Text insulin Management in type 2 diabetes mellitus PRACTICAL POINTERS FOR CLINICAL PRACTICE.
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Transcript of Text insulin Management in type 2 diabetes mellitus PRACTICAL POINTERS FOR CLINICAL PRACTICE.
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insulin Management in type 2 diabetes mellitus
PRACTICAL POINTERS FOR CLINICAL PRACTICE
What is so frightening about diabetes???
Denial, myths, fear....
I can’t have diabetes, I feel GREAATTTT!
Only fat people get diabetes, so if I keep my weight down, I won’t get it.
My grandmother told me that diabetes comes from eating too much sugar.
I took my medication once or twice a week. I really don’t think it helped, so I quit taking it.
the diabetes epidemic
MANAGE SMARTER AND MORE AGGRESSIVELY
Indications for Insulin therapy
Adjunctive therapy - used when oral agents alone fail to achieve target glycemic goals
Basal insulin at bedtime decrease fasting blood sugars, oral agents control blood sugar during the day.
Replacement therapy - used when both basal and meal-time insulin are needed.
Glucose Toxicity - use Intensive Insulin Therapy (IIT) for 2-4 weeks at diagnosis which may improve endogenous insulin secretion and sensitivity.
Triggers for starting insulin:
persistent glucose > 250 mg/dl.
HbA1c > 10%
ketonuria
symptoms - polyuria, polydipsia, weight loss
IIT used early can resolve glycemic issues faster than oral agents.
Other - during hospitalization, pre-operatively, with steroid therapy, or at any time that glycemic control deteriorates
triggers for starting insulin
HbA1c > 10%
Symptoms of polyuria, polydipsia, weight loss
Failure of multiple oral medications
Acute situations; e.g. infections, MI, stroke, trauma
Perioperative period
Pregnancy
Contraindications to oral medications
failure
Insulin Products
Insulin Regimens
How to Start and intensify INsulin
Starting insulin
Is a process
Generally takes a few weeks
Familiarize patient with insulin administration
Build patient confidence
Gradual improvement of glycemic control while avoiding hypoglycemic episodes
If available, consultation with CDE is invaluable
Start Simple
Long acting or immediate acting insulin
Add short acting with meals to reduce post-meal rises
Continue to use oral agents; Metformin, TZDs, DPP-4’s
Sulfonylureas - discontinue
May require 20-30% more insulin if oral agents are discontinued
Commercial for Certified Diabetes Educators
Insulin Regimens
Once daily injection of Glargine, Detemir, NPH
Given at bedtime to lower fasting blood glucose
Can be used alone or with oral agents
Detemir and NPH may need to be given twice daily
NPH associated with more hypoglycemia
Raising basal only can lead to lows at night
Glargine and Detemir are more costly than NPH
basal regimen
✰ Add short-acting insulin if post-meal blood sugars are high Split-Mix: consider that insulin proportions are typically 2/3 in morning and 1/3 in evening. Ratios of long-acting/NPH to rapid/Regular of 2:1 in am and 1:1 in evening. Split-mix often leads to hypoglycemia in middle of night related to NPH peak at 6-8 hours after dinner injection.
Intermediate and Short-Acting Regimen
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✰
Basal-Bolus Regimen
Ideal for replacement insulin therapy
Preferred for patients who have unpredictable mealtime and activity schedules.Basal insulin is 40-50% of total daily dose of insulinBolus given pre-meal - should be 50-60% - may be adjusted according to carbohydrate counting using insulin-to-carbohydrate ratio
How to Figure Insulin to CArb Ratio (I:CR)
To Figure I:CR To Figure I:CR divide amount of divide amount of
carb person is carb person is consuming by consuming by
amount of insulin amount of insulin taken at meal taken at meal
Example: Example: 60gm ÷ 10 units = 660gm ÷ 10 units = 6
I:CR is 1:6I:CR is 1:6
If person If person eats 75 eats 75
gm carbsgm carbs
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75 mg ÷ 75 mg ÷ 6 =6 =
12 units12 units☞
Sensitivity/Correction Factor
Used for patients with varying blood glucose
Corrects pre-meal highs or lows
Given only before meals
Ensures that the post-meal glucose will be in acceptable range
More commonly used in Type1 vs. Type 2
Calculation: Sensitivity/Correction
FactorDivide 1500 by total daily dose (TDD) insulin - this determines the sensitivity ratio.
Example: 1500 ÷ 50 units/day = 30
Correction Factor: If patient blood sugar is 250 mg/dl. and target blood glucose range is 100 mg/dl. , figure 1 unit of insulin is needed for every 30 pts. above target range of 100 mg/dl.
Doing the Math
Target Glucose Range: 100 mg/dl.I:CR 1:6Sensitivity Factor: 1:30Patient blood glucose is: 250 mg/dl.
Calculation: SMBG Target 250 mg/dl. - 100mg/dl. = 150Sensitivity: 1:30 150÷30 = 5 unitsI:CR person eats 75 gms. at lunch = 12 unitsMeal Bolus =12 units PLUS 5 units correction = 17 units
In Intensive Insulin Therapy (IIT)
If person eats 3 meals/day and 3 carb snacks they should bolus 6
times per day
Better managed with consistent carb intake at meals rather than snacks - reduces # of injections to 3 per day
IIT IMPortant tips
OR teach patient about non-carb snacks
Self MOnitoring of Blood Glucose (SMBG)
Very important component of insulin management to assess and make appropriate and safe changes
Recommendations for testing vary as to patient and insulin type : 1-2 times if on basal regimen only OR 2-4 times for combined regimen.
REMEMBER: 4-8 testings provide only 4-8 “snapshots.” Can lose alot of information in between & at night
IMPORTANT: Evaluate fasting and 2 hour postprandial blood glucose readings when chosing basal insulin only, mixed insulins, or basal-bolus regimens (IIT)
Target is a blood sugar < 180 mg/dl. or A1c of 7% or less.
Need to check postprandials at different meals to identify a pattern that may be ocurring
CONTINUOUS GLUCOSE MONITORING (CGMS)
Medical Nutrition Therapy
Proper nutrition is essential to insulin management.
ADA recommends individualized MNT
Teaches carb counting and is individualized to patient’s level of understanding
Current Nutrition Current Nutrition Recommendations: Recommendations:
3 meals / day; 30-45 gms. carbs 3 meals / day; 30-45 gms. carbs eacheach
With or Without With or Without 1-2 snacks in between meals - if 1-2 snacks in between meals - if
each snack is < 30 gms. no each snack is < 30 gms. no additional additional
rapid-acting insulin neededrapid-acting insulin needed
Focus of MNT
Lifestyle changes
Increased physical activity
Pt. may chose to eat 3 meals/day OR small meals with snacks
CArbohydrates
Greatest impact on postprandial blood sugars
Patient should understand which foods contains carbs
Understand portion size & number of servings per meal/snack
Total carb consumption vs. type of carb impacts blood sugar control
No evidence to support low vs. high glycemic index diets
Artificial sweeteners are FDA approved for DM
Protein
Is widely misunderstood in diabetes glycemic control
Does raise plasma glucose concentration - amt. produced is small and does not appear in general blood circulation
Protein has not been found to slow carbohydrate absorption
Does not treat hypoglycemia
Adequate intake is important to euglycemia
FAts
Intake should be limited
Saturated fat is the primary determinant of LDL
Trans fats increase LDL & lower HDL - limit as much as possible
Initial MNT guidelines
Consume 3 meals/day, not skip meals
Meals no more than 4-6 hrs. apart
Set maximum carbohydrate intake per meal
Avoid regular soda, fruit juice, sport drinks, choose water
Food label - focus on serving size & total carbs
Men: 60-70 gms carbs., Women: 45-60 gms
Barriers to insulin
Hypoglycemia
Weight gain
Psychological Barriers
Lipodystrophy
Allergic reactions
Glargine insulin associated with cancer risk
IN Summary
Insulin is very effective but underused in T2DM☤
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Insulin can be used earlier in disease and as an adjunct to oral medications
Transition to insulin should not be regarded as a failure by patient or
providerPrimary care providers should be
familiar with indications for insulin, insulin regimens used & side effects Adequate support for patients is key
to transitioning and the success of treatment
"Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to
turn a life around."
~ Leo Buscaglia ~
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