diabetes – the leap to insulin: an update on injectable diabetes
TRANSCRIPT
1
Injectables in Diabetes
Fadi Al-Khayer, MD, FACE
Connecticut Endocrinology Center
Storrs Mansfield, CT
In the United States, approximately 30 million persons have
diabetes or approximately 7 % of the US people.
Nearly 1.9 million Americans develop diabetes every year, or
approximately 5205 every day.
Individuals with type 2 diabetes may have the disease and
remain undiagnosed for over 10 years.
Worldwide, the number of people with diabetes is expected to
rise to more than 400 million by year 2025.
The American Diabetes Association (ADA) Standards for
Glycemic Control in Diabetes Mellitus
Parameter Normal Goal Additional action
suggested
Fasting or preprandial
glucose (capillary
whole blood)
< 100 80-120 <80 or >140 mg/dL
Bedtime glucose
(capillary whole
blood)
<120 100-140 <100 or >160 mg/dL
Hemoglobin A1c (%) <6% <7% >8%
The American College of Endocrinology Targets for
Glycemic Control
Target
Fasting glucose (capillary
whole blood)
< 110 mg/dL
Postprandial glucose
(capillary whole blood)
< 140 mg/dL
Hemoglobin A1c < 6.5 %
A1C Is a Combination of Both Fasting and Mealtime Glucose Measurements
Monnier L, et al. Diabetes Care. 2003;26:881-885.
•At A1C ranges of 7.3% to 9.2%,
overall glycemia is impacted
similarly by fasting blood
glucose (FBG) and
postprandial glucose (PPG)
•As A1C approaches goal,
elevated PPG contributes more
to the elevation in A1C
Relationship of A1C to Risk of
Microvascular Complications
Adapted with permission from Skyler JS. Endocrinol Metab Clin North Am. 1996;25:243
Retinopathy
Nephropathy
Neuropathy
Microalbuminuria
Rela
tiv
e R
isk
A1C (%)
15
13
11
9
7
5
3
1
6 7 8 9 10 11 12
The Pathogenesis of Type 2 Diabetes
An Imbalance of Beta-Cell Workload and Beta-Cell Response
Decreased Beta-Cell Response
Insulin resistance
Obesity
Food intake
Gastric Emptying – Rate of nutrient absorption
Glucagon secretion
Hepatic glucose output
Insulin secretion in
response to elevated
glucose
First-phase
insulin response
Increased
Beta-Cell
Workload
Hyperglycemia
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Barriers to Injectables, patients
Injection Technique
Inconvenience
Embarrassment
Frequency of injections
Type of injections
Injection Anxiety
FEAR OF PAIN
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Barriers to Injectables,
Physicians
Patients education time
Concern with angering or losing patients
Concern with patient's compliance
FEAR OF PAIN
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21
Fear of Pain
Was quite overestimated by physicians
rather than patients!
In one study, only 12% of patients were
afraid of injectables
Vs 48% of physicians who had this fear!
Remember, insulin is one of the most
UNPOPULAR medicines among
physicians! 21
23
Patients may surprise you!
In a survey of 797 patients with diabetes
80% of insulin naive patients were open to
taking insulin
20% opposed the idea
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24
Injectable medicines in
diabetes
Insulins (Basal, rapid, mixed)
GLP 1 Analogues (Byetta, Victoza,
Bydureon)
Amylin Analogues (Symlin)
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Different Insulin Preparations Currently Available in the United States
Insulin Type Onset (hr) Duration (hr) Peak (hr)
Short acting (regular insulin, R) 0.5-1.0 6-8 2-4
Rapid acting analogues
Lispro (Humalog®)
Aspart (NovoLog®)
Glulisine (Apidra®)
0.05-0.15
0.05-0.15
0.05-0.15
3-5
3-5
3-5
1-2
1-2
1-2
Intermediate acting
NPH
Lente
1-3
1-3
13-18
13-20
5-7
4-8
Long acting
Ultralente
Glargine (Lantus®)
Detemir (Levemir®)
2-4
1.5
1.5
18-30
24
Up to 24
10-14
None
None
Combinations
70/30 NovoLog® mix, 70% NPA, 30%
aspart)
75/25 Humalog® mix, 75% NPL, 25%
lispro
50/50 Humalog® mix, 50% NPL, 50%
lispro
and others
0.5-1.0
0.05-0.15
0.5-1.0
0.05-0.15
0.05-0.15
13-18
13-18
13-18
13-18
13-18
Dual
Dual
Dual
Dual
Dual
Insu
lin
Eff
ect
B D L HS
Bolus insulin
Basal insulin
Mimicking Nature The Basal-Bolus Insulin Concept
Endogenous insulin
Adapted with permission from McCall A. In: Insulin Therapy. Leahy J, Cefalu W, eds. New York, NY: Marcel
Dekker, Inc; 2002:193
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Basal Insulins
Lantus and Levemir (and degludec insulin
within one year from today)
Easy to initiate
10 units once a day
Monitor fasting glucose and increase (or
decrease) the dose by one unit every day
till the fasting glucose is between 80-120
mg/dL
27
28
Ultra rapid acting insulin
analogues
Humalog, Novolog, and Apidra
Easiest way to initiate is WITH the largest
meal of the day
Start 4 units with the largest meal
Monitor the PPG (two hours after the
meal), and increase (or decrease) the dose
by 1 unit every day till the PPG is below
140-150 mg/dL.
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29
GLP1 Analogues
Byetta is twice a day (5 mcg bid then in one month
increase to 10 mcg bid)
Victoza is once a day (start 0.6 mg once a day for 1
week then increase to 1.2 mg a day then if tolerated
you can increase it to 1.8 mg a day)
Bydureon is once a week (2 mg a week, needs to be
mixed)
Interesting combination with insulin 29
Amylin, the Missing Hormone
•Neuroendocrine hormone that is deficient in
diabetes
•Colocated and cosecreted with insulin from
pancreatic beta cells
3
Unger RH, Foster DW. In: Wilson JD, Foster DW, eds. Williams Textbook of Endocrinology.
8th ed. Philadelphia, PA: WB Saunders; 1992:1273-1275.
Amylin IHC staining
Insulin Immunofluorescence
Beta cell islet section
Human amylin
SYMLIN® Works in 3 Ways to Improve
Postprandial Glucose Control
•Enhances feeling of fullness at meals
•Slows inappropriately accelerated
gastric emptying
•Decreases hepatic glucose output
via suppression of postprandial
pancreatic glucagon secretion
8
Please see the Important Safety Information on slides 7, 27, and 28 and
accompanying SYMLIN Prescribing Information, including the Boxed Warning
regarding insulin-induced severe hypoglycemia.
SYMLIN (pramlintide acetate) Injection:
Fine Tuning Blood Glucose Control
With an Added Benefit of Weight Loss
©2009 Amylin Pharmaceuticals, Inc.
All rights reserved. 01-08-6614-C The SYMLIN mark, SYMLIN design mark, SymlinPen mark, and SymlinPen design mark are
registered trademarks of Amylin Pharmaceuticals, Inc. SYMLIN Support Program is a service mark of Amylin
Pharmaceuticals, Inc. All other brand names are the properties of their respective owners.
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Pearls
Type 2 diabetes is a progressive and complex
disease, requires multifactorial approach to
treatment
The ADA, EASD, AACE, and ACE consensus
algorithms for type 2 diabetes include multiple
injectable treatment options
Barriers to the use of injectable therapy exist among
patients and health care professionals
it is important not to compromise patient care
because of concerns regarding use of injectable
therapy
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Practical Points
Many pharmaceutical companies have educators
that are ready to teach your staff how to initiate their
medicines
The pens are quite easy and teach and use
Utilize the education materials and 24 hour support
provided by the manufactures for patients. English
and Spanish services are typically provided
Risk of hypoglycemia, while exists with injectable
medicines, is still low
Always reduce the dose of SU by 50% when adding
an injectable medicine 36