BEST 4 Diabetes Optimisation of insulin module
Confidence and competence Where would you rate yourself?
Why do all of our patient not achieve optimal blood glucose control?
Insulin Therapy Goals and Purpose of Insulin Therapy Barriers to the use of Insulin Current Concepts in Insulin Therapy Basal/Bolus Insulin (Insulin Pump Therapy)
Why do patients delay insulin treatment? Concern about injections Worry over hypoglycaemia Fears for weight gain Stigma of insulin injections Concern about employment False previous family experience Strong negative cultural beliefs
Why do patients delay insulin?
Reasons for poor diabetic control Delay in commencing insulin treatment Insufficient dose titration Failure to control fasting blood sugar Inappropriate insulin mix False concerns about maximum insulin dose
Helping Patient Accept Insulin Therapy Address patient concerns Dispel fear by countering misconceptions Review rationale for insulin use Hypoglycaemia is infrequent, and can be easily treated, and that severe hypoglycaemia is rare Treatment need not be burdensome Weight gain can now be managed with adjuvant treatment Is a common course of treatment for this progressive disease Promise patient support and close follow-up Monitoring can prevent hypoglycemia Today s technology can facilitate daily injections and readings
Recap Insulin Time action profiles Group Work
Recap Insulin devices Insulin terminology
CSII Continuous Subcutaneous Insulin Infusion Insulin Pump A continuous infusion of rapid acting insulin, no requirement for long acting insulin. For Type 1 s under secondary care. Make sure patient has insulin pens and insulin in case of pump failure.
Choice of insulin treatments Once daily NPH/Analogue Basal with oral agents/glp1 T2DM and some T1 patients dependant on others for care Twice daily Either Combination bd/tds Biphasic insulin (Human or Analogue) T1 or T2 or bd (NPH/Analogue T2DM) Basal Bolus T1 or T2DM (Human-NPH/Analogue Bolus-Basal) Insulin pump treatment T1DM only
Injection technique: key messages injection sites insulin storage injecting process correct use of injection device use of pen needles or syringes once site rotation injecting into subcutaneous fatty tissue absorption rates needle length appropriate use of skin folds disposal of injecting material http://www.trend-uk.org FIT (Oct 2011), The First UK Injection Technique Recommendations, 2 nd Edition
FIT (Forum for Injection Technique) Education topic areas At the beginning of injection therapy (and at least every year thereafter) the HCP should discuss: injection regimen choice and management of the devices used choice, care and self examination of injection sites correct injection technique (including site rotation, injection angle and possible use of skin folds) injection complications and how to avoid them optimal needle length safe disposal of used sharps http://www.trend-uk.org FIT (Oct 2011), The First UK Injection Technique Recommendations, 2 nd Edition
Needle length/skin fold? 1.8-2.5mm thick Depth varies depending on site Image reproduced with permission from Becton Dickenson
Needle length/skin fold? Needle length Skin fold Comments 4,5,6mm No Unless injecting into slim limbs/abdomen 8mm Yes Shortest length available for an insulin syringe 12.7mm Yes No clinical reason to use this length
Absorption rates and injection sites Insulin type Most favoured injection sites Why? NPH insulin Thigh, buttocks Slowest absorption sites Short-acting insulin Abdomen Fastest absorption site Premixed insulin (human or analogue) Insulin analogues: rapid and longacting GLP-1 agonists Abdomen morning Thigh or buttock eve meal May be given at any injection site Follow manufacturer s instructions Increase speed of short /rapidacting insulin to cover post prandial breakfast Leads to slower absorption and decreases risk of nocturnal hypoglycaemia Absorption rates do not appear to be site specific More studies are needed http://www.trend-uk.org FIT (Oct 2011), The First UK Injection Technique Recommendations, 2 nd Edition
Risks associated with lipohypertrophy Unpredictable and delayed insulin absorption Can result in larger insulin dosages being used May cause fluctuating glycaemic control with unpredictable hyperglycemia and hypoglycaemia Image reproduced with permission from Becton Dickenson
Management of lipohypertrophy Prevention Site rotation Fresh needle management Move away from the site for months/years Consider a reduction in insulin dosage Use blood glucose monitoring to assess need for further insulin dose alterations Encourage self inspection of sites and check at reviews Image reproduced with permission from Becton Dickenson
Images reproduced with permission from Becton Dickenson
www.fit4diabetes.com/united-kingdom/
Recap Hypoglycaemia BHFT Leaflet Hyperglycaemia and sick day rules Trend Leaflet www.trend-uk.org
Berkshire West Insulin Optimisation Framework for Type 2 Diabetes Recommend initiation on human basal insulin Review @ Patient able to self titrate & have carb awareness Consider alternatives if ; District Nurse to Administer 60u BD Basal Bolus Steroid Patients Nursing Home Patients Erratic Eating Patterns In these cases contact DSN team for advice Review @ 60u BD Review @ 60u BD BD Human or Review @ 60u BD BD Mix 50/50 TDS Mix 50/50 Review @ 30 units BD Analogue Mix Once Daily Human Basal Human Basal DSN Referral Recommended Low Skills and Capabilities High
The Ideal Basal Insulin... Mimics normal pancreatic basal insulin secretion Long-lasting effect around 24 hours Smooth, peakless profile Reproducible and predictable effects Reduced risk of nocturnal hypoglycemia Once-daily administration for convenience 6-32
What are the problems with basal insulin treatment? Insufficient length of action requiring twice daily dosage Large intra-dose variability leading to increased hypoglycaemia or loss of daytime control Excess basal insulin treatment, leading to weight gain High dose volumes in insulin resistant and obese patients
Where is the appropriate place of newer basal insulin therapy? Patients who are demonstrated have problems with basal insulin treatment Patients who are having to split basal insulin therapies Patients with nocturnal hypoglycaemia?? Patients with excess weight gain Patients requiring third party administration of insulin treatment
Starting with Basal Insulin Continue oral agent(s) at same dosage (eventually stop secretagogue) Add single, evening insulin dose (around 10 U) Glargine (bedtime or anytime?) NPH (bedtime) Mixed Insulin 70/30 (evening meal) or 75/25 Adjust dose by fasting BG Increase insulin dose weekly as needed Increase 4 U if FBG >10 mmol Increase 2 U if FBG = 7-10 Treat to target (usually <7mg/dL) 6-59
What are the real unmet needs in insulin therapy Early recognition of failure of oral therapy Strong positive recommendation of benefits of insulin treatment to patients Reassurance concerning potential negative consequences in therapy Intense support to optimise insulin dosage Regular review to identify problems with insulin therapy Time
What you need to do in practice tomorrow Do a search for all your patients with HbA1C is >85 mmol per mole Refer those patients to Expert and For those on tablets, move them either to basal insulin and tablets, premixed insulin, or basal insulin and GLP1 combination therapy if they are obese For those refusing insulin treatment, reassure on the safety of insulin treatment, demonstrate injection, and explain that poor diabetic control is not an option For those already on insulin treatment, ask the diabetes specialist nurses to come work with you to titrate insulin doses. For those patients who are gaining weight, consider adjunctive therapy with SGLT/GLP1 For those with body mass index greater than 35 and less than 65 years old suggest refer to bariatric service Analogue insulin is expensive, so only use in clinically justified situations
Case Studies Put knowledge into practice.
Confidence and competence Where would you rate yourself?
Thank you