Insulin Initiation In Primary Care
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Transcript of Insulin Initiation In Primary Care
Insulin Initiation In Primary Care
Dr Arla Ogilvie Endocrinologist Watford General HospitalWest Herts Hospitals NHS Trust
Does the Patient Need Insulin?
?Is it appropriate for the patient to be managed in Primary Care?
?Sufficient KnowledgeSkillsSupport TimeConfidence
? Have all other factors relating to control been addressed
Insulin Resistance….3Types
Liver
Muscle
Metabolic
Patient
Doctor
Before you start……Understand the patient• Is insulin necessary?• Factors in poor control
– Diet and ex– Compliance with Rx– Health beliefs– Fears
• Hypoglycaemia• Weight gain• Occupation
Understand the insulin• Type and regime
– Once daily + oral agents– Twice daily premix– (Basal bolus???)
• Starting dose• Patient EDUCATION• TIME for follow up• Dose titration• Regular review and support
Setting Individual Goals
• Optimise blood glucose control• Keep patient asymptomatic• Prevent long term complications• Avoid hypoglycaemia• Preserve Quality of Life
Safety is paramount!
Self-monitoring of blood glucose
• Monitoring glucose is essential for safe and successful insulin treatment:
– It guides dose adjustment– It allows patients to see the impact of behaviours and
diet on glucose• Patients MUST know how to monitor glucose• The most important aspect of self-monitoring is
that the patients DO something with the results
Diabetes UK. http://www.diabetes.org.uk/hcpreports/primary_recs.pdf, 2005 National Diabetes Support Team.
http://www.cgsupport.nhs.uk/downloads/NDST/Factsheet_Glucose_Self_Monitoring.pdf, 2005NICE. http://www.nice.org.uk/page.aspx?o=36882, 2005. Owens D et al. Diabetes and Primary Care 2004;6:8–16
Once-daily basal insulin• Duration depends on the insulin• Insulin analogues may provide 24-hour cover• Intermediate isophane preparations (Insulatard
and Humulin I) may only be active for 8 – 18 hours and have a more pronounced peak activity
Time (8–24 hours)
Insu
lin a
ctiv
ity
Insulin
Schematic representation
Benefits of a once-daily basal insulin regimen
• One injection per day• Useful for patients reluctant to start insulin treatment • Works best for morning hyperglycaemia• Useful where someone else has to administer insulin • May help overcome fear of starting insulin • Some basal insulin injections may provide a weight
benefit1
1.Philis-Tsimikas A et al. Clin Ther 2006;28:1569–81
Limitations of once-daily basal insulin regimen
• Does not provide insulin for post-meal glucose surges:– Assumes patient can produce sufficient insulin
to cover these mealtime requirements• Requires a fairly strict, predictable diet:
– Dosing during the day is inflexible and so patients need to intake similar calories each day
How Much?TYPE 2
Nocte Isophane insulin Insulatard or Humulin I
Start 10units + Metfomin and Sulphonylurea (Glitazone)
Titrate once or twice weekly
Newer agents•Gliptins •GLP1 Analogues
Are NOT licensedTo be given with insulin
Easy Dose Adjustment for Once Daily Basal Insulin
• The 3 – 0 – 3 Rule • After Initiation• Adjust insulin every 3 days• Based on fasting glucose• If average glu > 7 – increase by 3 units• If glu < 4mmol/l decrease by 3 units
Premixed insulin In
sulin
act
ivity
Brkfast Lunch Dinner Bedtime
Basal + Rapid acting component
Possible regimens:• Once daily with largest
daily meal (usually dinner)
• Twice daily with Twice daily with dinner and breakfastdinner and breakfast
• Three times daily, with each meal
Mixtard 30 – may need snacksWait 30 mins between injecting and eating
Novomix 30 No snacks neededInject and eat immediately
Benefits of a premixed insulin regimen
• Targets mealtime glucose• Can be initiated as one injection per day to
familiarise patient with injecting (Most need twice daily)
• Second or third injections of same insulin can be added if necessary to optimise control
• Need fairly regular lifestyles, Eat similar amounts at similar times
1. Garber AJ et al. Diabetes Obes Metab 2006;8:58–66
Analogue basal-bolus therapy
Breakfast Lunch Dinner Bedtime
Rapid-acting insulinLong-acting insulin
Insu
lin a
ctiv
ity
Rapid insulin
Long-acting insulin
Rapid insulin
Rapid insulin
Benefits of a basal-bolus insulin regimen
• Closest to natural insulin production by the body• Not necessary for majority of Type 2• May be needed for those who have erratic
mealtimes, work variable shifts• Gives more flexibility over type of food and
when it can be eaten• Suited to those who are highly motivated• Need to monitor 4 times daily to optimise doses
Insulin with or without oral agents?
• Oral agents can be continued when once daily basal insulin is initiated
• It is recommended that metformin is continued where possible in T2 DM
• Stop Sulphonylurea with premixed insulin• Glitazones can be used with insulin – usually
where intolerant to metformin. Oedema may be a problem
Commencing Insulin Therapy• Ensure patient can blood glucose monitor and understands BG targets• Assess patient for suitable device• Educate patient regarding :1. Storage, timing and action of insulin. 2. Device use and safety3. Injection technique, sites and rotation.4. Hypoglycaemia 5. Driving safety and legal Implications6. Sick day Rules – 7. Dose Adjustment and exercise ( if suitable)8. After education full assessment carried out to ensure patient
competence and safety.
POOR CONTROL -Troubleshooting!
Compliance - Rx, lifestyle, acceptance Unable to use Pen - check technique Withdrawing needle too soon - ‘count to 10’ Site problems -random rotation/hypertrophy Wrong timing of injections Eating to avoid hypos Rebound hyperglycaemia- check Sx of hypo