Insulin Basics. Bryan Primary Care Conference May 21, 2016 Shannon Wakeley MD Complete Endocrinology

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1 Insulin Basics Bryan Primary Care Conference May 21, 2016 Shannon Wakeley MD Complete Endocrinology

2 Disclosures Speakers Bureau for Sanofi, Astra Zeneca, Janssen, Boehringer-Ingelheim

3 Objectives Discuss the progressive nature of DM2 Review the traditional care model and issues with clinical inertia Discuss barriers to insulin initiation Review insulin options Discuss how to start basal and bolus insulin Review importance of recognizing and treating hypoglycemia

4 Case Study 76 yo F referred January 2016 for uncontrolled DM2, A1C creeping up - 7.6%. CKD3, HTN, HLP, morbidly obese metformin, glipizide Dr. Wakeley can see the patient..in 4 months!!

5 Case Study Patient arrives to office April 21,2016 A1C 6.7% What happened?? Now on Tresiba 16 units daily My sister got off all her DM meds - she quit eating sugar so I tried it too.guess what? It helps!!

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12 Barriers to Initiation of Insulin

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16 Insulin Options Rapid-Acting Intermediate Basal Apidra Humalog (u100/u200) Regular (u100/u500) Toujeo Tresiba (u100/u200) Novolog Afrezza Lantus Levemir NPH

17 Insulin Options Mixes novolin or humulin70/30 novolog 70/30 humalog 75/25 humalog 50/50 Contents 70% NPH/ 30% Regular 70% insulin aspart protamine/30% novolog 75% insulin lispro protamine/25% humalog 50% insulin lispro protamine/50% humalog

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20 Insulin Onset of Action Time to Peak Duration Timing of Dose Tresiba (u100/u200) 1 hr No peak 42 hrs Once Daily

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23 Initiating Basal Insulin Calculations vs Educated Estimate Titration - Slow and Steady

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25 Initiating Basal Insulin Example: 10 units q day, titrate up 2 units q 3 days until fastings are <120 Call/fax/ readings in 2-3 weeks **Tailor starting dose and titration instructions to the individual Morbidly obese patient with A1C 14% will require more insulin than patient with BMI of 27, A1C 7.4%

26 Initiating Bolus Insulin Individualize treatment regimen to match diet/activity level and prevailing glucose trends Achieve euglycemia without unacceptable weight gain or hypoglycemia Balance glucose control with patient preferences, dosing convenience and disease factors Assess eating habits Assess activity level Calculations vs Educated Estimate

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30 Initiating Bolus Insulin Correction insulin/sliding Scale Insulin Provides patient empowerment Tailor to your patient: 1/50>150 for DM1 (SS1) 2/50>150 for DM2 (SS2) insulin to be used with meal time elevations only** Blood Sugar Bolus Insulin unit >

31 Breakfast BG Insulin Lunch BG Insulin Dinner BG Insulin Bedtime BG Monday Tuesday Wednesday Thursday Friday Based on info schedule 4 units meal time insulin, *adjust basal

32 Fixed Bolus vs Insulin to Carb Ratio (ICR) FIXED BOLUS Ideal for patients that keep a consistent schedule and tend to eat the same amount of carbs at their meals ICR Ideal for patients with inconsistent schedules, don t eat the same thing every day Provides better control, less hypoglycemia *Patient has to be able to count carbs, do math

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34 BK BG grams Insulin Lunch BG grams Insulin Dinner BG grams Insulin Bed BG MON g TUES g g WED g g THUR 88 32g g FRI g find instances where premeal and post meal readings are similar 2. divide carbs by insulin given = ICR (1 unit/15g) 3. asses basal insulin for adequacy

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42 Summary Avoid Clinical Inertia Tailor regimen to your patients needs/preferences Empower your patient with basal insulin titration and rapid acting insulin correction Educate on symptoms and treatment of hypoglycemia