1. Managing the patient on insulin. A Practical Approach Neum Conference October 24, 2008 John A Geddes MD

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3. Managing the patient on insulin B.N je 57 godina stara ž ena kojoj je diagnosticiran diabetes prošle godina kada je bila u bolnici zbog oboljenja koronarnih arterija. Ona koristi Metformin 500mg tri puta dnevno i insulin koristi ujutro. Ona posje ć uje endokrinologa svakih 4 mjeseca. Ona dolazi po ramapril (BP je 146/92) i tablete za spavanje. Ona ima problema sa spavanjem, budi se dva puta u toku no ć i da ide na toalet i onda više ne mo ž e zaspati.

4. Managing the patient on insulin Posljednji put kad ste je vidjeli naru č ili ste neke krvne nalaze da uradi. Njena glukoza na tašte je bila 12,4. Ne ć e vidjeti endokrinologa u sljede ć ih dva mjeseca. Last time you saw her you ordered some blood work. Her fasting blood glucose was 10.8. She doesn’t see the endocrinologist for another two months.

5. Managing the patient on insulin Šta vi trebate da znate o ovom pacijentu u cilju postizanja zadovoljavaju ć e kontrole glukoze? What do you need to know about this patient in order to manage her insulin to achieve satisfactory glycemic control?

6. Managing the patient on insulin Diet/Nutrition Exercise Insulin

15. Managing the patient on insulin Diet/Nutrition Kinds of food consumed Frequency of meals Ability to count calories/carbohydrates? Availability of nutritional counselling?

16. Managing the patient on insulin Exercise Type Frequency Impediments to exercising

17. Managing the patient on insulin Insulin

18. Managing the patient on insulin Insulin Type Mode of administration Dose Frequency of administration

19. Managing the patient on insulin Insulin Type Regular, NPH, Lente, Ultra Lente Insulin Analogues Lispro/aspart (Rapid Acting)‏ Glargine (Lantis)‏ Detemir

21. Action Profiles of Various Insulin Types Plasma Insulin levels Hours Note: action curves are approximations for illustrative purposes. Actual patient response will vary. regular 6-10 hours NPH 12–20 hours lispro/aspart 4–6 hours  BASAL INSULINS glargine ~ 20-26 hours Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12  BOLUS INSULINS

22. Action Profiles of Mixed Insulin Types Plasma Insulin levels Hours Note: action curves are approximations for illustrative purposes. Actual patient response will vary. regular 6-10 hours NPH 12–20 hours Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

23. Action Profiles of Various Insulin Types Plasma Insulin levels Hours Note: action curves are approximations for illustrative purposes. Actual patient response will vary. NPH 12–20 hours lispro/aspart 4–6 hours  BASAL INSULINS Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12  BOLUS INSULINS

24. Action Profiles of Various Insulin Types Plasma Insulin levels Hours Note: action curves are approximations for illustrative purposes. Actual patient response will vary. lispro/aspart 4–6 hours  BASAL INSULINS glargine ~ 20-26 hours detemir – 20-24 hrs Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12  BOLUS INSULINS

25. Managing the patient on insulin Mode of Administration Syringe Pen CSII – Continuous Subcutaneous Insulin Infusion - INSULIN PUMP Inhaled

28. Morate razmotriti i tip inzulina koji se koristi. broj jedinica koje koristi I vrijeme administracije u svezi sa vrijednostima glukoze u toku dana, dijete i navike vježbanja pacijenta. You will need to consider the type of insulin used, the number of units taken and the time of administration in conjunction with the glucose readings over the day, the diet and exercise habits of the patient.

29. Managing the patient on insulin You will need to know the patient's glucose levels ( preferably from several different times of the day) and the Glycosylated Hgb (A1C)‏

30. ADA. Clinical Practice Recommendations. 2001. What are the goals of intensive glycemic management? Near-Normal Glycemia Avoid short term crisis Hypoglycemia Hyperglycemia Diabetic Ketoacidosis Avoid long term complications Improve quality of life

31. Targets for Glycemic Control Canadian Diabetes Guidelines - 2008 Hgb A1c < 7% Preprandial glucose – 4.0-7.0 mmol/l Postpradial glucose – 5.0 – 10.0 mmol/l (5.0 – 8.0 if HgbA1c target not met)‏ Canadian Diabetes Association Guidelines 22008

32. Targets for Glycemic Control Canadian Diabetes Guidelines - 2008 Hgb A1c < 7% Preprandial glucose – 4.0-7.0 mmol/l Postpradial glucose – 5.0 – 10.0 mmol/l (5.0 – 8.0 if HgbA1c target not met)‏ Canadian Diabetes Association Guidelines 22008

33. Targets for Glycemic Control Canadian Diabetes Guidelines - 2008 Hgb A1c < 7% Preprandial glucose – 4.0-7.0 mmol/l Postpradial glucose – 5.0 – 10.0 mmol/l (5.0 – 8.0 if HgbA1c target not met)‏ Canadian Diabetes Association Guidelines 22008

34. Targets for Glycemic Control Canadian Diabetes Guidelines - 2008 Hgb A1c < 7% Preprandial glucose – 4.0-7.0 mmol/l Postpradial glucose – 5.0 – 10.0 mmol/l (5.0 – 8.0 if HgbA1c target not met)‏ Canadian Diabetes Association Guidelines 22008

35. ADA. Clinical Practice Recommendations. 2001. What are the goals of intensive glycemic management? Near-Normal Glycemia Avoid short term crisis Hypoglycemia Hyperglycemia Diabetic Ketoacidosis Avoid long term complications Improve quality of life

37. Return to the patient: Otkrivate da B.N. koristi 32 jedinice M3 inzulina ujutro. Njen Hgb A 1C je 9, 6 %. Njena glukoza na tašte je 12, 2. You discover that B.N. is taking 32 units of M3 insulin in the morning. Her Hgb A1C is 9.6%. Her fasting blood sugar is 12.2.

38. Vi znate da ona treba više inzulina (ili više vje ž banja ili manje hrane). Ona vam govori da joj je jedanput ranije doktor pove ć ao insulin za 4 jedinice I da se osje ć ala u ž asno poslijepodne I da je morala uzeti meda. Ona se plaši da pove ć a njen insulin ponovo. Šta joj savjetujete? You know that she needs more insulin (or more exercise or less food). She tells you that once before a doctor had increased her insulin by 4 units and she ended up feeling terrible in the afternoon and had to eat honey. She is afraid to increase her insulin again. What will you advise?

39. Tokom sljede ć e sedmice pacijent je koristio glukometar da provjerava vrijednosti njene glukoze u razli č ito vrijeme u toku dana I dobila je sljede ć e rezultate: ujutro- 14,1 podne-11,1 4 pm-5.3 ve č e- 13.8 Tako đ e ste shvatili da ona uzima kafu, sir I pecivo za doru č ak, supu I vo ć e za ru č ak I da je njen glavni obrok u 5 I 30 kada joj muz do đ e s posla.

40. Plasma Insulin levels Hours Note: action curves are approximations for illustrative purposes. Actual patient response will vary. Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12 Blood Glucose HGBA1c - 9.6 AM 14,1 noon 11,1 4pm 5,3 hs 13,8

41. Teoretski… ova pacijentica treba više inzulina I treba bolju distribuciju inzulina tokom dana. Ovo se najbolje mo ž e posti ć i time da se podijeli doza inzulina I das a upotrebom multiplih injekcija NPH ili upotrebom nekog od novijih dugodjeluju ć ih insulin analoga kao bazalnog inzulina, I ako je potrebno dodaju se bolus ili pred obrok brzodjeluju ć i insulin uz obrok. In theory....this patient needs MORE insulin and needs it better distributed over the day. This is best accomplished by dividing the insulin doses and by either using multiple injections of NPH or by using one of thenewer long acting insulin analogues as a basal insulin and, if necessary, adding bolus or prandial rapid acting insulin with meals.

42. Mo ž ete pokušati pove ć ati njen UKUPNI insulin za 10% (3-4 jedinice) I podijeliti ih tako da dobije 2/3 ujutro 2/3 prije njene ve č ere. (M3 inzulin -22 jedinice ujutro, 14 jedinica prije ve č ere)‏ (Self monitoring with a glucometer will help to adjust the insulin requirements.)‏

43. Action Profiles of Various Insulin Types Plasma Insulin levels Hours Note: action curves are approximations for illustrative purposes. Actual patient response will vary. Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

44. Action Profiles of Various Insulin Types Plasma Insulin levels Hours Note: action curves are approximations for illustrative purposes. Actual patient response will vary. lispro/aspart 4–6 hours glargine ~ 20-26 hours detemir – 20-24 hrs Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

45. Managing the patient on insulin Patient concerns Hypoglycemic episodes Cost Use of needles Ability to comply (vision, Understanding)‏ Availability of Diabetes Education.

46. Educate the patient. (AND YOURSELF)‏ Glucose monitoring Diet and insulin needs Hypoglycemia Adjust the insulin (dose, type, time)‏ according to the response to therapy. Try for good glycemic control – all day Consider other factors (vision, exercise, age, intellect)‏ Basal/bolus therapy is now considered to be the management of choice. h

47. Edukovati pacijenta. (I sami sebe) Glukoza nadzor. Dijeta i potrebe inzulina. Hipoglikemija. Prilagodite inzulin (doza, vrsta, vrijeme) prema odgovoru na terapiju. Pokušajte dobre kontrole glikemije - cijeli dan Razmislite o drugim faktorima (vid, vježbe, dobi, intelekt) Bazalna terapija je sada smatrana kao izbor za upravljanje dijabetesom.