Basal-Bolus Insulin Therapy Veronica Brady, PhD, FNP-BC, BC-ADM, CDE ECHO January 18 2018
Terminology No longer using the term diabetic. Diabetes does not define people. People with diabetes are individuals with diabetes, not diabetics. Diabetic will continue to be used related to complications, e.g., diabetic retinopathy. ADA, Diabetes Care,2016;
Objectives Review insulin therapy Older Newer Latest Discuss starting Insulin Discuss adjusting Insulin
The Case of AB (Diagnosis) AB is a 34 year old male who presents to the office with complains of worsening vison, nocturia, nightmares, and extreme thirst. MH is non-contributory SH-tonsillectomy, appendectomy FH is significant for DM in his father and paternal grandmother, CAD in father with stents at age 54, HTN in his mother SH is significant for smoking ½ ppdx20 years, occasional ETOH, +marijuana. He is single and works in a packing warehouse.
The Case of AB cont Vitals-weight 234#, BMI 35, BP 149/87, P89 A1c in office today 9.3% PE- HEENT-WNL Cardio-RRR Lungs-CTA Abdomen-obese LE-trace edema, ++DP pulses, Feet-+sensation to 10gram monofilament
The Case of AB (year 1) AB returns to your office 3 months after diagnosis. He has been to DSME classes. He states that he has attempted to change his eating habits (less fatty foods, fewer sweets, etc.) and tried to exercise (he walks a lot at work and lifts heavy boxes). He weight today is 230#, BP: 140/90 Labs: chol-204mg/dl, LDL 112mg/dL, Cr-1.3, microalb-10, TSH 2.5, A1c-8%
The Case of AB (year 3) It has been 3 years since diagnosis. You have seen AB in clinic every 3-4 months in the interim since his first visit. In that time you have increased his Metformin to 1gm BID, started glimiperide 4mg BID and put him on max dose of Invokana 300mg/d. He is also on a statin and an ACE. He has managed to lose 12# and keep it off. He reports mild nausea, urinary frequency and some numbness and tingling of his feet.
The Case of AB (year 3) Labs: chol-157mg/dl, LDL 95mg/dL, urine microalb-25, A1c-8.8% PE: unremarkable
"There are two times to start insulin for type 2 diabetes," "The first is any time blood sugar is significantly out of control and a patient has symptoms,. "In these cases, the need for insulin may be short-term. The second time is when type 2 diabetes has progressed over many years and the pancreas can no longer make enough insulin to respond to other diabetes medications." Alaleh Mazhari, DO Loyola University Health System
Insulin A peptide hormone composed of 51 amino acids secreted by pancreatic beta cells Synthesized as preproinsulin, then cleaved to proinsulin and stored in secretory granules, which is then cleaved into C-peptide and insulin in the secretory granules
Rapid Acting Short Acting Intermediate Acting Long Acting Ultra Long Acting Insulins
What is the Best Practice for Managing Diabetes with Insulin? Anticipatory, physiologic insulin dosing prescribed as a basal/ bolus insulin regimen giving the right type of insulin, in the right amount, at the right time, to meet the insulin needs of the patient Wesorick, et al.
Normal Insulin Secretion Basal: continuous insulin to compensate for liver glucose Bolus: surge for food 1 st phase: rapid rise in serum insulin levels inhibits glucagon release and therefore inhibits glycogenolysis 2 nd phase: to maintain normoglycemia postprandially
Components of Physiologic Insulin Regimen Basal insulin (detemir, glargine, NPH,degludec) Circulates between feedings Restrains glucose production, and catabolism of stored fuels Defends against ketoacidosis About 50% of daily insulin requirement Nutritional insulin (aspart, glulisine, lispro, regular) Mimics rapid secretion of insulin in response to feeding Promotes assimilation of ingested nutrients Moderates post-prandial hyperglycemia
OLDER INSULINS
Rapid Acting Insulin Lispro/Humalog Glulisine/Apidra Aspart/Novolog Onset: 15 minutes Peak: 30-90 minutes Duration:3-5 hours 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Short Acting Insulin Regular Onset: Peak: Duration: 1 hr 2-4 hrs 4-12 hrs 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
NPH Intermediate Acting Insulin Onset: Peak: Duration: 1.5-4 hrs 4-12 hrs up to 24 hrs 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Long Acting Insulin Detemir/Levemir Onset: Peak: Duration: 0.8-2 hrs 3.2-9.3 hrs up to 24 hrs Glargine/Lantus Onset: Peak: Duration: 1-2 hrs peakless 24 hrs 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Premixed insulin at breakfast and supper 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Combination Insulins Humulin 70/30 Novolin 70/30 Relion 70/30 Humulin 50/50 Humalog Mix 75/25 Humalog Mix 50/50 Novolog Mix 7030 70% Isophane Suspension (intermediate acting insulin) 30% Regular 70% Isophane Suspension (intermediate acting insulin) 30% Regular 50% Isophane Suspension (intermediate acting insulin) 50% Regular 75% Lispro Protamine Suspension (NPL) (intermediate acting) 25% lispro 50% Lispro Protamine Suspension (NPL) (intermediate acting) 50% lispro 70% Aspart Protamine Suspension (intermediate acting) 30% aspart Vial: 28 days once in use, Pen: 10 days once in use 28 days once in use 28 days once in use Vial: 28 days once in use; Pen 10 days once in use Vial: 28 days once in use; Pen 14 days once in use
NEWER INSULINS
RAPID ACTING
Inhaled Insulin Stimulates glucose uptake by skeletal muscle and fat: inhibits hepatic glucose output
Inhaled Insulin Onset & peak duration of action Main Benefits Peak 53 minutes Duration 160 minutes Less hypoglycemia Common adverse effects Hypoglycemia, cough, throat pain or irritation Cautious Use Acute bronchospasm reported in patients with asthma and COPD using inhaled insulin Contraindications Contraindicated in patients with chronic lung disease, smoker, DKA, hypersensitivity to regular human insulin
Afrezza
Afrezza Considerations: Lung function-no smoking (none within 6 months) Set doses not possible to get 3 units Amount of insulin needed for each meal Must be at room temp for 10 minutes before use
Humalog U-200 Generic Name- lispro U-200 Brand Name: Humalog U-200 Manufacturer: Eli Lilly Form: analog Delivery: pre-filled pen (600 units) Storage: in use 28 days do not refridgerate Onset: 15 minutes Peak: 30-90 minutes Duration: 3-5 hours
INTERMEDIATE ACTING
U-500 pens Generic Name-regular U-500 Brand Name: Humulin R U-500 Manufacturer: Eli Lilly Form: human Delivery: 3 ml pen fill (1500 units) Storage- in use do not refrigerate 28 days Onset: 30 minutes Peak: 8 hours Duration: up to 24 hours
U-500 pens Considerations: Indicated for patients requiring more than 200 units of insulin/day. Administer 2-3 times a day 30 minutes before meals Do not mix with other insulins
U-500 Insulin Pharmacologic profile similar to NPH Useful in patients with: Obesity Immune-mediated insulin resistance Genetic abnormalities of the insulin receptor
U-500 Insulin Pharmacologic profile similar to NPH Useful in patients with: Obesity Immune-mediated insulin resistance Genetic abnormalities of the insulin receptor
LONG ACTING
Long-Acting Insulin Basaglar (biosimilar Lantus) Onset: Peak: Duration: 1-2 hrs peakless 24 hrs 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 8 19 20 21 22 23 24 x B L D x
Basaglar Generic Name-glargine Brand Name: Basaglar Manufacturer: Eli Lilly Form: analog Delivery: 3 ml pen fill Storage-pen in use 28 days Onset: one hour Peak: no peak Duration: 24 hours
Ultra Long Acting Insulin Glargine U-300/Toujeo Onset: Peak: Duration: 6 hrs peakless 36 hrs
Toujeo Generic Name: glargine U-300 Brand Name: Toujeo Manufacturer: Sanofi Form: Analog Delivery: (450unit) prefilled pen Storage-pen in use good for 42 days Onset: 6 hours Peak: No peak Duration: 36 hours Maximum single injection: 80 units
Comparison of U-100 & U-300 insulin glargine U-100 U-300
Ultra Long Acting Insulin Degludec/Tresiba Onset: Peak: Duration: ½-1.5 hrs peakless 42 hrs
Tresiba Generic Name: degludec Brand Name: Tresiba Manufacturer: Novo Nordisk Form: Analog Delivery: prefilled pen u-100 (300) u-200 (600) Storage: in use room temperature up to 48 days Onset: one hour Peak: No peak Duration: 42 hours Maximum single dose: 160 units
WHAT S THE LATEST?
Insulin + GLP-1 Soliqua 100/33 (glargine 100/lixisenatide 33mcg per ml) Using <60units of basal or lixisenatide If <30 units/day --start with 15 units (15glargine/5mcg lixisenatide); 30-60 units/day start 30 units Max dose 60 units (60G/20 lixisenatide) One hour prior to 1 st meal Supplied in 3ml prefilled pens
Insulin + GLP-1 Xultophy 100/3.6 (100 units degludec/3.6 mg liraglutide Using less than 50 units basal or liraglutide < 1.8 Starting dose 16 units (16 units degludec/0.58mg Max dose 50 units (50 units degludec/1.8mg liraglutide Independent of food Supplied in 3ml prefilled pens
Fiasp Generic Name- fast acting insulin aspart Brand Name- Fiasp Manufacturer- Novonordisk Form- analog Delivery- 3ml pre-filled pen, 10 ml vials Storage-open in use 28 days-room temperature Onset- 2.5 minutes (dose dependent) Peak- 63 minutes (dose dependent) Duration- 5-7 hours (dose dependent)
STARTING INSULIN & ADJUSTING INSULIN
Who Should be on Insulin? Type 1 diabetes at any age Uncontrolled hyperglycemia on oral agents Presentation with decompensated diabetes Pregnant women with hyperglycemia Critical illness e.g. myocardial infarction, sepsis No oral access Oral agents contraindicated e.g. NPO, renal or hepatic disease
How much insulin to start? New start: Usual starting total daily dose: 0.3-0.6 units/ kg larger dose if: steroid therapy, massive obesity smaller dose if: renal failure, hepatic failure, malnourished, type 1 diabetes Half basal, half prandial/bolus ± correctional
The Case of AB (cont) 37 yo male. 222#, BMI- 33, BP 150/90, A1c 8.8% It s time for insulin What to do?
The Case of AB (year 10) He is now 44 years old. He has regained the weight he previously lost plus an additional 20#--254# (BMI 38). He is not checking BG often, but no feelings of lows. His A1c is 10%. He states he is taking insulin as prescribed, but BG remains elevated What to do now?
Pharmacological Therapy For T2DM If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1C target over 3 months, add a second oral agent, a GLP-1 receptor agonist, or insulin. Use a patient-centered approach to treatment. Don t delay insulin initiation in patients not achieving glycemic goals. ADA, Diabetes Care,2016; American Diabetes Association Standards of Medical Care in Diabetes. Approaches to glycemic treatment. Diabetes Care 2016; 39 (Suppl. 1): S52-S59
Recommendations: Older Adults Glycemic goals for some older adults might be relaxed but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. Hypoglycemia should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacologic interventions. American Diabetes Association Standards of Medical Care in Diabetes. Older adults. Diabetes Care 2016; 39 (Suppl. 1): S81-S85
Questions?