INJECTABLE THERAPIES IN DIABETES. Barbara Ann McKee Diabetes Specialist Nurse

Transcription

1 INJECTABLE THERAPIES IN DIABETES Barbara Ann McKee Diabetes Specialist Nurse 1

2 Aims of the session Describe the different injectable agents for diabetes and when they would be used. Describe some common insulin regimens. Describe the GLP-1 therapeutic options. Describe optimal injection technique and the impact of technique on patient outcomes. 2

3 Learning Outcomes Recognise the different injectable agents for diabetes therapy Understand when the different injectables should be used Awareness of common insulin regimens Awareness of current GLP-1 therapies Understand injection technique and its impact on glycaemic control 3

4 What is Diabetes? Type 1: autoimmune destruction of beta cells leading to absence of intrinsic insulin Type 2: progressive loss of intrinsic insulin + insulin resistance + diminished incretin effect 4

5 The Incretin Effect The incretin hormones GLP-1 (Glucagon Like Peptide -1) & GIP (Gastric Inhibitory Peptide) are released by intestinal cells in response to ingestion of food & then travel in the bloodstream to the pancreas where they stimulate insulin secretion and inhibit production of glucagon and hepatic glucose release. 5

6 Insulin Resistance Cells fail to respond to normal actions of insulin causing hyperglycaemia and hyperinsulinaemia. This characteristic is observed in persons with central obesity and inactive lifestyle. High risk populations include: ethnic origin, steroid use, older age, cigarette smokers, other disease. 6

7 Injectable Therapies Insulin : Type 1 Diabetes (absence of insulin) : Type 2 Diabetes (progressive loss of insulin+ insulin resistance+ lowered incretin effect) where there is no longer a response to oral agents, secondary to beta cell exhaustion and insulin resistance GLP-1 : Is licensed for use in Type 2 Diabetes where there is no longer a response to oral agents and insulin therapy would adversely affect weight 7

8 What are they? (How they work).. Insulin: Peptide hormone, produced by beta cell in pancreas to regulate glycaemia (helps metabolise carbohydrates and fats and inhibits hepatic glucose production) GLP-1: Incretin gut hormone that stimulates insulin release, increases insulin sensitivity, inhibits beta cell apoptosis, depresses glucagon and promotes satiety all in a glucose dependant manner 8

9 Insulin in action 9

10 GLP-1 Modes of Action in Man Upon ingestion of food Stimulates insulin secretion Suppresses glucagon secretion GLP-1 is secreted from the L-cells in the jejunum and ileum Slows gastric emptying Reduces food intake - satiety This in turn Long term effects demonstrated in animals Increases beta-cell cell mass and maintains beta-cell efficiency Drucker DJ. Curr Pharm Des 2001; 7: Drucker DJ. Mol Endocrinol 2003; 17:

11 Why use them.. Insulin: Absence or diminishing supply of intrinsic hormone GLP-1: Incretin effect is diminished in Type 2 Diabetes 11

12 When to use them GG&C Guidelines: e/policiesprocedures/ggcclinicalguidelines/g GC%20Clinical%20Guidelines%20Electronic%2 0Resource%20Direct/Diabetes,%20Type%20 2%20Management.pdf 12

13 GG&C guidelines 1 st line lifestyle + Metformin 2 nd line lifestyle + Oral agents 3 rd line lifestyle + Injectables If HbA1c > 59 mmol/mol or individualised target is not met * if HbA1c is above 89mmol/mol at second line then consider using GLP-1 13

14 GG&C Guidelines Discuss with DSN/Consultant Supervised initiation Education Equipment Patient information Support and advice 14

15 Insulin's available Analogue or Human Rapid or short acting Long acting Premixed 15

16 Chose an insulin based on: Onset of action when it starts to work Time of peak action when its effect is greatest Duration of action over how long it works 16

17 Commonly seen regimens Type 1: twice daily mixed (short + long) three times mixed (short + long) four times 3 short + 1 long CSII pump therapy (short) Type 2: once daily long acting twice daily mixed (short + long) 17

18 Normal glucose/insulin response 18

19 Action of insulin 19

20 Age Insulin:considerations Other health problems, e.g. complications such as visual loss injecting, BG monitoring Social circumstances, e.g. patients holding LGV/PSV licence/employment Patient s attitude will they cope? Dietary assessment by a dietician prior to converting to insulin Patient s weight (4kgs gain over 6 months) 20

21 GLP-1 Short acting Intermediate Long acting/sustained release 21

22 GLP-1 Byetta(exenatide) short acting twice daily use in EGFR>30<60 Victoza(liraglutide) Intermediate acting -once daily Bydureon(exenatide) long acting -sustained release - once weekly 22

23 GLP-1: Considerations Weight (BMI >30) 6 month trial Target -5mmol/mol reduction in HbA1c And/or weight loss Discontinue if targets not met Less monitoring required Risk of hypo s if added to sulphonylurea 23

24 GLP-1 Discuss with DSN/consultant to start Preparation as with insulin + specifics Monitor progress 6 months trial Review at zero, three and six months Look for reduction in HbA1c of 5mmol/mol Desirable to see weight reduction Discuss with DSN/consultant if no therapeutic response 24

25 Injection technique Subcutaneous injection - Pen device Rotate sites to avoid lipohypertrophy 4, 5 or 6mm needle length (8mm if grossly obese) Inject at 90 degree angle Pinch target skin only if muscle under s/c layer Once needle inserted and dose delivered, count >10 secs before withdrawl 25

26 Injection technique Overuse of sites causes lipohypertrophy no or unpredictable absorption of drug Injection into muscle as above Poor/non absorption of drug impacts HbA1cincreases risk of complication- makes it impossible to advise or adjust drug dose Poor technique is painful disengagement of patient 26

27 Injection sites 27

28 Wall Charts Diabetes UK es-update/wallcharts--supplements/ 28

29 RESOURCES Guidelines DSN Secondary care pathway Managed Clinical Network Diabetes UK My Diabetes My Way 29

30 GG&C Management of Diabetes re/policiesprocedures/ggcclinicalguidelines/g GC%20Clinical%20Guidelines%20Electronic%2 0Resource%20Direct/Diabetes,%20Type%202% 20Management.pdf 30