BEST 4 Diabetes. Optimisation of insulin module

Transcription

1 BEST 4 Diabetes Optimisation of insulin module

2 Confidence and competence Where would you rate yourself?

3 Why do all of our patient not achieve optimal blood glucose control?

4 Insulin Therapy Goals and Purpose of Insulin Therapy Barriers to the use of Insulin Current Concepts in Insulin Therapy Basal/Bolus Insulin (Insulin Pump Therapy)

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7 Why do patients delay insulin treatment? Concern about injections Worry over hypoglycaemia Fears for weight gain Stigma of insulin injections Concern about employment False previous family experience Strong negative cultural beliefs

8 Why do patients delay insulin?

9 Reasons for poor diabetic control Delay in commencing insulin treatment Insufficient dose titration Failure to control fasting blood sugar Inappropriate insulin mix False concerns about maximum insulin dose

10 Helping Patient Accept Insulin Therapy Address patient concerns Dispel fear by countering misconceptions Review rationale for insulin use Hypoglycaemia is infrequent, and can be easily treated, and that severe hypoglycaemia is rare Treatment need not be burdensome Weight gain can now be managed with adjuvant treatment Is a common course of treatment for this progressive disease Promise patient support and close follow-up Monitoring can prevent hypoglycemia Today s technology can facilitate daily injections and readings

11 Recap Insulin Time action profiles Group Work

12 CSII Continuous Subcutaneous Insulin Infusion Insulin Pump A continuous infusion of rapid acting insulin, no requirement for long acting insulin. For Type 1 s under secondary care. Make sure patient has insulin pens and insulin in case of pump failure.

13 Choice of insulin treatments Once daily NPH/Analogue Basal with oral agents/glp1 T2DM and some T1 patients dependant on others for care Twice daily Either Combination bd/tds Biphasic insulin (Human or Analogue) T1 or T2 or bd (NPH/Analogue T2DM) Basal Bolus T1 or T2DM (Human-NPH/Analogue Bolus-Basal) Insulin pump treatment T1DM only

14 Injection technique: key messages injection sites insulin storage injecting process correct use of injection device use of pen needles or syringes once site rotation injecting into subcutaneous fatty tissue absorption rates needle length appropriate use of skin folds disposal of injecting material FIT (Oct 2011), The First UK Injection Technique Recommendations, 2 nd Edition

15 FIT (Forum for Injection Technique) Education topic areas At the beginning of injection therapy (and at least every year thereafter) the HCP should discuss: injection regimen choice and management of the devices used choice, care and self examination of injection sites correct injection technique (including site rotation, injection angle and possible use of skin folds) injection complications and how to avoid them optimal needle length safe disposal of used sharps FIT (Oct 2011), The First UK Injection Technique Recommendations, 2 nd Edition

16 Needle length/skin fold? mm thick Depth varies depending on site Image reproduced with permission from Becton Dickenson

17 Needle length/skin fold? Needle length Skin fold Comments 4,5,6mm No Unless injecting into slim limbs/abdomen 8mm Yes Shortest length available for an insulin syringe 12.7mm Yes No clinical reason to use this length

18 Absorption rates and injection sites Insulin type Most favoured injection sites Why? NPH insulin Thigh, buttocks Slowest absorption sites Short-acting insulin Abdomen Fastest absorption site Premixed insulin (human or analogue) Insulin analogues: rapid and longacting GLP-1 agonists Abdomen morning Thigh or buttock eve meal May be given at any injection site Follow manufacturer s instructions Increase speed of short /rapidacting insulin to cover post prandial breakfast Leads to slower absorption and decreases risk of nocturnal hypoglycaemia Absorption rates do not appear to be site specific More studies are needed FIT (Oct 2011), The First UK Injection Technique Recommendations, 2 nd Edition

19 Risks associated with lipohypertrophy Unpredictable and delayed insulin absorption Can result in larger insulin dosages being used May cause fluctuating glycaemic control with unpredictable hyperglycemia and hypoglycaemia Image reproduced with permission from Becton Dickenson

20 Management of lipohypertrophy Prevention Site rotation Fresh needle management Move away from the site for months/years Consider a reduction in insulin dosage Use blood glucose monitoring to assess need for further insulin dose alterations Encourage self inspection of sites and check at reviews Image reproduced with permission from Becton Dickenson

21 Images reproduced with permission from Becton Dickenson

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23 Recap Insulin devices Insulin terminology

24 Recap Hypoglycaemia BHFT Leaflet Hyperglycaemia and sick day rules Trend Leaflet

25 Berkshire West Insulin Optimisation Framework for Type 2 Diabetes Recommend initiation on human basal insulin Patient able to self titrate & have carb awareness Consider alternatives if ; District Nurse to Administer 60u BD Basal Bolus Steroid Patients Nursing Home Patients Erratic Eating Patterns In these cases contact DSN team for advice 60u BD 60u BD BD Human or 60u BD BD Mix 50/50 TDS Mix 50/50 30 units BD Analogue Mix Once Daily Human Basal Human Basal DSN Referral Recommended Low Skills and Capabilities High

26 The Ideal Basal Insulin... Mimics normal pancreatic basal insulin secretion Long-lasting effect around 24 hours Smooth, peakless profile Reproducible and predictable effects Reduced risk of nocturnal hypoglycemia Once-daily administration for convenience 6-32

27 What are the problems with basal insulin treatment? Insufficient length of action requiring twice daily dosage Large intra-dose variability leading to increased hypoglycaemia or loss of daytime control Excess basal insulin treatment, leading to weight gain High dose volumes in insulin resistant and obese patients

28 NICE recommendation for initiation onto insulin offer NPH insulin once or twice daily according to need

29 Analogue basal Insulin Patients who are demonstrated have problems with human basal insulin treatment Patients with nocturnal hypoglycaemia?? Patients with excess weight gain Patients requiring third party administration of insulin treatment

30 Starting with Basal Insulin Continue oral agent(s) at same dosage (eventually stop secretagogue) Add single, evening insulin dose (around 10 U) Glargine (bedtime or anytime?) NPH (bedtime) Mixed Insulin 70/30 (evening meal) or 75/25 Adjust dose by fasting BG Increase insulin dose weekly as needed Increase 4 U if FBG >10 mmol Increase 2 U if FBG = 7-10 Treat to target (usually <7mg/dL) 6-59

31 Case Studies Put knowledge into practice.

32 Confidence and competence Where would you rate yourself?

33 Community Diabetes Specialist Nurse Team