DiabetesVista Community Clinic and CSUSM Grant

Learning Objectives

• Identify barriers to effective patient teaching.• Identify and teach to the standards of medical care for the management of Type 2 diabetes

• Describe the physiology of insulin and carbohydrate metabolism

• Understand the mechanism of action, dosing, contraindications, adverse effects of insulin in diabetes management.

• Understand blood glucose monitoring and analysis of the numbers for diabetes management.

Insulin therapy: waiting ………… ……………………………… too long?

•Mainstay of therapy for many patients with diabetes when oral therapy fails

•Fear of “starting the needle”•Hypoglycemia and the fear of hypoglycemia

•Frequent fine tuning day to day with increased SMBG

•Weight gain, especially in Type 2 diabetic patients who already overweight.

Insulin therapy • CANDIDATES• Consider in patients with HA1c> 9% or BS 300-350mg/dL on presentation.

• Patients under the age of 35 usually have an atypical form of diabetes and may need insulin

• Patients with diabetes longer than 10-15 years have a greater chance of B-cell exhaustion

• Thin patients are more likely to have decreased levels of insulin and respond poorly to oral antidiabetic therapy

• Latent autoimmune diabetes in adults (LADA)

Education• Explain to the patient beta cell exhaustion has led to the decrease of circulating insulin. Often the beta cells have worked overtime for years.

• Don’t use insulin as a scare tactic

Insulin therapy

• Benefits:• Suppresses liver glucose production• Decreased post meal glucose levels• Improves abnormal lipoproteins.• Lessens glucose toxicity and improves B cell function

• Start: A1c 1.5% above goal and oral therapy not working (2-3 oral meds)

Combination Therapy Nighttime Insulin + Oral Antidiabetic

Drugs

• Patient does not need to know how to mix insulins• Patient compliance much better with one single injection at bedtime

• Patient does not need to take an injection at work• Nice way to initiate insulin• One injections versus multiple injections• Hypoglycemia at night most significant with NPH, less with detemir and least with glargine

• Example: Patient weighing 72 kg divided by 10=7.2 units of NPH, detemir or glargine

Basal Insulins: long acting analoguesInsulin

Onset of Action

Peak Action

Duration of Action

Lantus 1-2 hours

peakless

Up to 24 hours

Detemir

0.8 to 2 hrs.

Flat Up to 24 hours

NPH 2-3 hours

6-8 hours

16-20 hours

Insulin profile

Split premixed insulin: Two injections

• If glycemic control is not achieved , discontinue orals and consider split mixed insulin.

• Pre breakfast and pre dinner dose of an intermediate and fast acting insulin for Type 2 diabetes.

• Weight gain frequently occurs as insulin therapy intensifies.

• For obese patients: Novolog 70/30 or Humalog 75/25 equally split between pre breakfast and predinner.

• Morbidly obese patients: insulin requirements rise dramatically

• Thin patients: increased sensitivity to insulin• Very little flexibility in meals, need carb consistency

Insulin profile

Rapid acting analoguesOnset of action: 10-15 minutes

Peak of action: 1-2 hoursDuration of action: 3-5 hours

Glulisine

Apridra

Humalog

LisproNovolog

Aspart

Pre-mixed insulin profilesRapid acting and intermediate

Insulin Profiles

6 9 12 15 18 21 24 3 60

1

2

3

4

5

6

7

8

Glu

cose

Inf

usio

n R

ate

(mg/

kg/m

in

Time

Regular Insulin

Insulin Onset of Action

Peak Action Duration of Action

Regular 30 minutes 2-3 hours 6-8 hours

Premixed insulinsFast and intermediate acting insulin

Insulin profile

Mixed insulin profiles• Dosing prior to dinner with mixed increases risk of nocturnal hypoglycemia due to peak of the NPH

Mealtime Insulin & Long-acting InsulinBasal/Bolus Insulin Therapy

• Basal insulin given with rapid acting being given to cover the mealtime glucose increase.

• Provides flexibility for meals at differing times

• Fewer incidences of nocturnal hypoglycemia

• Add a mealtime insulin when the fasting is good but the patient’s A1C is not good -OR-

• Patient is using greater than 0.5 units/kg/day of basal insulin

Intensive Insulin Therapy

Instructing on insulin

• 100, 00o ER visits for insulin related errors or hypoglycemia, 1/3 result in hospitalization.

• Have patient check insulin labels before injecting to avoid mix up of rapid acting vs. basal insulin

• Incorrect timing• Emphasize the importance of eating meals after taking mealtime insulin

• Inability to see to draw up an accurate dose due to vision or dexterity

• Consider a magnifier, device that clicks with pen or “Count a Dose” for syringe users

GLP-1-Glucagon like polypeptides-1• Liraglutide (Victoza)• Exenatide (Byetta)• Exenatide ER (Bydureon)• Albiglutide (Tanzeum)• Dulaglutide (Trulicity)• Activates GLP-1 receptor sites• Lowers both fasting and postprandial BG

• Helps with weight reduction and rarely causes hypoglycemia: Popular

• Delays gastric emptying• HA1c reduction of ~1%-1.5%

GLP-1-Glucagon like polypeptides-1• Decreases fasting and post meal blood sugars and delays gastric emptying

• Strictly glucose dependent, no hypoglycemia

• Significant reductions in appetite and food

• New analogues resist the DPP-4 degradation

• Subcutaneous injection• S/E: N/V, diarrhea mild to moderate, titrate slowly; pancreatitis and thyroid cell CA risk

• $300-$450/month

Amylin analogue 0.5-1% Pramlintide Symlin

• Activates the amylin receptors in the B-cell

• Injection• Slows gastric emptying and creates a feeling of fullness (satiety)

• Decreases the secretion of glucagon• Weight loss• S/E: Nausea, hypoglycemia w/insulin need to reduce dose of insulin

• Administer by injection just prior to meals, titrate slowly, adjust insulin down

• ADA: Third line due small change in the HA1c

• HA1c reduction: 0.3-0.6%• $625/month

GLP-1-Glucagon like polypeptides-1

• Therapy: SC injection; 12-18% injection site reactions

• Contraindicated in ESRD or CrCl <30mL/min, caution with hepatic impairment

Amylin analogue 0.5-1% Pramlintide Symlin

• Injection• Slows gastric emptying and makes a feeling of fullness (satiety)

• Decreases the secretion of glucagon

• Weight loss• S/E: Nausea, hypoglycemia• ADA: Third line • $625/month

Self monitoring of blood glucose(SMBG)

• Accurate and immediate results• Valuable tool in educating patients

• Evaluate effects of their treatment

• Increase independence• Post prandial glucose can teach patients the effect of the carbs they consumed in that meal

• Prevent and detect hypoglycemia or hyperglycemia

• Assists in adjusting treatment to stress, exercise, and diet

• Plasma venous glucose measurements are within 15% of results of whole blood capillary glucose sample.

Why are patients so reluctant to perform SMBG?

• Discomfort from poking their finger

• Complex process with some systems

• Inaccurate results from poor techniques

• Broken meter • Alternative site testing is not as “real time” as the fingertip measurements

Blood sugar monitoringPatients on diet and oral meds

Pre breakfast: 2-3 tests/week1-2 hours post dinner: 2-3 tests/week

Combination therapy

with nighttime

insulin

Pre breakfast: 4-7 tests/weekPre-lunch: 2-3 tests/week2 hours post dinner: 2-3 tests/week

Intensive insulin therapy

One injection/day: 2 tests/day, no less than 1-3 depending on BS controlTwo injections/day: 4 tests, pre-meal and bedtimeMultiple injections: 4-7 tests/day

Techniques of blood sugar monitoring

• If you're unable to wash your hands, using an alcohol swab is a good alternative.

• Do you know what do when you get your results? What action did you take?

Continuous glucose monitoring

• Continuous glucose monitoring now has a sensor augmented low glucose suspend threshold pump for those with night time hypoglycemia or hypoglycemia unawareness.

Sick day management

• Stress hormones can elevate sugars

• If possible eat the same number of carbs, try liquids

• If vomiting, drink plenty of sugar free, caffeine free fluids to prevent dehydration.

• HOLD metformin with possible dehydration

• Take glucose every 3-4 hours

• Take regular meds unless otherwise instructed

• Check urine and blood ketones

Emergency: Diabetic ketoacidosis

•Occurs from insulin deficiency, more commonly seen in Type 1, however can be seen in Type 2

•Poor nutrition triggers dehydration and catabolism

•Physiologic stress •Poor metabolic control (glucose toxicity)

•Dehydration occurs as kidneys attempt to flush out ketones and sugar, depleting sodium, potassium and other electrolytes

DKA

• Key symptom: GI distress

• Nausea, vomiting, abdominal pain, anorexia

• Dyspnea• Myalgia• Headache• Hypothermia• Acetone breath• Dehydration• Stupor, confusion • Tachycardia

Emergency: Hyperosmolar hyperglycemic syndrome

Severe high blood sugar:>600Absence of ketosis or just slightMay be precipitated by infection, UTI or pneumoniaPlasma or serum hyperosmolality*• Onset of symptoms is more gradual over days to weeks

• More common in nursing home patients without access to free water

• Older obese patient with Type 2 DM• May mimic a CVA w/hemiparesis• Mental status changes much more common

• Profound dehydration: Excessive thirst, lethargy, delirium visual and sensory changes, coma and death

• Minimal GI affects• Kussmaul breathing is rare

Resources

• American Diabetes Association. (2013). Standards of care in diabetes, Diabetes Care, 36(1), January 2013.