LET S TALK INSULIN THE BASICS
|
|
- Spencer Ward
- 6 years ago
- Views:
Transcription
1 LET S TALK INSULIN THE BASICS
2 AUTHOR S DISCLOSURES Contracted for program development for Lifescan Canada Speaker for Lifescan, Lilly, BI, Consultant for Lilly, Janssen, Novo Nordisk, Lifescan Canada
3 OBJECTIVES After completing this workshop the participant will be able to: 1. Discuss benefits of SMBG with insulin use. 2. Practice pattern identification. 3. Identify insulin action times. 4. Discuss criteria for choosing patient specific insulin regimens. 5. Discuss action to be taken to prevent hypoglycemia.
4 PLAN FOR MANAGING DIABETES Insulin Activity Blood glucose Lifestyle Healthy eating
5 MANAGEMENT PLANS Every individual is different No one insulin plan will suit everyone Consider all factors that affect blood glucose levels. Meals: type, amount, and timing of meals Activity: type, duration, and timing of activity Insulin: type and timing of insulin Lifestyle: stress, anxiety, sleep patterns
6 INSULIN REGIMENS Type 1 diabetes to achieve glycemic targets use multiple daily insulin injections (MDI) or CSII (pump) Type 2 diabetes when glycemic targets are not met with lifestyle and antihyperglycemic agents insulin should be initiated -
7 NORMAL INSULIN SECRETION 60 Insulin Time of day Breakfast Lunch Supper adapted from Owens, Zinman,& Bolli,2001
8 INSULIN REGIMENS: 1. Basal insulin once or twice daily. 2. Premixed insulin 2-3 x per day. 3. MDI: basal and bolus insulin 4. CSII
9 BASAL INSULIN Type of Insulin When It Should Be Taken Onset (starts working) Peak (working hardest) Duration Interme diateacting Novolin NPH Humulin N Longacting As prescribed 1 3 hr 5 8 hr Up to 18 hr Longacting Lantus (Glargine) Levemir (Detemir) As prescribed 90 min No peak Up to 24 hr
10 Type of Insulin BOLUS INSULIN When It Should Be Taken Onset (starts working) Peak (working hardest) Duration Rapidacting NovoRapid Lispro: Humalog Glulisine 15 min or less before a meal min min 3 5 hr Shortacting Novolin Toronto Humulin R min before a meal 30 min 2 3 hr 6.5 hr
11 PREMIXED INSULINS Premix (with shortacting) Premix (with rapidacting) Type of Insulin When It Should Be Taken Novolin 30/70, 50/50 Humulin 30/70 NovoMix 30 Humulin Mix min before a meal 15 min or less before a meal Action Time Premixed insulin will have the same onset, peak, and duration as the types of insulin in the premix. For example: Novolin 30/70 will have the onset, peak, and duration of both regular and NPH insulin. NovoMix 30 will have the onset, peak, and duration of rapid-acting and intermediateacting insulin.
12 ACTION PROFILES OF BOLUS & BASAL INSULINS Plasma Insulin levels mu/l aspart/glulisine/lispro 3-5 hours regular 5-8 hours NPH ~14 hours Diagrammatic representation Action curves are approximations taken from different data sources. Actual patient response will vary detemir/glargine ~24 hours Hours Hours
13 KNOW THE ACTION PROFILE It is important that patients using insulin know the type and action profile of the insulin they are on. It will help them: Know when they are at risk of hypoglycemia Decide when to check their blood glucose Decide which factors in their management plan need to be adjusted to achieve their targets
14 ADDITION OF BASAL? MIXED? 1. Treat-to-Target trial: N or glargine added to OHA effective 2. Janka et al: Basal versus premixed Added to SU and metformin Basal more effective 3. Raskin et al: basal versus mixed d/c SU Mixed more effective if SU d/c
15 BASAL /BACKGROUND INSULIN Often a good starting point for insulin use Initially targeting fasting blood glucose Options: intermediate acting insulin N or NPH Longacting insulin : detemir or glargine What is the advantage of one over the other?
16 BASAL /BACKGROUND USING INTERMEDIATE-ACTING INSULIN Intermediate acting Breakfast Lunch Supper
17 DISCUSSION Mr. Singh presents with a prescription for detemir. You note he has type 2 diabetes and is already on NPH before breakfast and before supper He says the doctor just told him to take this one Why do you think the MD has prescribed detemir? What should you ask Mr. Singh? How should Mr. Singh be switched to detemir?
18 BASAL/ BACKGROUND USING LONG- ACTING INSULIN glargine/levemir Breakfast Lunch Supper
19 VARIABILITY IN TIME-ACTION PROFILE OF BASAL INSULINS Dose at each injection: 0.4 U/kg, thigh Clamp 1 Clamp 2 Clamp 3 Clamp 4 GIR mg/(kg min) NPH insulin 8.0 Insulin glargine 8.0 Insulin detemir Patient Patient Patient Time (hours) Time (hours) Time (hours) 0 Glucose infusion rate profiles following four non-consecutive injections of identical doses (0.4U/kg, thigh) in three patients T. Heise, et al. Diabetes 2004
20 INSULIN GLARGINE: THE ONLY BASAL INSULIN TO PROVIDE A 24-HOUR PROFILE WITH NO PRONOUNCED PEAK Glucose utilization rate (mg/kg/min) Hourly mean values Insulin Glargine (n=20) NPH Insulin (n=20) Time after SC injection (hours) SC, subcutaneous. Adapted from LANTUS (insulin glargine) Product Monograph 2005.
21 Glucose concentration (mg/dl) CONTROL OF POSTPRANDIAL BG NEEDED AS DIABETES PROGRESSES Fasting (nocturnal period) Morning Period Time of day (24-hour clock) Monnier L et al., Diabetes Care 2007; 30: Postprandial (daytime period) Curve 1 (blue): A1C <6.5% Curve 2 (red): 6.5 to <7% Curve 3 (green): 7 to <8% Curve 4 (orange): 8 to 9% Curve 5 (purple): 9% Diabetes duration (years)
22 DISCUSSION Mrs. Jones comes in with prescription for Insulin 30/70 15u ac breakfast and 10u ac supper. She is currently on glyburide 10 mg BID and metformin 1000 BID Should she discontinue her oral meds? When does premix insulin work? Why is she being started on premix? When should she take the insulin?
23 PREMIX INSULIN TWICE A DAY OR TWICE DAILY RAPID OR SHORT AND INTERMEDIATE Rapid or short acting Intermediate acting Breakfast Lunch Supper 23
24 PREMIX INSULIN Advantages 2 injections a day No mixing insulins leads to fewer mistakes Intermediate acting provides basal dose Intermediate may provide the bolus for lunch especially if using a premix containing short acting insulin. Disadvantages Cannot adjust for meals or activities Need for a consistent lifestyle Intermediate-acting insulin taken at supper might increase risk of hypoglycemia around 3 a.m.
25 PREMIXED/TWICE A DAY INSULIN 60 Insulin Breakfast Lunch Supper Michener, 2004
26 Rapid versus short acting insulin aspart, glulisine
27 MOST COMMON - RAPID-ACTING MIXTURE BEFORE BREAKFAST & DINNER
28 BASAL PLUS CONCEPT: A1C > 7.0% Continue basal at hs (overnight BG control) Continue Oral AHA (daytime BG control) Add 1 dose of prandial insulin with the meal with the greatest impact on 2 hr pc BG OR start with largest meal SMBG pre & 2 hours post meals to determine timing of 1 st dose
29 BASAL PLUS Pros Step-wise transition to more physiologic insulin replacement More flexibility with meal(s) Able to correct for high BG pre main meal Less risk of lows (nocturnal) People can be taught to adjust doses based on 2hr pc BG patterns & changes in food /activity Rapid-acting are preferred over short-acting insulins. Cons Two injections. Increase SMBG 3-4. Learn more about carbohydrate amount of food.
30 BASAL PLUS: HOW DOSE IT WORK? AHA Basal Basal Bolus
31 BASAL-BOLUS REGIMEN WITH LONG- ACTING INSULIN Rapid or short acting Long-acting insulin Breakfast Lunch Supper 31
32 THINK LIKE A PANCREAS. Physiological production of insulin: Basal/background insulin 50% Bolus /mealtime insulin 50%
33 KEY TO BETTER CONTROL Self monitoring of blood glucose
34 BLOOD GLUCOSE TARGETS Before Meals After Meals CDA Recommendations mmol/l mmol/l A1C Less than or equal to 7% Individualize
35 SHORT OR RAPID ACTING INSULIN: WHEN TO GIVE IT AND WHEN TO CHECK BG Type of Insulin When Given When to Check Rapid-acting Novolog or Humalog Given within 15 mins of start of meals Check at peak action time, hours after meal Short-acting Novolin R or Humulin R Given mins before meals Check at peak action 2-3 hours after injection Checking before and after meals allows the person to assess if the insulin was adequate for the meal
36 INTERMEDIATE ACTING INSULIN: WHEN TO GIVE IT AND WHEN TO CHECK BG Type of Insulin When Given When to Check Intermediate -acting Novolin N (NPH) or Humulin N Given before breakfast Given before supper Given at bedtime Peak action 5-8 hours, check around lunch and again presupper to determine duration of action Before bed, 2 to 3 a.m. once or twice a week until stable as it may cause hypoglycemia during the night and check before breakfast 2 to 3 a.m. once or twice a week until stable as it may cause hypoglycemia during the night and check before breakfast
37 LONG-ACTING INSULIN; WHEN TO GIVE IT AND WHEN TO CHECK BG Type of Insulin When Given When to Check Long-acting Lantus or Levemir Given before breakfast, supper or at bedtime Background insulin efficacy can be checked fasting and pre supper
38 PREMIX INSULIN: WHEN TO GIVE IT AND WHEN TO CHECK BG Type of Insulin When Given When to Check Premix (with short-acting) Novolin 30/70, 50/50 Humulin 30/70 Given mins before breakfast and supper Check at peak action 2-3 hours after injection and at 2 to 3 a.m. once or twice a week until stable as it may cause hypoglycemia during the night and check before breakfast Premix (with rapid-acting) NovoMix 30 Humulin Mix 25 Given within 15 mins before breakfast and supper Check at peak action time hours after meal and at 2 to 3 a.m. once or twice a week until stable as it may cause hypoglycemia during the night and check before breakfast
39 TWO WAYS TO LOOK AT BG Immediate Results If the level is low, what caused it? A skipped meal or some activity? If it is high, are you feeling sick? Did you eat more than usual? Patterns of Results from Several Days Are you always low at the same time of day? Or always high at The same time of day?
40 SAMPLE CHECKING PATTERN: RAPID OR SHORT ACTING PRE-MEALS WITH LONG- ACTING ONCE A DAY acb pcb acl pcl acs pcs 3 am After 7 or 8 days, have three sets of data for before and after each meal. A 3 a.m. check would also allow you to rule out low blood glucose at that time.
41 SAMPLE CHECKING PATTERN: PREMIX INSULIN TWICE A DAY acb pcb acl pcl acs pcs 3 am Checking after breakfast and pre-supper will determine if the morning premix dose is working. Checking post-supper and fasting will determine if the supper dose is working. Premix insulin at supper will peak in the middle of the night so it is important to check at 3 a.m. to ensure the blood glucose is not low.
42 WHAT IS A BLOOD GLUCOSE PATTERN Low pattern: 2 low results, in 5 days at the same time of day High pattern: 3 high results, in 5 days at the same time of day ac B pc B ac L pc L ac S M pc S T W T F 6.2 acb pc B ac L pc L ac S M pcs T W T F
43 PATTERNS IDENTIFY AREAS OF CONCERN Need consistency in lifestyle, meals and activity over the period before looking for patterns. When a high or low pattern is identified, a change may be needed. in foods, activities, timing of meals or injections, or doses of insulin. These changes should be discussed with a healthcare professional. Watch results for several days before making a change. Wait several days after making a change before making another change. If too many changes are made too often, blood glucose levels might start fluctuating.
44 WHAT PATTERN TO WORK ON FIRST When finding more than one kind of pattern, focus on addressing the patterns one at a time in this order: 1. Low pattern at any time 2. High before breakfast (fasting) pattern 3. High before other meals 4. High after meal pattern
45 PATTERN IDENTIFICATION Day Before Breakfa st After Breakfa st Before Lunch After Lunch Before Supper After Supper Mon Tues Wed Thurs Fri 6.2 Sat 7.6 Sun 6.8
46 POSSIBLE CAUSES OF LOW PATTERNS Possible causes Potential Action Not enough carbohydrates in your previous meal or snack You ve been more active than usual Your meal times have changed with more time between meals Too much insulin Alcohol intake Plan consistent meals and snacks Might need to increase snacks when active or reduce insulin Might need a snack between meals May need to reduce insulin dose Eat carbs when drinking
47 HIGH PATTERN BEFORE BREAKFAST Possible Causes Your supper time insulin is not lasting long enough or the dose you took is not enough Your supper time insulin is causing you to drop too low around 3 a.m., resulting in a rebound high before breakfast or the dose you took was too much You forgot your evening dose of insulin or the dose you took was not sufficient You had a larger meal than usual or had a late snack Potential Action Change timing of insulin or increase dose Move supper basal insulin to bedtime Remember to take all doses of insulin; may need to increase dose May need to eat earlier or reduce after supper snacks
48 HIGH PATTERNS AT TIMES OTHER THAN BEFORE BREAKFAST The pre-meal insulin did not cover the food consumed Your basal dose of insulin is not enough to keep your levels at target throughout the day The timing of your insulin is off in relation to the meal Check if you ate the appropriate amount of food or check with your diabetes care team about changing your insulin dose Discuss this with your diabetes care team Try to be consistent with meal times and when you take your insulin Your insulin dose may not be meeting your needs and should be adjusted by your healthcare professional
49 SUSANNE 56 years old, type 2 diabetes for 15 years Currently on glyburide 10 mg BID, metformin 1000 mg BID Comes to pharmacy with prescription for long-acting insulin to be taken at bedtime. Susanne asks you to show her how to take it and to go over the instructions she got from the doctor
50 HOW WILL YOU MAKE TIME TO DO THIS? Book her to come in later in the day? Ask someone to cover and take her into the consult room immediately? Teach her over the counter? Call the Diabetes Education centre and get her an appointment? Ask your Pharmacy Tech to do the teaching?
51 PLAN OF ACTION Evaluation Needs Assessment Implementation Plan Development
52 WHERE TO START?? 1 ST ASSESSMENT Ask her how she feels about giving insulin Ask her if she knows anyone else on insulin and what has been their experience Ask her if she has ever done an injection Ask her if she knows why the doctor has prescribed insulin
53 ATTITUDES TO INSULIN (POLANSKY 2003) Factor Description Frequency Perceived loss of control over life Poor self esteem Personal failure Perceived disease severity Restrict life, eat out, Travel, cannot stop Decisions time and dose, complicated Punishment gluttony, Sloth Causes problems, more dangerous 61.4% 40-50% 50% Hisp 72.2% Non Hisp 8.1% Injection Anxiety True phobia rare 50% Perceived lack of positive gain Disbelief/unaware of benefits 90%
54 2 ND PLAN WHAT SHE WANTS TO KNOW AND WHAT SHE NEEDS TO KNOW Reason for insulin at this stage of diabetes Action of insulin in relation to oral meds she is on Timing of injection How to prepare syringe or pen How to inject Possible side effects hypoglycemia, cause, S & S and treatment Storage of insulin Checking blood glucose when Titrating dose as per doctor s order
55 3 RD IMPLEMENTATION HOW TO DO THE TEACHING Explain that people with type 2 diabetes eventually run out of insulin Explain action of long acting insulin using flip chart Demonstrate preparation of syringe or pen Have her redemonstrate back to you Discuss sites and have her put needle into skin without injecting insulin
56 3 RD IMPLEMENTATION HOW TO DO THE TEACHING CONT D Explain hypoglycemia, use handouts to illustrate S & S and treatment Discuss timing of blood glucose checks and recording in logbook Discuss titrating insulin dose: need for follow-up
57 Target before meals Target after meals
58 HYPOGLYCEMIA MILD MODERATE SEVERE Trembling, Palpitations, Sweating, Anxiety, Hunger, Nausea, Tingling mmol/l Difficulty concentrating, Confusion, Weakness, Drowsiness, Vision Changes, Difficulty speaking, Headache, Dizziness, Tiredness mmol/ L Need assistance, either conscious or unconscious < 2.8 mmol/l
59 TREATMENT OF HYPOGLYCEMIA: mmol/l mmol/l < 2.8 mmol/l MILD MODERATE SEVERE 15 gms carbohydrate; ¾ cup regular pop ¾ cup juice 7-8 lifesavers 3 glucose tabs 4 dextrosols 3 tsp sugar, jam, or honey 20 gms carbohydrate 1 cup regular pop 1 cup juice lifesavers 4 glucose tabs 4 tsp sugar, jam or honey Glucagon kit, IV glucose, nothing by mouth Re-test in 15 minutes, if still < 4.0 mmol/l, retreat with: Another 15 gms of carbohydrate.
60 4 TH EVALUATING CAN SHE DO IT AT HOME? Watch her prepare syringe or pen Watch her put needle into skin Ask her what she might feel like if blood glucose went too low Ask her what she would do about it Ask her what time she will give insulin Ask where she will keep her insulin and where she will give it DO NOT ask her if she understands!!!
61 ROBERT 60 years old, type 2 diabetes for 20 years Current meds, metformin 1000 mg BID, sitagliptin 50 mg BID, A1C 8.5% Eats healthy, active lifestyle Brings a prescription to pharmacy for rapid acting insulin ac meals, long acting at bedtime
62 DISCUSSION Why is he being started on Insulin? What other options are there? Advantages Disadvantages
63 THE DIABETES TEAM Diabetes is not managed by any one discipline Diabetes is managed by a team consisting of The person with diabetes Family physician Diabetes educator Nurse Dietitian Pharmacist Endocrinologist Other health professionals Communication is the responsibility of all members of the team!
64 ONE WEEK LATER Robert has been to the Diabetes Education Centre and started insulin 1 week ago He comes to the Pharmacy to buy more test strips He shows you his log book
65 ROBERT acb pcb acl pcl acs pcs 3 am Mon Tues Wed Thurs Fri 14.0 Sat
66 HYPOS BEFORE SUPPER What might be the cause? Need to look at lifestyle issues before medication Timing of meals, activity in afternoon etc. How has he been treating them? Is treatment appropriate? Is he checking 15 minutes later? Should he have alcohol with super after a low? How can he prevent them?
67 WHAT ABOUT THE OTHER PATTERNS? Highs before breakfast Might be better when the lows before supper are gone Are you worried about the one that is 14??? Highs after supper May be partly rebound from the lows May be overtreating the low May be a supper that is too large Can t do anything about them until hypos are fixed
68 Insulin is only as good as its titration.
69 SUMMARY Discuss with clients Action of the insulin they are taking When to check blood glucose How to record blood glucose results How to look for patterns How to trouble-shoot results that are out of target Possible actions to improve blood glucose results
70 Key Planning Points for insulin initiation Insulin Regimen Injection technique Basal Mixed MDI Pen use Injection Hypoglycemia S/S Treatment
71 TAKE HOME MESSAGE one size does not fit all Individualize treatment Treat to target early Titrate according to SMBG
Starting and Helping People with Type 2 Diabetes on Insulin
Starting and Helping People with Type 2 Diabetes on Insulin Elaine Cooke, BSc(Pharm), RPh, CDE Pharmacist and Certified Diabetes Educator Maple Ridge, BC Objectives After attending this session, participants
More informationINSULIN 101: When, How and What
INSULIN 101: When, How and What Alice YY Cheng @AliceYYCheng Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form
More informationDiabetes Head to Toe May 31, 2017
Innovations in Insulin Joanne Reid RN CDE jmreid@gbhs.on.ca Danielle Benedict RPh Outline Setting the stage Insulin as pancreas replacement therapy Commonly used insulins New insulins Case Studies Dosing
More informationAdjusting Insulin Doses
Adjusting Insulin Doses Everyone with diabetes, including you, will need to adjust your insulin doses at some time. There are several reasons why a person may need an insulin adjustment. These reasons
More informationPHARMACISTS INTERACTIVE EDUCATION CASE STUDIES
PHARMACISTS INTERACTIVE EDUCATION CASE STUDIES Disclaimer: The information in this document is not a substitute for clinical judgment in the care of a particular patient. CADTH is not liable for any damages
More informationWhat do you need to know before you go home?
What do you need to know before you go home? What is Insulin Types of Insulin Injection Sites How to Inject Insulin Correctly Low Blood Sugar and Treatment Sick Day Management After leaving the Hospital:
More informationPHARMACISTS INTERACTIVE EDUCATION CASE STUDIES
PHARMACISTS INTERACTIVE EDUCATION CASE STUDIES Disclaimer: The information in this document is not a substitute for clinical judgment in the care of a particular patient. CADTH is not liable for any damages
More informationGuide to Starting and Adjusting Insulin for Type 2 Diabetes*
Guide to Starting and Adjusting Insulin for Type 2 Diabetes* www.cadth.ca * Adapted from Guide to Starting and Adjusting Insulin for Type 2 Diabetes, 2008 International Diabetes Center, Minneapolis, MN.
More informationBeyond Basal Insulin: Intensification of Therapy Jennifer D Souza, PharmD, CDE, BC-ADM
Beyond Basal Insulin: Intensification of Therapy Jennifer D Souza, PharmD, CDE, BC-ADM Disclosures Jennifer D Souza has no conflicts of interest to disclose. 2 When Basal Insulin Is Not Enough Learning
More informationTips and Tricks for Starting and Adjusting Insulin. MC MacSween The Moncton Hospital
Tips and Tricks for Starting and Adjusting Insulin MC MacSween The Moncton Hospital Progression of type 2 diabetes Beta cell apoptosis Natural History of Type 2 Diabetes The Burden of Treatment Failure
More information24 Hour Support. Telephone Available 24 hours a day, 7 days a week
Contents Page What is SHAIRE? 1 What is basal-bolus regimen? 2 Why do I need a basal-bolus regimen? 3 How does basal insulin work? 3 How does rapid-acting insulin work? 4 How often should I test my Blood
More informationManaging Diabetes when you are having a colonoscopy
Managing Diabetes when you are having a colonoscopy Disclaimer This is general information developed by The Ottawa Hospital. It is not intended to replace the advice of a qualified health-care provider.
More informationMixed Insulins Pick Me
Mixed Insulins Pick Me Alvin Goo, PharmD Clinical Associate Professor University of Washington School of Pharmacy and Department of Family Medicine Objectives Critically evaluate the evidence comparing
More informationPrior to making any insulin adjustments the following knowledge and skills are required:
Diabetes Control Diabetes Control Food, activity and insulin influence your blood glucose levels. At times it may seem like a juggling act as you attempt to balance these three factors. Home blood glucose
More informationType 2 Diabetes Mellitus Insulin Therapy 2012
Type 2 Diabetes Mellitus Therapy 2012 Michael T. McDermott MD Director, Endocrinology and Diabetes Practice University of Colorado Hospital Michael.mcdermott@ucdenver.edu Preparations Onset Peak Duration
More informationCase Study: Competitive exercise
Case Study: Competitive exercise 32 year-old cyclist Type 1 diabetes since age 15 Last HbA1 54 No complications and hypo aware On Humalog 8/8/8 and Levemir 15 Complains about significant hypoglycaemia
More informationAdjusting Your Diabetes Medicine and Diet for a Test or Procedure
health information Adjusting Your Diabetes Medicine and Diet for a Test or Procedure The guidelines below will help you adjust your diabetes medicine and diet as you get ready for your procedure or lab
More informationDiabetes: What You Need to Know
UW MEDICINE PATIENT EDUCATION Diabetes: What You Need to Know Discharge review before you leave the hospital We want to be sure that we explained your diabetes instructions well, so that you know how to
More informationInsulin Prior Authorization with optional Quantity Limit Program Summary
Insulin Prior Authorization with optional Quantity Limit Program Summary 1-13,16-19, 20 FDA LABELED INDICATIONS Rapid-Acting Insulins Humalog (insulin lispro) NovoLog (insulin aspart) Apidra (insulin glulisine)
More informationInsulin Basics. Bryan Primary Care Conference May 21, 2016 Shannon Wakeley MD Complete Endocrinology
Insulin Basics Bryan Primary Care Conference May 21, 2016 Shannon Wakeley MD Complete Endocrinology Disclosures Speakers Bureau for Sanofi, Astra Zeneca, Janssen, Boehringer-Ingelheim Objectives Discuss
More informationBRIAN MOSES, MD, FRCPC (INTERNAL MEDICINE) CHIEF OF MEDICINE, SOUTH WEST HEALTH
Insulin Initiation BRIAN MOSES, MD, FRCPC (INTERNAL MEDICINE) CHIEF OF MEDICINE, SOUTH WEST HEALTH Disclosures In the past 12 months, I have received speakers honoraria from AstraZeneca, Boehringer Ingelheim,
More informationINSULIN INITIATION AND INTENSIFICATION WITH A FOCUS ON HYPOGLYCEMIA REDUCTION
INSULIN INITIATION AND INTENSIFICATION WITH A FOCUS ON HYPOGLYCEMIA REDUCTION Jaiwant Rangi, MD, FACE Nov 10 th 2018 DISCLOSURES Speaker Novo Nordisk Sanofi-Aventis Boheringer Ingleheim Merck Abbvie Abbott
More informationStroke Hyperglycemia Insulin Network Effort (SHINE) Trial Treatment Protocols. Askiel Bruno, MD, MS Protocol PI
Stroke Hyperglycemia Insulin Network Effort (SHINE) Trial Treatment Protocols Askiel Bruno, MD, MS Protocol PI SHINE Synopsis Acute ischemic stroke
More informationThis certificate-level program is non-sponsored.
Program Name: Diabetes Education : A Comprehensive Review Module 5 Intensive Insulin Therapy Planning Committee: Michael Boivin, B. Pharm. Johanne Fortier, BSc.Sc, BPh.LPh, CDE Carlene Oleksyn, B.S.P.
More informationInpatient Glycemic Management:
Disclosure to Participants Conflict of Interest (COI) and Financial Relationship Disclosures: Dr. Seley attended Advisory Board Meeting: Alliance (Boehringer-Ingelheim/Lilly) Bayer Diabetes Care Sanofi
More informationSelf-Monitoring Blood Glucose (SMBG) Frequency & Pattern Tool
Self-Monitoring Blood Glucose () Pattern Recommendation: Basal Insulin Only (To Target) NPH or long-acting analogue, typically given at. at least as often as is being given. Optional, less frequent can
More informationINSULIN THERAY دکتر رحیم وکیلی استاد غدد ومتابولیسم کودکان دانشگاه علوم پزشکی مشهد
INSULIN THERAY DIABETES1 IN TYPE دکتر رحیم وکیلی استاد غدد ومتابولیسم کودکان دانشگاه علوم پزشکی مشهد Goals of management Manage symptoms Prevent acute and late complications Improve quality of life Avoid
More informationPremixed Insulin for Type 2 Diabetes. a gu i d e f o r a d u lt s
Premixed Insulin for Type 2 Diabetes a gu i d e f o r a d u lt s March 2009 What This Guide Covers / 2 Type 2 Diabetes / 3 Learning About Blood Sugar / 4 Learning About Insulin / 5 Comparing Medicines
More informationAgenda. Indications Different insulin preparations Insulin initiation Insulin intensification
Insulin Therapy F. Hosseinpanah Obesity Research Center Research Institute for Endocrine sciences Shahid Beheshti University of Medical Sciences November 11, 2017 Agenda Indications Different insulin preparations
More informationBasal Bolus Insulin Therapy Frequently Asked Questions
1. What is Basal Bolus Insulin Therapy (BBIT)? 2. What evidence supports the use of subcutaneous Basal Bolus Insulin Therapy? 3. Does Basal Bolus Insulin Therapy apply to all patients? 4. What s wrong
More informationInsulin Management. By Susan Henry Diabetes Specialist Nurse
Insulin Management By Susan Henry Diabetes Specialist Nurse The Discovery of Insulin - 1921 - Banting & Best University Of Toronto Discovered hormone insulin in pancreatic extract of dog - Marjorie the
More informationEvolving insulin therapy: Insulin replacement methods and the impact on cardiometabolic risk
Evolving insulin therapy: Insulin replacement methods and the impact on cardiometabolic risk Harvard/Joslin Primary Care Congress for Cardiometabolic Health 2013 Richard S. Beaser, MD Medical Executive
More informationNew basal insulins Are they any better? Matthew C. Riddle, MD Professor of Medicine Oregon Health & Science University Keystone Colorado 15 July 2011
New basal insulins Are they any better? Matthew C. Riddle, MD Professor of Medicine Oregon Health & Science University Keystone Colorado 15 July 2011 Presenter Disclosure I have received the following
More informationINSULIN IN THE OBESE PATIENT JACQUELINE THOMPSON RN, MAS, CDE SYSTEM DIRECTOR, DIABETES SERVICE LINE SHARP HEALTHCARE
INSULIN IN THE OBESE PATIENT JACQUELINE THOMPSON RN, MAS, CDE SYSTEM DIRECTOR, DIABETES SERVICE LINE SHARP HEALTHCARE OBJECTIVES DESCRIBE INSULIN, INCLUDING WHERE IT COMES FROM AND WHAT IT DOES STATE THAT
More informationSubjects are requested to perform self-monitoring of blood glucose (SMBG) 4 times per
APPENDIX 1 Insulin Titration Algorithm Subjects are requested to perform self-monitoring of blood glucose (SMBG) 4 times per day. All subjects will be contacted weekly to review hypoglycemia and adverse
More informationProviding Stability to an Unstable Disease
Basal Insulin Therapy Providing Stability to an Unstable Disease Thomas A. Hughes, M.D. Professor of Medicine - Retired Division of Endocrinology, Metabolism, and Diabetes University of Tennessee Health
More informationHypoglycemia, Sick Days/DKA and Hospitalization
Hypoglycemia, Sick Days/DKA and Hospitalization General survival skills for your client with diabetes at home and in Hospital Diabetes Canada guidelines for your client with diabetes while they are in
More informationInitiation and Adjustment of Insulin Regimens for Type 2 Diabetes
Types of Insulin Rapid-acting insulin: lispro (Humalog), aspart (NovoRapid), glulisine (Apidra) Regular short-acting insulin: Humulin R, Novolin ge Toronto, Hypurin Regular Basal insulin: NPH (Humulin
More informationBlood Sugar and Insulin
PATIENT & CAREGIVER EDUCATION Blood Sugar and Insulin This information explains high and low blood sugar levels and how to manage them. About Blood Sugar and Insulin Your body uses a sugar called glucose
More informationUsing Insulin in the Primary Care Setting: Interactive Cases
Using Insulin in the Primary Care Setting: Interactive Cases Irl B. Hirsch, MD University of Washington School of Medicine Dualities (Nov, 2011) Research Grants: sanofi-aventis, Novo Nordisk, Halozyme,
More informationComprehensive Diabetes Treatment
Comprehensive Diabetes Treatment Joshua L. Cohen, M.D., F.A.C.P. Professor of Medicine Interim Director, Division of Endocrinology & Metabolism The George Washington University School of Medicine Diabetes
More informationDEMYSTIFYING INSULIN THERAPY
DEMYSTIFYING INSULIN THERAPY ASHLYN SMITH, PA-C ENDOCRINOLOGY ASSOCIATES SCOTTSDALE, AZ SECRETARY, AMERICAN SOCIETY OF ENDOCRINE PHYSICIAN ASSISTANTS ARIZONA STATE ASSOCIATION OF PHYSICIAN ASSISTANTS SPRING
More informationTimely!Insulinization In!Type!2! Diabetes,!When!and!How
Timely!Insulinization In!Type!2! Diabetes,!When!and!How, FACP, FACE, CDE Professor of Internal Medicine UT Southwestern Medical Center Dallas, Texas Current Control and Targets 1 Treatment Guidelines for
More informationModule 5. Understanding Insulin Therapy
Module 5. Understanding Insulin Therapy EDUCATIONAL OBJECTIVES Upon completion of this activity, participants will be better able to: 1. Define the basic physiologic concept of basal-bolus insulin; 2.
More informationDisclosure 1/16/2017. Michael R. Brennan D.O., M.S., F.A.C.E Director Beaumont Endocrine Center Chief of Endocrine Beaumont Grosse Pointe 1/16/2017 2
Therapy For Diabetes Michigan Association of Osteopathic Family Physicians Mid-Winter Family Medicine Update Shanty Creek Resort, MI January 19-22nd 2017 Michael R. Brennan D.O., M.S., F.A.C.E Director
More informationType 1 Diabetes - Pediatrics
Type 1 Diabetes - Pediatrics Introduction Type 1 diabetes prevents the body from removing sugar from the blood stream normally. Diabetes can lead to serious health problems if it is not treated. Currently
More informationBEST 4 Diabetes. Optimisation of insulin module
BEST 4 Diabetes Optimisation of insulin module Confidence and competence Where would you rate yourself? Why do all of our patient not achieve optimal blood glucose control? Insulin Therapy Goals and Purpose
More informationMANAGEMENT OF TYPE 1 DIABETES MELLITUS
MANAGEMENT OF TYPE 1 DIABETES MELLITUS INVESTIGATIONS AND TREATMENT MANSI NAIK VII SEMESTER INVESTIGATIONS FASTING BLOOD SUGAR PLASMA GLUCOSE HEMOGLOBIN A 1c SYMPTOMS OF TYPE 1 DIABETES MELLITUS Polyuria
More informationPoll Question 2. Special Boot Camp Workshop Beverly Dyck Thomassian, RN, MPH, BC ADM, CDE President, Diabetes Education Services.
Special Boot Camp Workshop Beverly Dyck Thomassian, RN, MPH, BC ADM, CDE President, Diabetes Education Services Poll Question 1 Mary takes 6 units lispro (Humalog) before dinner. Which BG result reflects
More informationObjectives 2/13/2013. Figuring out the dose. Sub Optimal Glycemic Control: Moving to the Appropriate Treatment
Sub Optimal Glycemic Control: Moving to the Appropriate Treatment Judy Thomas, MSN, FNP-BC Holt and Walton, Rheumatology and Endocrinology Objectives Upon completion of this session you will be better
More informationInsulin 301: Case, after case, after case
Insulin 301: Case, after case, after case Learning objectives By the end of this session, you will be able to : 1. List the 3 types of insulin, 3 insulin regimens and pros/cons of each 2. Select the regimen
More informationComplete this CE activity online at ProCE.com/InsulinPart2
Complete this CE activity online at ProCE.com/InsulinPart2 Case 1: A 67 year old male with T2DM History and Presentation John is a 67 year old retiree who has been visiting your pharmacy/clinic for over
More informationInformation for Patients
Information for Patients Guidance for Diabetic Persons having an OGD or Bronchoscopy This guidance is provided to assist with your preparation for your endoscopic procedure. If you feel unclear about how
More informationThe York Diabetes Care Model
This Session The York Diabetes Care Model The annual review what s it for and how to do it How to make the diagnosis of diabetes and who to test Categorisation of diabetes at diagnosis Basics of Insulin
More informationSample Exam Questions
Disclaimer These are not validated questions. They have been created to enhance your learning and provide practice in reading and answering multiple choice questions. Some questions have been created to
More informationTools for Life Introduction to patterns
Tools for Life Introduction to patterns Insulin Food Activity Tools for Life. Questions? 1-800-227-8862 OneTouch.com 2011 LifeScan, Inc. Milpitas, CA 95035 11/11 AW 3085039B 3 YOU + Congratulations for
More informationIn-hospital management of diabetes
Dr. Tom Elliott MBBS, FRCPC Medical Director 400-210 W Broadway phone: 604.683.3734 Vancouver, BC fax: 604.628.3821 V5Y 3W2 Canada email: moa@bcdiabetes.ca In-hospital management of diabetes General Management
More informationNewer Insulins. Boca Raton Regional Hospital 15th Annual Internal Medicine Conference
Newer Insulins Boca Raton Regional Hospital 15th Annual Internal Medicine Conference Luigi F. Meneghini, MD, MBA Professor of Internal Medicine, UT Southwestern Medical Center Executive Director, Global
More informationMy sick day plan for Type 1 Diabetes
My sick day plan for Type 1 Diabetes When you get sick, your blood sugar levels may be harder to keep under control. Your blood sugars may go too high or too low. Be prepared before you get sick. This
More informationApplication of the Diabetes Algorithm to a Patient
Application of the Diabetes Algorithm to a Patient Apply knowledge gained from this activity to improve disease management and outcomes for patients with T2DM and obesity Note: The cases in this deck represent
More informationDISCLAIMER: ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics.
DISCLAIMER: Video will be taken at this clinic and potentially used in Project ECHO promotional materials. By attending this clinic, you consent to have your photo taken and allow Project ECHO to use this
More informationLantus to levemir conversion
Lantus to levemir conversion The Borg System is 100 % Lantus to levemir conversion 16-6-2005 Ask the Expert on... Lantus Conversion. Karen Shapiro, PharmD, BCPS. Disclosures. June 16, 2005. Question. Would
More informationBEST 4 Diabetes. Optimisation of insulin module
BEST 4 Diabetes Optimisation of insulin module Confidence and competence Where would you rate yourself? Why do all of our patient not achieve optimal blood glucose control? Insulin Therapy Goals and Purpose
More informationType I Type II Insulin Resistance
Insulin An aqueous hormonal solution made in the pancreas. Affects metabolism by allowing glucose to leave the blood and enter the body cells, preventing hyperglycemia. It is measured in units, e.g. 100
More informationReviewing Diabetes Guidelines. Newsletter compiled by Danny Jaek, Pharm.D. Candidate
Reviewing Diabetes Guidelines Newsletter compiled by Danny Jaek, Pharm.D. Candidate AL AS KA N AT IV E DI AB ET ES TE A M Volume 6, Issue 1 Spring 2011 Dia bet es Dis pat ch There are nearly 24 million
More informationInsulin Initiation and Intensification. Disclosure. Objectives
Insulin Initiation and Intensification Neil Skolnik, M.D. Associate Director Family Medicine Residency Program Abington Memorial Hospital Professor of Family and Community Medicine Temple University School
More informationMedications for Diabetes
Medications for Diabetes Sweet, but not too sweet Colette Raymond, Pharm D June 15, 2011 Learning Objectives At the end of this presentation you should be able to: Understand the prevalence and types of
More informationDiabetes Basics. Type 1 diabetes The body cannot make insulin Requires insulin injection Is not treated with oral diabetes medicines (pills)
Diabetes Basics What is Diabetes? Diabetes is a disease in which the pancreas is unable to make insulin or the body is unable to use insulin or both. This leads to high blood sugar levels in the blood.
More informationThe principles of insulin adjustment guidance
The principles of insulin adjustment guidance Tips for insulin titration Blood glucose (BG) monitoring is needed to help identify the efficacy of treatment in diabetes. Monitor blood glucose according
More informationStarting Insulin in General Practice
Starting Insulin in General Practice Timothy Kenealy GP & Assoc Prof of Integrated Care, University of Auckland Auckland DHB / my version + Counties DHB version Starting Insulin surprisingly simple, safe
More informationSponsor / Company: Sanofi Drug substance(s): Insulin Glargine (HOE901) Insulin Glulisine (HMR1964)
These results are supplied for informational purposes only. Prescribing decisions should be made based on the approved package insert in the country of prescription. Sponsor / Company: Sanofi Drug substance(s):
More informationVirginia School Diabetes Medical Management Plan (DMMP) Part 1 Contact Information and Medical History
Virginia School Diabetes Medical Management Plan (DMMP) Part 1 Contact Information and Medical History Virginia Diabetes Council - School Diabetes Care Practice and Protocol - Provides guidelines, recommended
More informationI. General Considerations
1 2 3 I. General Considerations A. Type I ( Juvenile Onset or IDDM) IDDM results from autoimmune destruction of beta cells inability to secrete insulin --> ketone formation --> DKA 4 Diabetic Ketoacidosis
More informationBlood Glucose Monitoring
Blood Glucose Monitoring What is Glucose? A simple sugar that enters the diet as part of sucrose, lactose, or maltose Part of a polysaccharide called dietary starch Most of the body s energy comes from
More informationSociety for Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery
Society for Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery Girish P. Joshi, MB BS, MD, FFARCSI Anesthesia & Analgesia
More informationDiabetes Technology Continuous Subcutaneous Insulin Infusion Therapy And Continuous Glucose Monitoring In Adults: An Endocrine Society Clinical
Diabetes Technology Continuous Subcutaneous Insulin Infusion Therapy And Continuous Glucose Monitoring In Adults: An Endocrine Society Clinical Practice Guideline Task Force Members Anne Peters, MD (Chair)
More informationImportant Stuff. Basal Bolus What Adjustments? Pt weighs 80kg
Diabetes Boot Camp Class 4 Beverly Dyck Thomassian, RN, MPH, BC ADM, CDE President, Diabetes Education Services Special Insulin and Pattern Management Diabetes Education Services 1998-2015. All rights
More informationCalgary Diabetes Centre Insulin Pump Therapy: Preparation and Expectations
Calgary Diabetes Centre Insulin Pump Therapy: Preparation and Expectations This is a long and important document. It lists the steps for starting insulin pump therapy at the Calgary Diabetes Centre. It
More informationEndocrinology and Diabetes. Steroid-Induced Diabetes Education Handbook
Endocrinology and Diabetes Steroid-Induced Diabetes Education Handbook High blood sugar (Hyperglycemia) Causes High blood sugar (also called hyperglycemia) is when there is too much sugar in your
More informationMy Sick Day Plan for Type 1 Diabetes on Multiple Daily Injections (MDI)
My Sick Day Plan for Type 1 Diabetes on Multiple Daily Injections (MDI) When you are sick, your blood sugar levels may be harder to keep under control. Your blood sugar may go too high or too low. Use
More informationNph insulin conversion to lantus
Nph insulin conversion to lantus Search 26-2-2003 RESPONSE FROM AVENTIS. We appreciate the opportunity to respond to Dr. Grajower s request for information regarding Lantus ( insulin glargine [rdna origin.
More informationThe Signs, Symptoms, and Causes of Hypoglycemia
The Signs, Symptoms, and Causes of Hypoglycemia Tam Doan PharmD, CDE, BC-ADM Clinical Pharmacist, Diabetes Care Manager Santa Clara Valley Medical Center Fruitdale, CA Agenda What is hypoglycemia? What
More informationInsulin Therapy Management. Insulin Therapy
Insulin Therapy Management Insulin Therapy Contents Insulin and its effect on glycemic control Physiology of insulin secretion Insulin pharmacokinetics and regimens Insulin dose adjustment for pregnancy
More informationWhat the Pill Looks Like. How it Works. Slows carbohydrate absorption. Reduces amount of sugar made by the liver. Increases release of insulin
Diabetes s Oral s - Pills These are some of the pills that are currently available in Canada to treat diabetes. Each medication has benefits and side effects you should be aware of. Your diabetes team
More informationInsulin Initiation, titration & Insulin switch in the Primary Care-KISS
Insulin Initiation, titration & Insulin switch in the Primary Care-KISS Rotorua GP CME 9 June 2012 Dr Kingsley Nirmalaraj FRACP Endocrinologist, BOPDHB & Suite 9, Promed House, Tenth Ave, Tauranga Linda
More informationRemote attendees, please mute your phones as a courtesy thank you!
Welcome! Remote attendees, please mute your phones as a courtesy thank you! Diabetes: The Ins and Outs of Insulin CareOregon Pharmacy Today s Agenda Introduction 8:00-8:15am RN perspective 8:15 8:45am
More informationLet Them Eat Cake Clinical Practice Recommendations for Diabetes Management
Let Them Eat Cake Clinical Practice Recommendations for Diabetes Management Mimi Cunningham, MA, RDN, CDE Idaho Health Care Association 2015 Winter Workshop Goals You Go Home With Confidence in your knowledge
More informationPharmacy Plan Guidance
Pharmacy Plan Guidance The pharmacy plan is a tool used during the site readiness process to develop and document the site-specific procedures for study drug ordering, labeling and dispensing for the SHINE
More informationKeeping your diabetes support as mobile as you are,
Millions of people have diabetes. But we at Novo Nordisk know that managing diabetes is a personal journey. That is why we created the e-book Your guide to better office visits, with valuable insights
More informationManagement of Diabetes New Concepts New Devices New Medications. Richard J. Comi, MD Professor of Medicine Geisel School of Medicine at Dartmouth
Management of Diabetes New Concepts New Devices New Medications Richard J. Comi, MD Professor of Medicine Geisel School of Medicine at Dartmouth Objectives: At the end of this lecture, the learner will
More informationInsulin Prior Authorization Criteria For Individuals Who Purchased BlueCare/KS Solutions/EPO Products
Insulin Prior Authorization Criteria For Individuals Who Purchased BlueCare/KS Solutions/EPO Products FDA LABELED INDICATIONS 1-13,16-21 Rapid-Acting Indication Onset Peak Duration Insulins Admelog (insulin
More informationLearning Objectives. Perioperative SWEET Success
Perioperative SWEET Success PERIOPERATIVE SWEET SUCCESS PRESENTED BY: KENDRA MARTIN, RN, BSN, CDE JENNIFER SIMPSON, RN, BC-ADM, MSN, CNS Disclosure to Participants Notice of Requirements For Successful
More informationType 1 Diabetes. Dr. Tom Elliott MBBS, FRCPC Medical Director
Dr. Tom Elliott MBBS, FRCPC Medical Director 4102 2775 Laurel St. phone: 604.675.2491 Vancouver, BC fax: 604.875.5931 V5Z 1M9 Canada email: info@bcdiabetes.ca Type 1 Diabetes Type 1 diabetes (previously
More informationInitiation and Titration of Insulin in Diabetes Mellitus Type 2
Initiation and Titration of Insulin in Diabetes Mellitus Type 2 Greg Doelle MD, MS April 6, 2016 Disclosure I have no actual or potential conflicts of interest in relation to the content of this lecture.
More informationUpdate on Insulin-based Agents for T2D. Harry Jiménez MD, FACE
Update on Insulin-based Agents for T2D Harry Jiménez MD, FACE Harry Jiménez MD, FACE Has received honorarium as Speaker and/or Consultant for the following pharmaceutical companies: Eli Lilly Merck Boehringer
More informationI can tell you about low blood sugar and how to treat it
Our Journey with Diabetes Si usted desea esta información en español, por favor pídasela a su enfermero o doctor. I can tell you about low blood sugar and how to treat it Low blood sugar is when the blood
More informationVirginia School Diabetes Medical Management Forms
Virginia School Diabetes Medical Management Forms Student School Effective Date Date of Birth Grade Homeroom Teacher Instructions: 1. Part 1- Contact Information and Diabetes Medical History. To be completed
More informationSupplemental Health Record and Authorization for Care of Child with Insulin Dependent Diabetes
477 Beaverkill Road Olivebridge, New York 12461 (845) 657-8333 Ext. 15 Fax (845) 657-8489 martin.bernstein@ashokancenter.org www.ashokancenter.org 2012-13 Supplemental Health Record and Authorization for
More information[Insert School Logo] School Grade Teacher Physician Phone Fax Diabetes Educator Phone 504 Plan on file Yes No
[Insert School Logo] 1 INDIVIDUALIZED HEALTH PLAN (IHP for SCHOOLS): DIABETES WITH PUMP Picture of Student Student DOB Home Phone Mother Work Phone Cell Phone Father Work Phone Cell Phone Guardian School
More informationWhen and how to start insulin therapy in type 2 diabetes
When and how to start insulin therapy in type 2 diabetes Anne Kilvert MD, FRCP Most patients with type 2 diabetes will eventually require insulin due to the progressive decline in betacell function. Dr
More information