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 of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368. Today s Presenter Kimberly Bisanz, MFCS, RDN, LD, CDE At age 14, decided to become a dietitian (thank you 4-H!) as long as she didn t have to work with diabetes At age 20, still wanted to be a dietitian, as long as she could specialize in diabetes At age 27, earned the CDE designation Research Interest: Flexible intensive insulin therapy in people with Type 2 Diabetes 4
Objectives After this presentation, you should be able to: Identify at least 2 types of basal insulin and 2 types of bolus insulin used for MDI therapy Explain 3 approaches to carbohydrate quantification Describe snacking guidelines for persons using MDI therapy 5 Disclosures No financial relationships outside of my current employer, Mayo Clinic 6
What is your experience with diabetes? Photo by Daniel Frese from Pexels 7 By the numbers Bisanz K, Parker A, Byrne C, Parker S, Thomas J, Mancino J, Hand RK. Identification of generalist RDN knowledge gaps in diabetes MNT compared to diabetes credentialed RDNs: results of a survey to inform educational opportunities. Journal of the Academy of Nutrition and Dietetics. E published: http://jandonline.org/article/s2212-2672(18)30072-8/fulltext 8
Diabetes Self-Management Education & Support Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care 9 2015;38:1372 1382 MDI = 4 or more injections per day Multiple Daily Injections/Multi-Dose Injections Basal-Bolus Insulin Therapy Intensive Insulin Therapy Pixabay.com 10
Insulin Options Basal Insulins Long-acting glargine: Lantus (2000), Basaglar (2015), Toujeo (2015) detemir: Levemir (2005) Ultra Long-acting degludec: Tresiba (2015) Bolus Insulins Short-acting regular (10/1982) Rapid-acting aspart: Novolog (11/2001), Fiasp (9/2017) lispro: Humalog (6/1996) glulisine: Apridra (2/2004) 2012 Mayo Foundation for Medical Education and Research. All rights reserved. Used with permission of Mayo Foundation for Medical Education & Research 11 Which of the following patient scenarios has the strongest indication for initiating MDI? A. PWDT2, new diagnosis, A1c 10% B. PWDT2 on metformin, A1c 10% C. PWDT2 on basal insulin, SGLT2, GLP-1, A1c 10% D. PWDT1, new diagnosis, A1c 10% 12
SGLT2i Metformin? Sulfonylureas DPP-4i? Basal Insulin NPH Pumps GLP-1 13 Non-diabetic State 2012 Mayo Foundation for Medical Education and Research. All rights reserved. Used with permission of Mayo Foundation for Medical Education & Research This illustration was made available by written permission of The Regents of the University of California. All rights reserved. 14
Type 1 diabetes mellitus Gold-standard for full pancreas replacement Most people with type 1 diabetes should be treated with multiple daily injections of prandial insulin and basal insulin or continuous subcutaneous insulin infusion. A Insulin pump (continuous insulin infusion CII) Only uses rapid acting insulin Always attached so no injections Allows for fine tuning of basal rates Drawbacks: technology, troubleshooting, DKA, attached, cost American Diabetes Association (2018). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes 2018. Diabetes Care, 41(Supplement 1), S73-S85. Accessed April 03, 2018. https://doi.org/10.2337/dc18-s008. 15 Type 2 Diabetes Mellitus When control cannot be achieved with other agents For patients with type 2 diabetes who are not achieving glycemic goals, drug intensification, including consideration of insulin therapy, should not be delayed. B Diabetes Progression Long-standing T2DM can result in insulin deficiency Co-morbidities Contra-indication of non-insulin oral medications & injectables American Diabetes Association (2018). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes 2018. Diabetes Care, 41(Supplement 1), S73-S85. Accessed April 03, 2018. https://doi.org/10.2337/dc18-s008. 16
Which of the following patient scenarios has the strongest indication for initiating MDI? A. PWDT2, new diagnosis, A1c 10% B. PWDT2 on metformin, A1c 10% C. PWDT2 on basal insulin, SGLT2, GLP-1, A1c 10% D. PWDT1, new diagnosis, A1c 10% 17 MDI Considerations Pro s Flexibility Efficacy Neutral CV risk Con s Hypo Risk Weight Gain Cost Injection Complexity American Diabetes Association (2018). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes 2018. Diabetes Care, 41(Supplement 1), S73-S85. Accessed April 03, 2018. https://doi.org/10.2337/dc18-s008. 18
T2DM Diagnosis 57 year old male financial manager. Motivated to improve eating and increase physical activity along with starting metformin. 5 years First follow-up with PCP. Presents with fatigue & ED. A1c 9.1% SGLT2 initiated and 3 months later GLP-1 added. 3 months later A1c 6.9%. 3 years Continues on triple-therapy, A1c slowly deteriorating (7.3%) CKD stage 3 diagnosed. 6 months NSTEMI with stent placement and AKI from contrast. CKD stage 4. Metformin, SGLT2, and GLP-1 discontinued. Basal insulin started. 3 months A1c 8.1% Rapid-acting insulin added to meals 1 st to dinner then sequentially to breakfast and lunch as BG targets not met. Pexels 19 Intermission Pixabay 20
What are your priority topics when educating PWD (pick 2)? Limiting sugar/carbohydrate Macronutrient distribution Label reading Meal timing Meal planning Weight management Heart health 21 Medical Nutrition Therapy Diabetes Goals Encourage healthful eating patterns, to achieve glycemic, blood pressure, and lipid goals achieve and maintain body weight goals. delay or prevent complications of diabetes. Individualize MNT based on personal and cultural preferences, health literacy and numeracy, access to healthful food choices, willingness and ability to make behavioral changes, as well as barriers to change. To maintain the pleasure of eating by providing positive messages about food choices while limiting foods only when indicated by scientific evidence. Focus on practical, day-to-day meal planning rather than on individual macronutrients, micronutrients, or single foods. Evert, A. B., Boucher, J. L., Cypress, M., Dunbar, S. A., Franz, M. J., Mayer-Davis, E. J., Neumiller, J. J., Nwankwo, R., Verdi, C. L., Urbanski, P., & Yancy, W. S. (2014). Nutrition Therapy Recommendations for the Management of Adults With Diabetes. Diabetes Care, 37(Supplement 1), S120-S143. https://doi.org/10.2337/dc14-s120 22
Medical Nutrition Therapy - MDI Healthy Eating I.D. Timing Counting 23 Vegetables Milk Fruit Breads, Starches Meats/ Protein
Carbohydrate Identification Fruits Sugar Milks Protein Sweets Carbohydrates Breads Fat Starch Starchy Veggie Grains Photo by Miguel Á. Padriñán, Pexels 25 Carbohydrate Intake - Timing Carbohydrate with bolus insulin Non-carb snacking Non-carb beverages Separate meals by at least 4 hours to avoid insulin stacking 4 hours 2012 Mayo Foundation for Medical Education and Research. All rights reserved. Used with permission of Mayo Foundation for Medical Education & Research 26
Carbohydrate Intake - Quantity Counting in choices (=15g) Counting in grams Estimation/Consistency with Plate Method Estimation of small/medium/large 2012 Mayo Foundation for Medical Education and Research. All rights reserved. Used with permission of Mayo Foundation for Medical Education & Research 27 Carbohydrate Intake - Goals DM: Individualize Macronutrient Composition The registered dietitian nutritionist (RDN), in collaboration with the adult with diabetes, should individualize the macronutrient composition of the healthful eating plan within the appropriate energy intake. Limited research regarding differing amounts of carbohydrate (39% to 57% of energy) and fat (27% to 40% of energy), reported no significant effects on A1C or insulin levels in adults with diabetes, independent of weight loss. Limited research reports mixed results regarding the effects of the amount of protein (ranging from 0.8g to 2.0g per kg per day) on fasting glucose levels and A1C. Rating: Fair Imperative Consider co-morbidities Academy of Nutrition and Dietetics Evidence Analysis Library Diabetes Type 1 and 2. Accessed 4 May 2018 https://www.andeal.org/topic.cfm? menu=5305&pcat=5488&cat=5470 28
Insulin Dose Adjustment/ Pattern Management American Diabetes Association Consider: blood glucose levels, pharmacodynamic profile of each formulation Yale Diabetes Center Rely SMBG for several days to 1 2 weeks Consider: diet, activity level, and stress In absence of severe hyper/hypoglycemia, adjust in 10 20% increments Mayo Clinic Based on 3-day patterns Basal: adjust by 10% if BG +/- for >40mg/dL HS to pre-breakfast (-20% if >80mg/dL drop Bolus: adjust preceding bolus +/-10% if BG outside of pre-prandial BG goal range. (-20% if severe hypoglycemia) American Diabetes Association (2018). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes 2018. Diabetes Care, 41(Supplement 1), S73-S85. Accessed April 03, 2018. https://doi.org/10.2337/dc18-s008. Yale Diabetes Center. (2011). Diabetes Facts and Guidelines. Silvio E. Inzucchi, M.D. Available at: https://medicine.yale.edu/intmed/drc/diabetescenter/living/50135_yale%20national%20f_102165_284_13584_v1.pdf Mayo Clinic Integrated Outpatient Adult Protocol: Multiple Daily Injection (MDI) Insulin Dose Adjustment, MC2222-160. Internal document. 29 Real Life Challenges Using insulin to carbohydrate ratio (1:15) Flexibility vs. responsibility How to snack non-carb vs. >3-4 hours Alcohol Risk of hypoglycemia but hyperglycemia possible too Exercise Type of activity and timing with food matters Dose adjustment of bolus insulin vs. adjust food intake 30
Beyond Vial & Syringe NovoPen Echo: Half units dosing increments Memory: records dose, time since last injection https://www.novologpro.com/prescribing/insulin-pens/novopen-echo.html Insulin Delivery: V-Go T2DM only Daily application U-100 rapid-acting insulin only Preset basal rate (20, 30, or 40u/24 hours) Bolus, 2u/click, up to 36u/day https://www.go-vgo.com/hcp Image used with permission from Valeritas 31 Innovations in BG Monitoring CGM: Libre Factory calibration = no daily fingerstick calibrations Wear for 10 days Measure BG every minute, records readings q 15 min, stores up to 8 hours of data https://www.myfreestyle.com/provider/freestyle-libre-product Image used with permission of Abbott 32
Resources 33 Questions Pixabay 34
Evaluation Continuing Education Credits MFLN Nutrition & Wellness is offering 1.0 CPEU for today s webinar. Please complete the evaluation at: https://vte.co1.qualtrics.com/jfe/form/sv_bi3qdknde7jyhh7 35 Upcoming Event Enhancing the U.S. Army Performance through Key Nutrition Initiatives Tuesday June 19, 2018 11:00am - 12:00pm EDT learn.extension.org/events/3370 36