Insulin Initiation magelang dr Soni W.pdf

8/13/2019 Insulin Initiation magelang dr Soni W.pdf

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Insulin Initiation :Benefit ofInsulin Detemir in type 2 DMManagement

Sony Wibisono M

Surabaya Diabetes andNutrition Center Dr. Soetomo

Teaching Hospital, Facultyof MedicineAirlanggaUniversity,

Surabaya


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OutlinesPresentation structure

Diabetes is a progressive disease and is increasingin prevalence

The mapping of insulin treatment based recent guidelines

Insulin Initiation, when we should start with basal insulin

Insulin therapy in or outpatient in clinical practice

Conclusion


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20102000171 million1

2030

552 million2

2011

366 million2

Diabetes is a global diseaseEstimated global prevalence of diabetes

1. Wild. Diabetes Care. 2004. 27:1047-1053.2. International Diabetes Federation. IDF Diabetes Atlas. Fifth Edition. 2011


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1. Adapted from: Ramlo-Halsted BA, Edelman SV. Clincial Diabetes 2000;18(2): http://journal.diabetes.org/clinicaldiabetes/v18n22000/pg80.htm

T2DM: Progressive loss of insulin

secretion with increasing insulin resistance

1

Impairedglucose tolerance

Undiagnoseddiabetes

Insulin resistance

Knowndiabetes

Insulin secretionPostprandial glucose

Fasting glucose

Microvascular complications


Macrovascular complications

Macrovascular complications


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Diabetes is a progressive disease

Type 2 diabetes (T2DM) progression is characterised by decline in beta-cell function andworsening insulin resistance1

Getting to, or maintaining, target HbA1c levels in T2DM requires intensified treatmentover time2

1. Fonseca VA. Br J Diab Vasc Dis 2008;8:S32. Nathan DM, et al. Diabetes Care 2009;32:193-203


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Diabetes being a progressive disease that is increasing

in prevalence

T2DM results in a progressive loss of insulin secretion with increasing insulinresistance1

By 2030, IDF predicts 552 million people worldwide will have diabetes2

Diabetes is the fourth most common diagnosed chronic condition3

Many people with diabetes do not have good glycaemic control3

1. Ramlo-Halsted BA, Edelman SV. Clincial Diabetes 2000;18(2): http://journal.diabetes.org/clinicaldiabetes/v18n22000/pg80.htm2. International Diabetes Federation. IDF Diabetes Atlas. Fifth Edition. 20113. Brunton. Curr Med Res Opin 2011;2765-72


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New position statement of the ADA and EASD onmanagement of hyperglycemia in type 2 diabetes

I n z u c c i SE , e t a l . D ia b e t o l o g i a . 2 0 1 2

BasalInsulin


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New ADA/EASD Position on Sequential InsulinStrategy in Type 2 Diabetes

Non-InsulinRegimes

Basal Insulin OnlyUsually with OAD

Basal Insulin + 1 mealtimerapid-acting injection Pre-mixed Insulin twice-daily

Basal Insulin + 2 mealtimerapid-acting injection

1

2

+3

Low

Mod.

High

Number ofInjections

RegimenComplexity

FlexibilityLess FlexibleMore Flexible

Convenience*More ConvenientLess Convenient

Inzucci SE, et al. Diabetologia. 2012. * Gumprecht et al. Intensification to to biphasic insulinaspart 30/70. Int J Clin Pract 2009


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Patient Centered Approach


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What is the optimal target HbA1c level?

Goals of optimum HbA1c levels:

Good glycaemic control

Minimise development and progression of microvascularand macrovascular complications

HbA1c


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Treat T2DM early for long-term benefits1

Long-term benefits in reducing cardiovascular risk can be achieved withgood control from diagnosis1

-14%

-37%

-21%

Myocardial infarction


Death related to diabetes

Each HbA1cpercentage

pointreductioncounts3

HbA1c

-1%

1. Holman, et al. NEJM2008;359:1577892. UKPDS 6. Diabetes Res 1990;13(1):1-113. Stratton, et al. BMJ2000;321(7258):405-12

50% of patients with T2DM with complicationsalready have them at diagnosis2


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Insulin remains the most efficacious glucoselowering agent

Decrease in HbA1c: Potency of monotherapy

HbA1c

%

Nathan et al., Diabetes Care 2009;32:193-203.

CHOOSING INSULIN EARLIERFOR BETTER EFFICACY


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Insulin can be initiated at any time

Traditionally, insulin has been reserved as the last line of therapy

However, considering the benefits of normal glycemic status, Insulin

can be initiated earlier and as soon as possible

InadequateLifestyle

+ 1 OAD + 2 OAD + 3 OAD

INITIATE INSULIN


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How to start Basal Insulin Start with basal insulin (Insulin Detemir) 10 U or 0,1-0,2 U per Kg BB

Once daily injection, anytime injection but in same time per each day


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Simple Dose titration with Levemir

Patients who experienced hypoglycemia reduced their daily dose by 3 units

FPG target range70-90 mg/dL

FPG 90 mg/dl (5.0 mm/L)

Mean 3-day FPG (mg/dL)

Maintaindose

units

FPG target range80-110 mg/dL

FPG 110 mg/dL (6.1 mmol/L)

Blonde L et al. D ia b et e s O b es M e t ab . 2009; 11(6):623-631.

Increase

3 units

Decrease

3 units

Levemir Dose Titration Guidelines:3-0-3 Algorithm

Start with Levemir 10 U or 0,1-0,2 U per Kg BB


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Levemir/Glargine Head-to-Head:Similar Profiles in Type 2 Diabetes

Time (h)

Klein O et al. Diab Obes Metab 2007; 9:290-299

Glucoseinfus

ionrate

(mg/kg/m

in)

0 2 4 6 8 10 12 14 16 18 20 22 24

0

0.5

1.0

1.5

2.0

2.5

3.0

0.4 U/kg 0.8 U/kgInsulin detemir

Insulin glargine


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Levemir reduces nocturnal hypoglycaemia by up to65% compared to NPH

Phillis-Tsimikas. Clin Ther 2006;28(10):156981; Riddle et al 2003. Diabetes Care; 26 (11): 3080-6; Asakura T et al, 2008. Expert Opin Pharmacother; 10 (9): 1-5; Hanel H et al 2008. J Diabetes

-

Insulin NPH

Insulin Determir

Insulin glargine

Relative

Risk

Riddle et al., 2003 Phillis-Tsimikas et al., 2006

-29% -44% -53% -65%

NPH vs. glargine NPH vs. detemir


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Observational study of people with T2DM inroutine clinical practice

Study objectives

Primary: number of attributed adverse drugreactions (includes major hypoglycaemia)

Secondary: other safety and effectivenessmeasures

BASELINEWeek 0BASELINEWeek 0

INTERIMWeek 12INTERIMWeek 12

FINALWeek 24FINALWeek 24

Start a studyinsulin

Biphasic insulinaspart 30

Insulin detemir Insulin aspart

Start a studyinsulin

Biphasic insulinaspart 30

Insulin detemir Insulin aspart

A1chieve study overview and design


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HbA1c (%) FPG (mg/dl) PPG (mg/dl)

Baseline values 9.5 219 263

n 147 317 295

Levemir OAD:Indonesia efficacy results

-101*

-115*

-120

-100

-80

-2.2*

-3.0

-2.0

-1.0

0.0

Changefrom

baselineto

week24

Insulin nave

*p


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Levemir OAD:Indonesia hypoglycaemia results

5,10

0,30

4,80

0,00 0,00 0,000,0

1,0

2,0

3,0

4,0

5,0

6,0

Overall Major Nocturnal

Insulin nave Insulin nave Insulin nave

No. of pt w/hypo 19 0 1 0 18 0

Perc

entwithatleastoneeven

t

Baseline24 weeks


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A1chieve: Self-rated health in insulin naive

patients (Levemir)

24 weeks

Baseline

Best imaginablehealth

Worst imaginablehealth

Patients onLevemir

0

10

20

30

40

50

6070

80

90

100

Baseline 24 weeks


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Levemir

NovoRapid

Insulin endogen

--------

NovoMix

Breakfast Lunch Dinner Bed time

Physiologic insulin secretionAnalogue insulin mechanisme of action


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2 00 - 3003 00 - 4004 00 - 5005 00 - 6006 00 - 700

468

1012

EXAMPLE :HYPERGLYCEMIA 680 mg/dl

APIDRA

DOSE (S.C.): FORMULA X2.MT6 X2 = 12 UNITS

APIDRA for TOMMOROW : 3 X 12 U

HYPERGLYCAEMIA >200 mg/dl, EXAMPLE : 680 mg/dlFORMULA X2. MT FOR SGC AND MAINTENANCE S.C. DOSEFORMULA X2. MT

BASELINE GLUCOSEBefore SGC (mg/dl)

NOVORAPID DOSESubcutaneous (S.C.) Injection in unit

SUBCUTANEOUS GLYCEMIC CONTROL (SGC)(Clinical Experiencies : Tjokroprawiro 1987-2013)

6 X2 = 12FORMULA X2. MT

680

APIDRA : Onset 5-15 Mins; Peak 1-2 Hrs; Duration 3-4 Hrs

MT = MAINTENANCE

RGC


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Continued

or

- LEVEMIR : 20 units (1/3 of 60) Mornings

- SU : Mornings, or Mornings and EveningsAMETHOD- - NOVORAPID : Formula X2

-LEVEMIR : 20 units Evenings

- SU : Mornings, or Mornings and EveningsBMETHOD- - NOVORAPID : Formula X2

PERKENI-CONSENSUS 2006 : Insulin Dose > 30 Units/day in CTOIis not Recommended STOP OAD, and Give PREMIX Twice Daily (ADA/EASD-2012)

INPATIENTS TREATED withAPIDRA 3x 20Units per Day:1Total dose of NOVORAPID 60 units perDay

USE FORMULA 1/3METHOD- A OR B

(Clinical Experiences : Tjokroprawiro 2007-2013)(Clinical Experiences : Tjokroprawiro 2007-2013)

CTOI with FORMULA 1/3 for DISCHARGED-PATIENTS


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or

2 DIABETIC OUTPATIENTS FAILED with 2-4 OADs :

the figures of the first two fe. : 1-h PG450 mg/dL, theFirst two is45depending on 1-h PG (OneHour PlasmaGlucose) , and Special attention to

FORMULA 1/3 (based onthe figures of the first two , that is 45):Thus, the Initial Dose : 1/3 of 45 = 15 Units


CTOI with FORMULA 1/3 for DIABETIC-OUTPATIENTS16

- LEVEMIR : 15 Units Mornings (At the Same Time of the Day)

- SU : Mornings, or Mornings and EveningsAMETHOD- - NOVORAPID : Formula X2

- LAVEMIR : 15 units Evenings (At the Same Time of the Day)

- SU : Mornings, or Mornings and EveningsBMETHOD- - NOVORAPID : Formula X2


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3 Units Increase if Pre Prandial PG(Morning-Glucose) : 130-200 mg/dL

5 Units Increase if Pre Prandial PG(Morning-Glucose) : > 200 mg/dL

II STEP-DOWN FORMULAS TO END LEVEMIR INJECTIONTHE 1st FIGURE ( 2or1 ) INDICATES DAY, whereas :

THE 2nd FIGURE ( 2or1 ) INDICATES DECREASE in LEVEMIR DOSE

FORMULA 2-2 : Every 2Days 2 U Decrease , until LEVEMIR INJECTIONOFF

Every2Days 1 U Decrease ,FORMULA 2-1 : until LEVEMIROFFFORMULA 1-2 : EveryDay 2 U Decrease , until LANTUSOFF

FORMULA 1-1 : EveryDay 1 U Decrease , until LANTUSOFF


FORMULAS : 1/3 , STEP-UP : 3-3-5 , STEP-DOWN : 2-2 , 2-1 , 1-2 , 1-1

ISTEP-UP FORMULA 3-3-5 WITH LEVEMIR

THE 1st 3 INDICATES DAY, whereas the 2nd & 3rd 3& 5 INDICATE LEVEMIR DOSE

INCREASING INSULIN DOSE (3 or 5 units) after 3 DAY-EVALUATION


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FORMULA MP-25.4

FORMULA DEX-4.4

(Clinical Experiences: Tjokroprawiro 2010-2013)

APIDRA FORMULA for STEROID TREATED DM-Pts

FORMULA MP-25.4 and DEX-4.4

1 INTRAVENA METHYL PREDNISOLONE(MP) 25 mg :

This 25 mg MP SHOULD be BACKED UPwith 4 unitsAPIDRA SCor IVMETHYL PREDNISOLONE(MP)50 mg : with 8 unitsNovorapid SCor IV

METHYL PREDNISOLONE (MP) 125 mg :with 20 units Novorapid SC / IV / PUMP

INTRAVENA DEXAMETHASON (DEX) 4 mg: BACKED UPwith 4 unitsAPIDRA SCor IV

INTRAVENA DEXAMETHASON (DEX) 8 mg: BACKED UPwith 8 units Novorapid SCor IV

INTRAVENA DEXAMETHASON (DEX) 16mg: BACKED UPwith 16units Novorapid SC/ IV

2

3

1

2

3

INTRAVENA METHYL PREDNISOLONE (MP) 25 mg :

Every 25 mg MP SHOULD be BACKED UPwith 4 units NOVORAPID SCor IV

INTRAVENA DEXAMETHASON (DEX) 4 mg : BACKED UPwith 4 units Novorapid SCor IV

1 Flacon 2 ml : 125 mg MP. Diluted with 3 ml NaCl 0.9%

5 ml with 125 MP . Thus : 1 ml Contains 25 mg MP


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Conclusion

Diabetes is a progressive disease that is increasing in prevalence in the world

Starting with basal insulin detemir is easy way to reach better glycemic control

In Indonesia, in real life clinical practice (A1chieve study) Levemir show significantimprovements in overall glycaemic control in terms of HbA1c, FPG and PPG.

Premixed insulin NovoMix is one option for insulin intensification, provide simple andconvenient for patients


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Thank You

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