4/16/2018. Flexible Intensive Insulin Therapy (FIIT) in People with Type 2 Diabetes: A Viable Option. Disclosures. Outline. No financial disclosures

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1 Flexible Intensive Insulin Therapy (FIIT) in People with Type Diabetes: A Viable Option Kim Bisanz, MFCS, RDN, LDN, CDE Minnesota Academy of Nutrition & Dietetics Annual Meeting April 19, MFMER slide-1 Disclosures No financial disclosures 18 MFMER slide- Outline Identify and describe Intensive Insulin Therapy (IIT) and Flexible Intensive Insulin Therapy (FIIT) Provide an overview of FIIT outcomes in existing research Describe my study looking at FIIT in people with Type Diabetes Discuss practice implications for dietitians 18 MFMER slide-3 1

Objectives The audience member will be able to: 1.

basal-bolus insulin. Specify patient characteristics that are likely to improve the FIIT experience.

Insulin Options Basal Insulins Long-acting glargine: Lantus (), Basaglar (15), Toujeo (15) detemir: Levemir (5)

2 Objectives The audience member will be able to: 1. Identify potential beneficial clinical outcomes of using FIIT in people with type diabetes who have progressed to basal-bolus insulin. Specify patient characteristics that are likely to improve the FIIT experience. 18 MFMER slide-4 Intensive Insulin Therapy (IIT) Multiple Daily Injections (MDI) Basal Bolus 18 MFMER slide-5 Insulin Options Basal Insulins Long-acting glargine: Lantus (), Basaglar (15), Toujeo (15) detemir: Levemir (5) Ultra Long-acting degludec: Tresiba (15) Bolus Insulins Short-acting regular (1/198) Rapid-acting lispro: Humalog (/199) aspart: Novolog (11/1), Fiasp (9/17) glulisine: Apidra (/4) 18 MFMER slide-

When goals and life don t align 18 MFMER slide-7 Flexible Intensive Insulin Therapy (FIIT) Insulin to Carbohydrate Ratio (I:C) Dose Adjustment For Normal Eating (DAFNE) 18 MFMER slide-8 Audience Poll

3 When goals and life don t align 18 MFMER slide-7 Flexible Intensive Insulin Therapy (FIIT) Insulin to Carbohydrate Ratio (I:C) Dose Adjustment For Normal Eating (DAFNE) 18 MFMER slide-8 Audience Poll What do you think would be beneficial clinical outcomes of using FIIT in people with type diabetes? 1. Decreased insulin needs. Increased freedom to eat 3. Improved A1c 4. Weight loss 5. Improved insulin adherence Join at Slido.com with #F MFMER slide-9 3

Outcomes in People with T1DM Muhlhauser, et al (1983): 5-day inpatient training. At 1 year & months: improved glycemia and decreased hospitalizations DAFNE Study Group (): 5-day outpatient course.

4 Outcomes in People with T1DM Muhlhauser, et al (1983): 5-day inpatient training. At 1 year & months: improved glycemia and decreased hospitalizations DAFNE Study Group (): 5-day outpatient course. At months: significantly improved QoL and glycemia without worsening severe hypoglycemia or cardiovascular risk. Speight, et al (1): ~4 years after DAFNE training, A1c improvements decreased but still significant, QoL improvement sustained. Lowe, et al (8): % T1DM. 4-day training w/o unique follow-up. Improvements in A1c, empowerment, and QoL which were largely sustained at 1 year. 18 MFMER slide-1 Outcomes in People with TDM Kloos, et al (7): 8 weeks. 7/3 bid vs. FIIT. Metabolic outcomes, patient preferences similar Bergenstal, et al (8): month RCT. Set bolus insulin vs. I:C. Glycemic control, severe hypoglycemia, lipids similar; Total daily insulin dose and weight gain lower with I:C Lowe, et al (8): TDM (4%). 4-day training w/o unique follow-up. Improvements in A1c, empowerment, and QoL which were largely sustained at 1 year. 18 MFMER slide-11 For people with type 1 diabetes or those with type diabetes who are prescribed a flexible insulin therapy program 18 MFMER slide-1 4

Study Goal: Identify characteristics and explore the experiences of persons with type diabetes who are started on FIIT during an inpatient hospitalization.

education completed by diabetes nurse educator and RD, CDE Successful teach back of a standardized application scenario Exclusion criteria Previous use of flexible intensive insulin therapy

5 Study Goal: Identify characteristics and explore the experiences of persons with type diabetes who are started on FIIT during an inpatient hospitalization. 18 MFMER slide-13 Methods Inclusion criteria (all needed): 18 years or older Type diabetes Diabetes discharge recommendations of flexible intensive insulin therapy Standard inpatient diabetes education completed by diabetes nurse educator and RD, CDE Successful teach back of a standardized application scenario Exclusion criteria Previous use of flexible intensive insulin therapy (self-reported) Data Collection Largely self-reported Surveys administered at baseline & after months Baseline: demographics, diabetes history, previous nutrition knowledge, ADDQoL19 Six Months: Current DM therapy, experiences with FIIT, ADDQoL19 18 MFMER slide-14 Results: Participant Characteristics All Participants n = Baseline only Participants n = 1 Full Participants n = 8 Gender (M:F) 14: 8:4 : Age at recruitment (years) Education level: Less than high school High School Some college -4 yr college degree Post-graduate courses Post-graduate degree 5 3 Residence 8 urban, 1 4 urban, 8 rural 4 urban, 4 rural rural Diabetes Duration (years) Previous DM Med Use: Fixed basal-bolus Other insulin Non-insulin DM med MFMER slide-15 5

A1C (%) Number of participants (n=) 4/1/18 Results: Rationale for Patients to use FIIT Influencer Number of Participants Glycemic control 15 Flexible eating 11 Hospital approach 8 Weight loss 7 18

6 A1C (%) Number of participants (n=) 4/1/18 Results: Rationale for Patients to use FIIT Influencer Number of Participants Glycemic control 15 Flexible eating 11 Hospital approach 8 Weight loss 7 18 MFMER slide-1 Results: Baseline nutrition knowledge None Some Experienced Baseline knowledge prior to education for FIIT 18 MFMER slide-17 Results: Paired A1c 14 Baseline A1C average: 8.% Follow-up A1C average: 7.% Baseline -month Individual Participants 18 MFMER slide-18

slide-19 Results: Paired Weights 1 Baseline average: 13.8 kg Follow-up average: 99.

7 Weight (kg) 4/1/18 Results: Hypoglycemia Participant Mild Hypoglycemia in past months Severe Hypoglycemia in past months Baseline Follow-up Baseline Follow-up MFMER slide-19 Results: Paired Weights 1 Baseline average: 13.8 kg Follow-up average: 99. kg Baseline -month Individual Participants 18 MFMER slide- Results: Factors impacting FIIT implementation 18 MFMER slide-1 7

8 Results: Diabetes-related Quality of Life Work life, vacation, family life, friendships & social life, sex life, reactions of others, living situations, and dependence on others Leisure activity, travel, physical activity, relationships, physical appearance, self-confidence, motivation, future feelings, financial situation, freedom to eat, and freedom to drink 18 MFMER slide- Study Summary FIIT in TDM may improve glycemia and weight management efforts but may not improve QoL. Some characteristics & circumstances improve likelihood of success (areas to emphasize during education if not present) Numeracy skills Prior insulin use Familiarity with carb sources & counting Healthcare access and follow-up 18 MFMER slide-3 From Research to Practice RDN SOP: Initiate, implement, and adjust protocol- or physician-order-driven nutritionrelated medication orders and pharmacotherapy plans in accordance with established policy or protocols consistent with organizational policy and procedure. Minnesota State Licensure supports Identify patients & advocate to provider Assist with identifying & adjusting I:C Provide education & counseling 18 MFMER slide-4 8

Determining the Insulin to Carbohydrate Ratio Consistent Carbohydrate Ex: Eat g carb/meal, adjusting bolus insulin until

4u for g carb, 4: = 1:15 Rule of 5 (45) Divide 5 by TDD = 1 unit insulin : gram carb Weight based 18 MFMER slide-5 Total

3 units/kg Type 1 DM Type DM with: Renal failure Frail Elderly Low body weight Malnourished Hypoglycemia risk.

9 Determining the Insulin to Carbohydrate Ratio Consistent Carbohydrate Ex: Eat g carb/meal, adjusting bolus insulin until BG within goal. 4u for g carb, 4: = 1:15 Rule of 5 (45) Divide 5 by TDD = 1 unit insulin : gram carb Weight based 18 MFMER slide-5 Total Daily Insulin Dose (TDD).3 units/kg Type 1 DM Type DM with: Renal failure Frail Elderly Low body weight Malnourished Hypoglycemia risk.4 units/kg Type DM normal body weight.5 units/kg Type DM with: Obesity High dose steroids Insulin resistance 18 MFMER slide- Weight Based Weight, lbs Ratio 1 to 19 1:1 11 to 19 1:15 13 to 139 1:14 14 to 149 1:13 15 to 159 1:1 1 to 19 1:11 17 to 179 1:1 18 to 189 1:9 19 to 199 1:8 to 39 1:7 >4 1: (BW#)(.8) TDD 18 MFMER slide-7 9

Ratio Units of insulin 45g CHO Units of insulin g CHO Units of insulin 75g CHO Units of insulin 9g CHO 1:1 45 75 9 1: 3 37 45 1:3 15 5 3 1:4 11 15 19 1:5 9 1 15 18 1: 7 19 1 15 1:7 9 11 13 1:8 8 9 11

rounded down when X.5 18 MFMER slide-8 Education & Counseling Use teach back Create menu with carb & non-carb items and foods with/without labels. How much carb? Using ratio of :, how much insulin?

Improving Adherence Complexity of dosing regimen Safety & tolerability Perceptions of medication Economic considerations Patient-provider interaction 18 MFMER slide-9 Conclusions FIIT may improve

10 Ratio Units of insulin 45g CHO Units of insulin g CHO Units of insulin 75g CHO Units of insulin 9g CHO 1: : : : : : : : : : : : : : : : : : : : : :3 1 3 *units of insulin rounded to nearly whole number; rounded down when X.5 18 MFMER slide-8 Education & Counseling Use teach back Create menu with carb & non-carb items and foods with/without labels. How much carb? Using ratio of :, how much insulin? Incorporate BG/correction scale. Improving Adherence Complexity of dosing regimen Safety & tolerability Perceptions of medication Economic considerations Patient-provider interaction 18 MFMER slide-9 Conclusions FIIT may improve adherence to intensive insulin regimens because of its safety, tolerability, efficacy, and possible cost savings Those with numeracy skills, familiarity with carbohydrates and insulin are most likely to succeed on FIIT Dietitians can identify individuals who would benefit from transition from IIT to FIIT and provide the education and counseling necessary for successful implementation. 18 MFMER slide-3 1

11 Audience Poll In what patient situations would you consider advocating for FIIT? Join at Slido.com with #F MFMER slide-31 11

The ABCs of MDI: Gaining a working knowledge of Multiple Daily Injection insulin therapy. Today s Presenter

FD Title Slide The ABCs of MDI: Gaining a working knowledge of Multiple Daily Injection insulin therapy learn.extension.org/events/3369 3 This material is based upon work supported by the National Institute