15 th Annual DAFNE collaborative meeting Tuesday 28 th June 2016

Transcription

1 15 th Annual DAFNE collaborative meeting Tuesday 28 th June 2016 Sponsored by: Abbott Diabetes Care and Lilly Diabetes

2 Type 1 and exercise Royal Berkshire Hospital Centre for Diabetes and Endocrinology

3 Exercise is good for people with T1DM Better control Less obesity Less retinopathy Less Nephropathy But may be difficult to manage

4 What do we need to know to manage T1DM Exercise Effect of exercise on blood glucose Differences between types of exercise Timing, type and quantity of carbohydrate What to do with bolus insulin dose What to do with basal insulin rate How to reduce the risks of nocturnal hypoglycaemia

5 Glycaemic response with types of exercise

6 mmmol/l mmmol/l Glucose - mmmol/l What Happens to Blood Glucose in Exercise in Type 1 Diabetes? /01/ /10/2005 (Thu) Exercise Exercise :00 06:00 09:00 12:00 15:00 18:00 21:00 00:00 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00: /11/2005 Aerobics Cycling 5.6 Data from Buckinghamshire 0.0 Hospitals Diabetes 03:00 06:00 09:00 12:00 15:00 18:00 21:00 00:00

7 Different forms of exercise cause different blood glucose responses Mean ± SE plasma glucose during the experimental sessions (represented by box) and 60 min of recovery (n = 12 for aerobic exercise and no-exercise control; n = 11 for resistance exercise)., no-exercise control;, resistance exercise,, aerobic exercise. astatistically significant change from baseline in aerobic exercise. bstatistically significant change from baseline in resistance exercise. cstatistically significant difference between no-exercise control session and aerobic session. dstatistically significant change throughout recovery after aerobic exercise. Yardley J E et al. Dia Care 2013;36:

8 Different forms of exercise have different effect on later SC glucose Mean ± SE glucose as measured by CGM from 1 to 12 h postexercise., no-exercise control session;, aerobic exercise session;, resistance exercise session. Yardley J E et al. Dia Care 2013;36: Copyright 2011 American Diabetes Association, Inc.

9 Repeated resistance exercise has different effects on glucose Tuner et al. Scan J. Med Sci 2014

10 Glucose levels during and following different forms of exercise Aerobic first Resistance first Aerobic first Resistance first

11 Effect of high or low intensity exercise on blood glucose in T1DM

12 Delayed hypoglycaemia CGMS following exercise in T1DM

13 Likelyhood of further hypoglycaemia following morning or afternoon exercise

14 Pre bed glucose values are a poor predictor of later hypoglycaemia after exercise

15 Risk of nocturnal hypoglycaemia is different with different forms of exercise Aerobic exercise likely to cause nocturnal hypoglycaemia, and risk increases if exercise is later in day Resistance exercise unlikely to cause nocturnal hypoglycaemia Why? Intermittent aerobic and high intensity very likely to produce nocturnal hypoglycaemia Mixed exercise, if aerobic exercise occurs first, hypoglycaemia more likely and occurs early in morning

16 Carbohydrate support

17 Why not just start with a high glucose? Some mathematics Available free glucose space is 20% lean person total weight 1mm/l measured glucose is 0.18g free glucose or total 2.5g in 70 kg person Thus raising bg to 15mmol/l, will only provide 25g readily available glucose. At 60%VO 2 max glucose oxidation typically 130 μmol/kg/min. Thus approximately 2g/min or 12 minutes!

18 Capillary Blood Glucose Concentration (mg/dl) Effect of Carbohydrate Ingestion on the Glycaemic Response of Type 1 Diabetic Adolescents During Exercise CHO 8% CHO 10% 66.5 g Strategy 2 Taking extra glucose whilst exercising Using the mouth to do the liver s job 50 0 * 55.3 g Time (min) (0) Exercise * (30) (60) Recovery Data are means ± SD; *p<0.05. Perrone C, Laitano O, Meyer F. Diabetes Care. 2005;28:

19 Glucose Concentration (mm) Strategies for Glucose Replacement During Exercise Glucose 20 g 20 g 20 g 10 mm 5 mm Glucose 60 g 10 mm 5 mm 90 minutes aerobic exercise

20 Low Glycemic Index Meal and Bedtime Snack Prevents Postprandial Hyperglycemia Following Evening Exercise in Type 1 Diabetes Diabetes Care 2014;37:1 9

21 Insulin dose adjustment

22 Change from baseline in plasma glucose (mmol.l) Change from baseline in plasma glucose (mmol.l) Change from baseline in plasma glucose (mmol.l) Change from baseline in plasma glucose (mmol.l) A B Exercise at 50% VO 2 max for 30 min Baseline plasma glucose (mmol/l) LP 100% = 10.7 ± 0.7 LP 50% = 9.4 ± 0.8 Exercise intensity -5 Reducing 120 pre-exercise meal insulin Time (minutes) Exercise at 75% VO 2 max for 30 min Baseline plasma glucose (mmol/l) LP 100% = 8.5 ± 1.3 LP 25% = 6.8 ± 1.1 (% VO 2 max) Time (minutes) Rabasa-Lhoret R et al. Diabetes Care. 2001;24: * B 5 Exercise at 50% VO 2 max for 60 min * Baseline plasma -2 glucose (mmol/l) -3 LP 50% = 8.7 ± 1.0 LP 25% = 6.0 ± A Exercise at 25% VO 2 max for 60 min 0 % Dose reduction -1 Baseline plasma % Dose -2 glucose (mmol/l) -3 LP 100% = 8.8 ± 0.55 LP 50% = 6.1 ± min of exercise reduction 60 min of exercise Time (minutes) Data are means ± SEM; *p<0.05 by repeated measures using ANOVA; LP: lispro Time (minutes) * *

23 Large pre and post exercise bolus dose insulin reductions reduce post exercise hypoglycaemia Diabetes Care, 2013, 36, 8,

24 Reducing basal insulin by 20% reduces nocturnal hypoglycaemia following exercise

25 Role of CSII Enables normal basal insulin to be markedly reduced or suspended whist performing exercise. Enables rapid post exercise increase in insulin to deal with post exercise glycogenic peak. Enables lower post exercise nocturnal basal rate with intermittent exercise patterns. The standard for patient who do exercise regularly, but at varying time and types.

26 Opportunities to adjust insulin infusion rate Reduce bolus before exercise By how much and how soon? Reduce basal rate before exercise By how much and when? Post exercise bolus or increased basal rate Which is better? Reduced bolus after exercise How much? Reduce overnight basal rates How much, and all night or just part?

27 Glucose Concentration (mg/dl) Prevention of Hypoglycemia During Exercise in Children With Type 1 Diabetes by Suspending Basal Insulin Basal insulin continued Basal insulin stopped 0 Baseline Rest #1 Rest #2 Rest #3 End Post 15 Post 30 Post 45 Black dots denote mean values; Boxes denote median, and 25th and 75th percentiles. The Diabetes Research in Children Network. Diabetes Care 2006;29:

28 CSSI basal rate reduction with endurance exercise Rates of hypoglycaemia Rates of hyperglycaemia * M50 M80 M50 M80 *Fisher s exact test; p = **Fisher s exact test; p = ** Lumb A, Carr J, Peters G, Karpe K and Gallen IW. ADA 2012-A-1616

29 Effect of 50% CSII rate reduction 1 hour before rest or exercise Patients with BG >7 mm had rising BG whereas those BG< 7 mm had hypoglycaemia with moderate exercise

30 CSII PATIENTS TEND TO HAVE LESS POST EXERCISE HYPERGLYCEMIA Yardley et al, Diab Tech Ther 2013

31 Automatic low glucose infusion suspend during exercise

32 53 miles Highland Fling from Milngavie to Tyndrum on the West Highland Way. Dinner Lasagne and sticky toffee pudding 4 am porridge Race started at 6am Cannula came of at 18 miles in so ran the last 35 miles solely on water using the short effort to keep from dropping a few times I finished 175th out of 1000 runners Ian in Gallen so finished just before 5pm then spike.

33 Effect of CSSI disconnection Zisser DIABETES CARE, VOLUME 31, NUMBER 2, FEBRUARY 2008

34 CSII on during exercise Time: -3h -2h -1h -10 min +10 min +1h EXERCISE MEAL BOLUS 10 g CH * Carbohydrates! Moderate exercise: 0,3-0,9 g/kg x h g CH * MEAL BOLUS** BASAL *Depending on BG **Reduced insulin to CHO Ratio Temporary reduction of basal dose: 1,5 2 h prior to exercise back to ordinary basal depending on energy status and insulin sensitivity Target (mmol/l) 4-7 (8) 5-8 >4 4-7 (8) Slide reproduced with permission from Dr. Peter Adolfsson

35 Advice following exercise (CSSI) Exercise Type Prolonged Aerobic exercise Resistance exercise Aerobic/high intensity mixed Advice Restart normal basal IR before exercise finishes or post exercise bolus+food Reduce nocturnal insulin IR by for first 4 hours of night by10% Check BG 3 am if sleeping alone Normal insulin/food Restart normal basal IR before exercise finishes or post exercise bolus+food Reduce nocturnal insulin IR by for entire night by 10% Check BG 3 am if sleeping alone Mixed exercise, aerobic first Reduce nocturnal insulin IR by for first 4 hours of night by 10% Check BG 3 am if sleeping alone

36 Things to consider before exercise What type of exercise is it? Will blood glucose go down or up? Which order shall I do the exercise? How close is exercise to the last meal injection? Will meal injection still be working? Does basal pump infusion rate need to change? Is the rate too high for exercise? Has there been a hypo in the last 24 hours Is it safe to exercise? What is the blood glucose value before exercise? take extra glucose, or exercise less hard, or bolus insulin?

37 Summary of Clinical Strategies to Maintain Glycaemic Control With Exercise Strategy Advantages Disadvantages Reducing pre-exercise bolus insulin Reducing pre-exercise basal insulin Taking extra CHO with exercise Reduces hypoglycaemia during and following exercise; reduces CHO requirement As above Useful for unplanned or prolonged exercise Needs pre-planning; not helpful for spontaneous exercise or for late post-prandial exercise As above, causes pre- and late post-exercise hyperglycaemia May not be possible with some exercises; not helpful where weight control is important; easy to overreplace causing hyperglycaemia Pre- or post-exercise sprint Insulin pump therapy Reducing basal insulin postexercise Reduces hypoglycaemia following exercise Offers flexibility and rapid change in insulin infusion rates postexercise Reduces nocturnal hypoglycaemia Effect limited to shorter and less intense exercise Expensive; may not be practical for contact sports (e.g., rugby/ football/judo) May cause morning hyperglycaemia Lumb AN, Gallen IW. Curr Opin Endocrinol Diabetes Obes. 2009;16: