Injectable Therapies in Diabetes Diabetes Specialist Nurse Joyce Robson
Learning Outcomes Think about the place of injectible therapies in diabetes Insulin therapy GLP1 antagonists Consider commonly used profiles and regimes Consider safe practice in injectible therapies
SIGN 154
When do we use injectibles therapies in diabetes? Type 1 diabetes Always require insulin No alternative No insulin production leads to burning of body fats for fuel, and ketone production > DKA Type 2 diabetes - 40-50% may require insulin Insulin resistance after some time- Variable time line - may have poor response to oral agents. Injectibles may be required Insulin or GLP1 antagonist
Which injectibles in T2DM? Patients with low BMI osmotic symptoms, weight loss Consider insulin therapy sooner may be insulin deplete Patients with BMI >30kg/m2 if possible avoid insulin - consider GLP-1 Agonists 40-50% will require insulin therapy eventually Now have combination insulin/glp1 agonist - XULTOPHY
...Insulin in T2DM With concurrent problems, may require insulin urgently for example... Steroid therapy Acute infection Pre or post surgery Gestational diabetes Type 2 diabetes in pregnancy
Normal profile in health In health with no diabetes... Breakfast Lunch Evening Meal Blood sugar Mealtime insulin Background insulin required for basal metabolic requirements
Which insulin to use? Aim to match insulin profile to meet these basic needs and any specific needs of the individual Human vs analogue Rapid action Short action Intermediate action Long action Mixed insulins Insulin mixed with GLP1 Vial form or pens? 200 and 300 iu strengths*****
Commonly used insulin regimes Once daily background insulins To reduces average blood glucose levels eg. Humulin I, Insulatard, Insuman basal, Levemir, Lantus, Abasaglar, Tresiba...often used with oral agents. - less burden for patients or DNs Twice daily insulin regimes Using basal insulins or pre mixed insulins, to target blood glucose profile more specifically e.g. HumulinI, Insuman Comb 50, Novomix 30, Humalog Mix 50...often used to escalate treatment if once daily regime ineffective
Common Insulin regimes cont. Three times daily mixed insulin eg. Humalog Mix 50, Insuman Comb 50 If patient is highly insulin resistant Multiple dose injections basal bolus eg. Insulatard, Lantus or Levemir plus Novorapid or Humalog, Fiasp usually for patients with type 1 diabetes Insulin Pumps Constant infusion of rapid acting insulin T1DM only
Insulin therapy getting it right... Injection technique / timing /compliance Carbohydrates too much/ too little Avoiding and treating hypos appropriately checking BG results not just HbA1c results Lipohypertrophy - 2/3 insulin injectors Hands off / Hands on inspection
...getting it right Self managing where possible morning insulin lunch / tea time results evening insulin supper / b fast results Stable blood sugars lead to HbA1c results and improved outcomes
Getting it wrong... Datix data... Delivery devices Wrong syringes used Withdrawing insulin from pen devices Sharps disposal Insulin prescriptions Communication pathways Patients fasting
Glucagon LikePeptide-1 agonists GLP1s Used only in Type 2 diabetes Increases insulin production when blood glucose levels are high. Reduces insulin production when blood glucose levels are normal Results in No hypos (unless on another agent for example gliclazide or insulin)
GLP1 how do they work? Incretin gut hormone which patients with T2DM often short of GLP1 injections weight loss + improves glycaemic control Slows down gastric emptying reduce appetite Increases feelings of satiety reduce appetite Increases insulin production improves BG control Reduces glucose release from liver improves BG control
GLP1agents commonly in use dulaglutide (Trulicity) Once weekly injections exenatide (Bydureon) once weekly injection liraglutide (Victoza) once daily injection Degludec/liraglutide (Xultophy) once daily insulin/glp1 mixture Useful for patients who need to avoid hypos eg. taxi drivers, HGV drivers Side effect can be nausea initially
Injection techniques Size 4 or 5mm needles now - no need to pinch 90 degree angle Rotate sites / Why? Lypohypertrophy avoidance Encourage patients not to resheath or -reuse needles DSN support initially towards patient self managing - use of Injection prompt sheets Sharps disposal BD safe clip Safety pen needles
DN dependent patients on insulin Observe GGC policy Administration of Insulin by Injection and Blood Glucose Monitoring, District Nursing Syringe/needle - if prescribed insulin is available in vial form- minimise risk of needlestick injuries. If prescribed insulin not available - use a pen device and BD safe clip to remove needle Ask patient to remove needle if possible and place in sharps box Safety pen needles may be available soon
Further Learning 5 Modules available on Learn Pro Contact diabetes team if any concerns or need advice
Any Questions??? Thank you
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