemia < 3.8 mmol • Patients may experience hypoglycemia at different glycemic levels [...]... HumaPen® • Insulin pumps • Syringes • Disposable: multidose, prefilled (3.0 mL) – NovolinSet® (NPH, Toronto, 30/70 ) – Humulin® N www.diabetesclinic.c 20 Advancing Insulin Therapy Through Device Innovation www.diabetesclinic.c 21 Goal of Insulin Therapy We are trying to duplicate how the pancreas works in releasing insulin for someone who doesn’t have diabetes www.diabetesclinic.c 22 Non-diabetic Insulin. .. doesn’t have diabetes www.diabetesclinic.c 22 Non-diabetic Insulin and Glucose Profiles Breakfast Lunch Supper 75 Insulin (µU/mL) 50 Insulin 25 Basal insulin 0 9.0 Glucose 6.0 Glucose (mmo/L) 3.0 Basal glucose 0 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 a.m p.m Time of Day www.diabetesclinic.c 23 Insulin Preparations Rapid-acting Aspart (NovoRapid®) Vial and cartridge Lispro (Humalog®) Start < 15 min Short-acting... 0–15 min After Meal www.diabetesclinic.c 1998 Roper Starch Canada, Premix Insulin Using 33 Dissociation of Regular Human Insulin Regular Human Insulin 10-3 M 10-3 M ⇔ formulation 10-5 M ⇔ hexamers peak time 2-4 hr 10-8 M ⇔ dimers monomers capillary membrane www.diabetesclinic.c 34 Objectives for the Development of ShortActing Insulin Analogues • Modify time action to address – Postprandial hyperglycemia... Postprandial hyperglycemia – Hypoglycemia • Improve safety and convenience www.diabetesclinic.c 35 Whats’ new in type 1 diabetes treatment? • Insulin analogues • Physiological insulin replacement • Aggressive intensive management – – – – 4 injections per day Insulin infusion pumps Continuous glucose monitoring systems Integrated technologies for monitoring control www.diabetesclinic.c 36 ... Peakless vial only Lantus (Glargine) vial only Levemir (Detemir) cartridge www.diabetesclinic.c 24 Insulin PreMixes • Regular + intermediate – Novolin® 10/90, 20/80, 30/70, 40/60, 50/50 – Humulin® 30/70, 20/80 • Analogue Pre-Mix – Humalog® 25/75 (insulin lispro protamine suspension) – NovoMix 30* (protaminated insulin aspart) * Not available www.diabetesclinic.c 25 Normal Blood Glucose Levels Blood Glucose... • Other resources may exist for training, i.e retail pharmacy www.diabetesclinic.c 17 C Blood Glucose Monitoring • To adjust the insulin treatment • To detect or confirm hypoglycemia or severe hyperglycemia • To adjust treatment to the circumstances of daily life using an insulin scale prescribed by the attending physician • To improve patient safety and increase motivation to comply with treatment... Limitations of Regular Human Insulin • Slow onset of activity – Should be given 30 to 45 minutes before meal • Inconvenient for patients • Long duration of activity – Lasts up to 12 hours • Potential for late postprandial hypoglycaemia (4-6 hours) – Need for additional snack www.diabetesclinic.c 32 Adherence to Injection Recommendation (Canada) "When do you inject your insulin? " % of Respondents 100 . you in initiating insulin in your office – When to start insulin therapy? – Insulins, doses, delivery options – Patient training www.diabetesclinic.c a 3 Challenges in Initiating Insulin? 1. Patient. needles www.diabetesclinic.c a 4 Type 1 Diabetes: • Impaired or absent ß cell function:  ↓ insulin secretion • Normal insulin action:  ↑ insulin sensitivity • The insulin deficiency results in unacceptable blood glucose control www.diabetesclinic.c a 5 Type. www.diabetesclinic.c a 1 INTENSIVE INSULIN THERAPY J. Robin Conway M.D. Diabetes Clinic, Smiths Falls, ON 1-800-717-0145 www.diabetesclinic.c a 2 Objectives • Optimize