Insulin Initiation In Primary Care

Dr Arla Ogilvie Endocrinologist Watford General HospitalWest Herts Hospitals NHS Trust

Does the Patient Need Insulin?

?Is it appropriate for the patient to be managed in Primary Care?

?Sufficient KnowledgeSkillsSupport TimeConfidence

? Have all other factors relating to control been addressed

Insulin Resistance….3Types

Liver

Muscle

Metabolic

Patient

Doctor

Before you start……Understand the patient• Is insulin necessary?• Factors in poor control

– Diet and ex– Compliance with Rx– Health beliefs– Fears

• Hypoglycaemia• Weight gain• Occupation

Understand the insulin• Type and regime

– Once daily + oral agents– Twice daily premix– (Basal bolus???)

• Starting dose• Patient EDUCATION• TIME for follow up• Dose titration• Regular review and support

Setting Individual Goals

• Optimise blood glucose control• Keep patient asymptomatic• Prevent long term complications• Avoid hypoglycaemia• Preserve Quality of Life

Safety is paramount!

Self-monitoring of blood glucose

• Monitoring glucose is essential for safe and successful insulin treatment:

– It guides dose adjustment– It allows patients to see the impact of behaviours and

diet on glucose• Patients MUST know how to monitor glucose• The most important aspect of self-monitoring is

that the patients DO something with the results

Diabetes UK. http://www.diabetes.org.uk/hcpreports/primary_recs.pdf, 2005 National Diabetes Support Team.

http://www.cgsupport.nhs.uk/downloads/NDST/Factsheet_Glucose_Self_Monitoring.pdf, 2005NICE. http://www.nice.org.uk/page.aspx?o=36882, 2005. Owens D et al. Diabetes and Primary Care 2004;6:8–16

Once-daily basal insulin• Duration depends on the insulin• Insulin analogues may provide 24-hour cover• Intermediate isophane preparations (Insulatard

and Humulin I) may only be active for 8 – 18 hours and have a more pronounced peak activity

Time (8–24 hours)

Insu

lin a

ctiv

ity

Insulin

Schematic representation

Benefits of a once-daily basal insulin regimen

• One injection per day• Useful for patients reluctant to start insulin treatment • Works best for morning hyperglycaemia• Useful where someone else has to administer insulin • May help overcome fear of starting insulin • Some basal insulin injections may provide a weight

benefit1

1.Philis-Tsimikas A et al. Clin Ther 2006;28:1569–81

Limitations of once-daily basal insulin regimen

• Does not provide insulin for post-meal glucose surges:– Assumes patient can produce sufficient insulin

to cover these mealtime requirements• Requires a fairly strict, predictable diet:

– Dosing during the day is inflexible and so patients need to intake similar calories each day

How Much?TYPE 2

Nocte Isophane insulin Insulatard or Humulin I

Start 10units + Metfomin and Sulphonylurea (Glitazone)

Titrate once or twice weekly

Newer agents•Gliptins •GLP1 Analogues

Are NOT licensedTo be given with insulin

Easy Dose Adjustment for Once Daily Basal Insulin

• The 3 – 0 – 3 Rule • After Initiation• Adjust insulin every 3 days• Based on fasting glucose• If average glu > 7 – increase by 3 units• If glu < 4mmol/l decrease by 3 units

Premixed insulin In

sulin

act

ivity

Brkfast Lunch Dinner Bedtime

Basal + Rapid acting component

Possible regimens:• Once daily with largest

daily meal (usually dinner)

• Twice daily with Twice daily with dinner and breakfastdinner and breakfast

• Three times daily, with each meal

Mixtard 30 – may need snacksWait 30 mins between injecting and eating

Novomix 30 No snacks neededInject and eat immediately

Benefits of a premixed insulin regimen

• Targets mealtime glucose• Can be initiated as one injection per day to

familiarise patient with injecting (Most need twice daily)

• Second or third injections of same insulin can be added if necessary to optimise control

• Need fairly regular lifestyles, Eat similar amounts at similar times

1. Garber AJ et al. Diabetes Obes Metab 2006;8:58–66

Analogue basal-bolus therapy

Breakfast Lunch Dinner Bedtime

Rapid-acting insulinLong-acting insulin

Insu

lin a

ctiv

ity

Rapid insulin

Long-acting insulin

Rapid insulin

Rapid insulin

Benefits of a basal-bolus insulin regimen

• Closest to natural insulin production by the body• Not necessary for majority of Type 2• May be needed for those who have erratic

mealtimes, work variable shifts• Gives more flexibility over type of food and

when it can be eaten• Suited to those who are highly motivated• Need to monitor 4 times daily to optimise doses

Insulin with or without oral agents?

• Oral agents can be continued when once daily basal insulin is initiated

• It is recommended that metformin is continued where possible in T2 DM

• Stop Sulphonylurea with premixed insulin• Glitazones can be used with insulin – usually

where intolerant to metformin. Oedema may be a problem

Commencing Insulin Therapy• Ensure patient can blood glucose monitor and understands BG targets• Assess patient for suitable device• Educate patient regarding :1. Storage, timing and action of insulin. 2. Device use and safety3. Injection technique, sites and rotation.4. Hypoglycaemia 5. Driving safety and legal Implications6. Sick day Rules – 7. Dose Adjustment and exercise ( if suitable)8. After education full assessment carried out to ensure patient

competence and safety.

POOR CONTROL -Troubleshooting!

Compliance - Rx, lifestyle, acceptance Unable to use Pen - check technique Withdrawing needle too soon - ‘count to 10’ Site problems -random rotation/hypertrophy Wrong timing of injections Eating to avoid hypos Rebound hyperglycaemia- check Sx of hypo