Insulin in special situation รศ.พญ.ท พาพร ธาระวาน ช สาขาต อมไร ท อฯ ภาคว ชาอาย รศาสตร ม.ธรรมศาสตร

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1 Insulin in special situation รศ.พญ.ท พาพร ธาระวาน ช สาขาต อมไร ท อฯ ภาคว ชาอาย รศาสตร ม.ธรรมศาสตร

2 Titles Exercise Travel Sick day care In-hospital admission Pregnancy Ramadan Driving

3 SMBG is needed in special situation Need proper interpretation Patient must know the treatment goal. Adjust food intake SMBG Adjust Rx Adjust activity

4 Effect of exercise and diabetes Improve blood sugar control Reduce CVD risk factors Contribute to weight loss Improve well-being T2D prevention

5 ADA 2016: physical activity recommendation Adults with diabetes should be advised to perform at least 150 min/ week of moderateintensity aerobic physical activity (50 70% of maximum heart rate), spread over at least 3 days/week with no more than 2 consecutive days without exercise. A

6 ADA 2016: physical activity recommendation In the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least twice per week. A

7 Source of energy during exercise Glycogenolysis Gluconeogenesis Other source: FFA

8 Glucose uptake during exercise GLUT4 Insulin dependent GLUT4 Non-insulin dependent Depend on muscle contraction

9 Acute effect of exercise Decrease glucose Increase glucose glucose uptake (last >24 hrs to 72 hrs) Catecholamines (last 1-2 hrs post-exercise)

10 BP CVD Neuropathy Retinopathy Glycemic control Bone and joint Avoid insulin peak Injection site Evaluation

11 Exercise intensity Intensity Degree % of maximum predicted heart rate Low Can sing < 50% Moderate High Can talk, can not sing Short talk Need a break between talk 50-70% 70-85%

12 What to do?? SMBG Carb Insulin 15 mins before and after exercise Then q 1 hr if > mod. Intensity exercise > 2hrs. Unplanned exercise: consume gm q 30 min Easily absorbable carbohydrate Post exercise snack Planned exercise: decrease insulin pre and post-exercise Insulin reduction dosage may be 50-90% of TDD Decrease post-exercise insulin dosage in unplanned exercise

13 Consider Intensity Duration Baseline glucose Timing relate to meal and insulin Time of the day Environment Individual insulin response In general effects last for > 24 to 72 hours

14 First step: determine sugar level SMBG 15 min before exercise >250 mg/dl +ketone or > 300 mg/dl < 100 mg/dl In between Postpone exercise Need Carb Allow exercise

15 Second step: determine carb Intensity/ duration Low intensity or < 30 min High intensity < < gm Not required 50 gm 15 gm q min 15 gm/hr St. Joseph s Health Care London 2012

16 Second step: determine carb Moderate intensity min > 60 min < < gm before gm during gm Not required during exer gm before gm q min 15 gm/hr St. Joseph s Health Care London 2012

17 Step 3: Insulin dosage % to decrease RI/ rapid insulin Intensity of exercise Duration 0% Low, moderate, high Short (<30 min) 5% Low Intermediate-long 10% Moderate Intermediate (30-60 min) 20% Moderate Long (>60 min) 20% High Intermediate 30-50% High Long St. Joseph s Health Care London 2012

18 Step 3: Insulin dosage Basal insulin: may decrease dose if activity last > 90 mins Early morning exercise: decrease evening dosage (10-30%) Late morning and afternoon exercise: decrease morning dosage (no more than50%)

19 Example ฉ ดยา lantus 20 U เช า, aspart U ข จ กรยาน 45 นาท หล งอาหารเย น17.00 เวลา น. DTX before exercise 80 mg/dl

20 First step: SMBG 15 min before exercise DTX 80 >250 mg/dl +ketone or > 300 mg/dl < 100 mg/dl The others Postpone exercise Need Carb Allow exercise

21 Second step: Moderate intensity Cycling 45 mins min > 60 min < < gm before gm during gm Not required during exer gm before gm q min 15 gm/hr

22 Step 3: % to decrease RI/ rapid insulin Intensity of exercise Duration 0% Low, moderate, high Short (<30 min) 5% Low Intermediate-long 10% Moderate Intermediate (30-60 min) 20% Moderate Long (>60 min) 20% High Intermediate 30-50% High Long

23 Example ฉ ดยา lantus 20 U เช า, aspart U ข จ กรยาน 45 นาท หล งอาหารเย น17.00 เวลา น. DTX before exercise 80 mg/dl Decrease the short-acting insulin of the dinner injection (10%)

24 Travel Hypoglycemia occur 10% during travel. Causes: Dietary patterns Difficulties in adjusting insulin dose Timing Air pressure-> malfunction pump J Travel Med 2006, 13:

25 Travel: < 3-5 time zones, < 3 days Keep their watch at local time Continue basal insulin at basal time Bolus before meal

26 Travel Insulin/equipment Separate carrying case on board Clear insulin label Cold pack if > 1 month Extra-insulin and pen Disposal kit DM ID Custom/on board Disposal kit Carrying case SMBG kit Snack Visual/scan inspection Doctor letter Special meal Time zone Time different East or west

27 Less hour: less insulin more hour: extra dose of insulin

28 Time zone difference 3 hrs: East bound: 1 injection Travel day After arrival Usual dose or decrease by 10-20% Inject using local time

29 Time zone difference 3 hrs: East bound: 2 injection Travel day Decrease last NPH or long acting by 20% Give 2 doses of long-acting insulin 18 hrs apart After arrival Inject using local time

30 10 hr 55 min Journal of Diabetes & Metabolic Disorders 2013, 12:59

31 Sick day care SMBG หากก นไม ได ให หาอาหารท ม แคลอร ก น หากน าตาลส ง ให ด มน าเปล าเพ มข น (หากไม ม ป ญหาโรคห วใจ หร อ volume overload) หากน าตาลส ง > 300 mg/dl หร อ > 250 mg/dl + ketone ให พบแพทย

32 Sick day care Day ac เช า Ins ac เท ยง Insul in ac เย น Insul in Mixtard Mixtard sick vomit 50 จะทาย งไง ฉ ดเท าเด ม ฉ ดลดลง hs ไม ฉ ด

33 Sick day care 15 gm Carb DTX at 15 min If DTX > 70mg/dl

34 Sick day care ก นอาหาร ฉ ดยา ฉ ดลดลง ฉ ดยา mixtard แล วก นข าวเลย ลดยาลง 20% หากฉ ดยา rapid acting -> ก นข าวก อนแล วค อยฉ ดยา

35 In-hospital

36 Definition of in-hospital hyperglycemia Random plasma glucose > 140 mg/dl J Clin Endocrinol Metab 2012;97:16-38.

37 Glycemic Target in Hospitalized Subjects ADA 2014 Non-critical illness Pre-prandial glucose < 140 mg/dl Random glucose < 180 mg/dl If glucose < 100 mg/dl-> re-evaluation If glucose < 70 mg/dl-> adjust insulin dosage Critical illness Glucose mg/dl Insulin infusion should be considered

38 General Guideline Good glycemic control with no acute complication Continue current medication Poor glycemic control and/or oral antidiabetes contraindication Basal bolus insulin injection Insulin drip

39 General Guideline Indication of insulin drip Shock NPO Hyperglycemic emergency

40 Management Insulin drip Currently insulin sc and good glycemic control RI drip 80% of TDD Glucose drip Monitor CBG q 30 min-2 hrs

41 Management Insulin drip Currently on oral medication-> off oral med Insulin dosage U/hr + Glucose drip Dosage depend on age, glycemic control, insulin resistance, stress Monitor CBG q 30 min-2 hrs Decrease insulin if DTX < 100 mg/dl adjust insulin dosage U/hr Goal CBG??? Monitor K

42 Transition to insulin sc Calculate insulin in the last 6 hrs=6 U In this patient TDD = 24 U/day Split to basal 24/2=12 U/day Prandial 12/3=4 U before meal

43 Insulin drip Insulin naive Current Ins User RI IU/hr+Dextrose RI 80% TDD +Dextrose

44 Basal bolus < 70 yrs > 70 yrs or Cr > 2 mg/dl TDD 0.5IU/kg/d TDD 0.3 IU/kg/day

45 Basal plus < 70 yrs > 70 yrs or Cr > 2 mg/dl Basal 0.25 IU/kg/d Basal 0.15 IU/kg/d

46 Impact of Pregnancy on DM complications DR DN Peripheral neuropathy Autonomic neuropathy CAD

47 Preconception Evaluation DM type Glycemic control A1C should be less than 6.5 (Thai) -7% Shift to insulin before conception DM complications Comorbidities eg. HTN, thyroid disorder, NASH, dyslipidemia

48 Initial Evaluation in Preconception Review eating patterns, physical activity and psychosocial problems Counsel the patient on prognosis Evaluate medication Folate 400 mcg/day (preconception), 600 mcg/day (periconception and prenatal periods) B12 level in T1DM TFT

49 Folic Decrease neural tube defect folic acid 5 mg daily beginning 3 months before withdrawing contraceptive We suggest that at 12 weeks gestation, the dose of folic acid be reduced to 0.4 to 1.0 mg/d, which should be continued until the completion of breastfeeding.

50 TFT in Pregnancy During pregnancy TSH should not be more than 2.5 mcu/ml (first half) 3 mcu/ml (2 nd half) Should not be less than 0.03 mu/ml

51 Co-morbidities Autoimmune thyroid disease Celiac disease Pernicious anemia Eating disorder NASH CVD

52 Oral Antihyperglycemic Agents Should be stopped Start insulin

53 GUNNAR L. NIELSEN, et al. Diabetes Care 29: , 2006

54 Monitoring SMBG 6-8 times/day 1 CGM may be useful in T1DM lower infant birth weight reduced risk of macrosomia 2 A1C monthly Urine ketone if ill or has persistent hyperglycemia 1 Castorino K., et al. Clinical Chemistry 2011; 57: 2: Byrne EZ, et al. Diabetes Rev. 2008; 4:

55 Glycemic Goal Throughout Pregnancy Premeal, bedtime and overnight Peak postprandial glucose DTX ADA Thai <140 (1hr) <120 (2hr) am. >60 A1C % <6.0% (1 st trimester) <6.5% (2 nd, 3 rd )

56 Initial Insulin-dosing Guidelines Weeks gestation Insulin dosage (IU/kg) 1 st trimester nd trimester rd trimester 0.9 Full term 1 Postpartum (and lactation) 0.55 Night time basal insulin should be decreased by 50% in lactating women. Castorino K. et al. Clinical Chemistry; 2011: 57:

57 Case 2 nd trimester TDD 60 U/day NPH RI Or (RI+NPH)-0-(RI+NPH)

58 Ramadan: Basal bolus Basal Bolus OD regimen dose by 15-30% Dinner Bid regimen Take morning dose at iftar (เย น) Reduce evening dose by 50% and take at suhoor (เช า) Normal dose at iftar Omit lunch insulin Reduce suhoor dose by 25-50% IDF 2016

59 Ramadan: premixed Once-daily Twice-daily Normal dose at iftar Normal dose at iftar Reduce suhoor dose by 25-50% IDF 2016

60 Case Premixed Suhoor (เช า): 15 Iftar (เย น): 20

61 Driving Hypoglycemia 2 episodes of severe hypoglycemia in 6-12 mos Hypoglycemia unawareness in 3 mos Disabling hypoglycemia Insulin starting during 1 mo in T2D, 2 mo in T1D Hyperglycemia > 400 mg/dl Co-morbidities Vision, DR, neuropathy OSA CAD วารสารเบาหวาน ป ท 47 ฉบ บท 1

62 Driving DTX > 90 mg/dl before driving Prepare snack, added sugar drink Eat on time DTX q 2-4 hr If hypoglycemia Park the car Switch off Correct hypoglycemia

63 Titles Exercise Travel Sick day care In-hospital admission Pregnancy Ramadan Driving

64 น กถ งเบาหวาน น กถ งเรา...ท มเบาหวานรพ.ธรรมศาสตร