Injectable Therapies in Diabetes

Diabetes Specialist Nurse

Joyce Robson

Learning Outcomes

• Think about the place of injectible therapies in diabetes

• Insulin therapy

• GLP1 antagonists

• Consider commonly used profiles and regimes

• Consider safe practice in injectible therapies

SIGN 154

When do we use injectibles

therapies in diabetes?

• Type 1 diabetes – Always require insulin

No alternative –No insulin production leads to burning of body fats for fuel, and ketone production > DKA

• Type 2 diabetes - 40-50% may require insulin

Insulin resistance � after some time- Variable time line - may have poor response to oral agents. Injectibles may be required

– Insulin or GLP1 antagonist

Which injectibles in T2DM?

• Patients with low BMIosmotic symptoms, weight lossConsider insulin therapy sooner – may be insulin deplete

• Patients with BMI >30kg/m2 – if possible • Patients with BMI >30kg/m2 – if possible avoid insulin - consider GLP-1 Agonists

• 40-50% will require insulin therapy eventually

Now have combination insulin/GLP1 agonist -XULTOPHY

......Insulin in T2DM

• With concurrent problems, may require insulin urgently – for example.......

• Steroid therapy

• Acute infection• Acute infection

• Pre or post surgery

• Gestational diabetes

• Type 2 diabetes in pregnancy

Normal profile in health

In health with no diabetes.........

Mealtime insulin

Background insulin required for basal metabolic requirements

Blood sugar

Breakfast Lunch Evening Meal

Which insulin to use?

• Aim to match insulin profile to meet these basic needs and any specific needs of the individual

• Human vs analogue

• Rapid action• Rapid action

• Short action

• Intermediate action

• Long action

• Mixed insulins

• Insulin mixed with GLP1

• Vial form or pens?

• 200 and 300 iu strengths*****

Commonly used insulin regimes• Once daily– background insulins

To reduces average blood glucose levels• eg. Humulin I, Insulatard, Insuman basal, Levemir,

Lantus , Abasaglar, Tresiba.......often used with oral agents. - less burden for patients or DNs

• Twice daily insulin regimes Using basal insulins or pre mixed insulins, to target

blood glucose profile more specifically

e.g. HumulinI, Insuman Comb 50, Novomix 30, Humalog Mix 50......often used to escalate treatment if once daily regime ineffective

Common Insulin regimes cont.

• Three times daily mixed insulineg. Humalog Mix 50, Insuman Comb 50 – If patient is highly insulin resistant

• Multiple dose injections basal bolus• Multiple dose injections basal boluseg. Insulatard, Lantus or Levemir plus Novorapid or Humalog, Fiasp – usually for patients with type 1 diabetes

• Insulin Pumps Constant infusion of rapid acting insulin – T1DM only

Insulin therapy – getting it right.....

• Injection technique / timing /compliance

• Carbohydrates – too much/ too little

• Avoiding and treating hypos appropriately checking BG results – not just HbA1c results

• Lipohypertrophy - 2/3 insulin injectors

Hands off / Hands on inspection

.......getting it right

• Self managing where possible

• morning insulin � lunch / tea time results

• evening insulin � supper / b’fast results• evening insulin � supper / b’fast results

Stable blood sugars lead to HbA1c results and improved outcomes

•

Getting it wrong.......

• Datix data........

• Delivery devices

• Wrong syringes used

• Withdrawing insulin from pen devices• Withdrawing insulin from pen devices

• Sharps disposal

• Insulin prescriptions

• Communication pathways

• Patients fasting

Glucagon LikePeptide-1 agonists GLP1s

Used only in Type 2 diabetes

Increases insulin production

when blood glucose levels are high.

Reduces insulin production

when blood glucose levels are normal

Results in ����No hypos

(unless on another agent for example gliclazide or insulin)

GLP1 – how do they work?

• Incretin gut hormone which patients with T2DM often

short of

• GLP1 injections � weight loss + improves

glycaemic controlglycaemic control

• Slows down gastric emptying �reduce appetite

Increases feelings of satiety �reduce appetite

• Increases insulin production � improves BG control

Reduces glucose release from liver � improves BG

control

GLP1agents commonly in use

• dulaglutide (Trulicity) Once weekly injections

• exenatide (Bydureon) once weekly injection

• liraglutide (Victoza) once daily injection

• Degludec/liraglutide (Xultophy) once daily insulin/GLP1 • Degludec/liraglutide (Xultophy) once daily insulin/GLP1

mixture

• Useful for patients who need to avoid hypos – eg. taxi

drivers, HGV drivers

• Side effect can be nausea initially

Injection techniques

• Size 4 or 5mm needles now - no need to pinch 90 degree angle

• Rotate sites / Why?

• Lypohypertrophy avoidance

• Encourage patients not to resheath or -reuse needles

• DSN support initially towards patient self managing - use of Injection • DSN support initially towards patient self managing - use of Injection prompt sheets

• Sharps disposal BD safe clip

• Safety pen needles

DN dependent patients on insulin

• Observe GGC policy – Administration of Insulin

by Injection and Blood Glucose Monitoring, District

Nursing

• Syringe/needle - if prescribed insulin is

available in vial form- minimise risk of

needlestick injuries. needlestick injuries.

• If prescribed insulin not available - use a pen

device and BD safe clip to remove needle

• Ask patient to remove needle if possible and

place in sharps box

• Safety pen needles – may be available soon

Further Learning

• 5 Modules available on Learn Pro

• Contact diabetes team if any concerns or need adviceneed advice

Any Questions???

Thank you

Thank you