Text insulin Management in type 2 diabetes mellitus PRACTICAL POINTERS FOR CLINICAL PRACTICE

What is so frightening about diabetes???

Denial, myths, fear.... I can’t have diabetes, I feel GREAATTTT! Only fat people get diabetes, so if I keep my weight down, I won’t get it. My grandmother told me that diabetes comes from eating too much sugar. I took my medication once or twice a week. I really don’t think it helped, so I quit taking it.

the diabetes epidemic

MANAGE SMARTER AND MORE AGGRESSIVELY

Indications for Insulin therapy Adjunctive therapy - used when oral agents alone fail to achieve target glycemic goals Basal insulin at bedtime decrease fasting blood sugars, oral agents control blood sugar during the day. Replacement therapy - used when both basal and meal-time insulin are needed. Glucose Toxicity - use Intensive Insulin Therapy (IIT) for 2-4 weeks at diagnosis which may improve endogenous insulin secretion and sensitivity. Triggers for starting insulin: persistent glucose > 250 mg/dl. HbA1c > 10% ketonuria symptoms - polyuria, polydipsia, weight loss IIT used early can resolve glycemic issues faster than oral agents. Other - during hospitalization, pre-operatively, with steroid therapy, or at any time that glycemic control deteriorates

triggers for starting insulin HbA1c > 10% Symptoms of polyuria, polydipsia, weight loss Failure of multiple oral medications Acute situations; e.g. infections, MI, stroke, trauma Perioperative period Pregnancy Contraindications to oral medications failure

Insulin Products

Insulin Regimens

How to Start and intensify INsulin

Starting insulin Is a process Generally takes a few weeks Familiarize patient with insulin administration Build patient confidence Gradual improvement of glycemic control while avoiding hypoglycemic episodes If available, consultation with CDE is invaluable

Start Simple Long acting or immediate acting insulin Add short acting with meals to reduce post-meal rises Continue to use oral agents; Metformin, TZDs, DPP-4’s Sulfonylureas - discontinue May require 20-30% more insulin if oral agents are discontinued

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Insulin Regimens

Once daily injection of Glargine, Detemir, NPH Given at bedtime to lower fasting blood glucose Can be used alone or with oral agents Detemir and NPH may need to be given twice daily NPH associated with more hypoglycemia Raising basal only can lead to lows at night Glargine and Detemir are more costly than NPH basal regimen

✰ Add short-acting insulin if post-meal blood sugars are high Split-Mix: consider that insulin proportions are typically 2/3 in morning and 1/3 in evening. Ratios of long-acting/NPH to rapid/Regular of 2:1 in am and 1:1 in evening. Split-mix often leads to hypoglycemia in middle of night related to NPH peak at 6-8 hours after dinner injection. Intermediate and Short-Acting Regimen ✰ ✰

Basal-Bolus Regimen Ideal for replacement insulin therapy Preferred for patients who have unpredictable mealtime and activity schedules. Basal insulin is 40-50% of total daily dose of insulin Bolus given pre-meal - should be 50-60% - may be adjusted according to carbohydrate counting using insulin-to-carbohydrate ratio

How to Figure Insulin to CArb Ratio (I:CR) To Figure I:CR divide amount of carb person is consuming by amount of insulin taken at meal Example: 60gm ÷ 10 units = 6 I:CR is 1:6 If person eats 75 gm carbs ☟ ☞ 75 mg ÷ 6 = 12 units ☞

Sensitivity/Correction Factor Used for patients with varying blood glucose Corrects pre-meal highs or lows Given only before meals Ensures that the post-meal glucose will be in acceptable range More commonly used in Type1 vs. Type 2

Calculation: Sensitivity/Correction Factor Divide 1500 by total daily dose (TDD) insulin - this determines the sensitivity ratio. Example: 1500 ÷ 50 units/day = 30 Correction Factor: If patient blood sugar is 250 mg/dl. and target blood glucose range is 100 mg/dl., figure 1 unit of insulin is needed for every 30 pts. above target range of 100 mg/dl.

Doing the Math Target Glucose Range: 100 mg/dl. I:CR 1:6 Sensitivity Factor: 1:30 Patient blood glucose is: 250 mg/dl. Calculation: SMBG Target 250 mg/dl mg/dl. = 150 Sensitivity: 1:30 150÷30 = 5 units I:CR person eats 75 gms. at lunch = 12 units Meal Bolus =12 units PLUS 5 units correction = 17 units

In Intensive Insulin Therapy (IIT) If person eats 3 meals/day and 3 carb snacks they should bolus 6 times per day Better managed with consistent carb intake at meals rather than snacks - reduces # of injections to 3 per day IIT IMPortant tips OR teach patient about non-carb snacks

Self MOnitoring of Blood Glucose (SMBG) Very important component of insulin management to assess and make appropriate and safe changes Recommendations for testing vary as to patient and insulin type : 1-2 times if on basal regimen only OR 2-4 times for combined regimen. REMEMBER: 4-8 testings provide only 4-8 “snapshots.” Can lose alot of information in between & at night

IMPORTANT: Evaluate fasting and 2 hour postprandial blood glucose readings when chosing basal insulin only, mixed insulins, or basal-bolus regimens (IIT) Target is a blood sugar < 180 mg/dl. or A1c of 7% or less. Need to check postprandials at different meals to identify a pattern that may be ocurring

CONTINUOUS GLUCOSE MONITORING (CGMS)

Medical Nutrition Therapy Proper nutrition is essential to insulin management. ADA recommends individualized MNT Teaches carb counting and is individualized to patient’s level of understanding Current Nutrition Recommendations: 3 meals / day; gms. carbs each With or Without 1-2 snacks in between meals - if each snack is < 30 gms. no additional rapid-acting insulin needed

Focus of MNT Lifestyle changes Increased physical activity Pt. may chose to eat 3 meals/day OR small meals with snacks

CArbohydrates Greatest impact on postprandial blood sugars Patient should understand which foods contains carbs Understand portion size & number of servings per meal/snack Total carb consumption vs. type of carb impacts blood sugar control No evidence to support low vs. high glycemic index diets Artificial sweeteners are FDA approved for DM

Protein Is widely misunderstood in diabetes glycemic control Does raise plasma glucose concentration - amt. produced is small and does not appear in general blood circulation Protein has not been found to slow carbohydrate absorption Does not treat hypoglycemia Adequate intake is important to euglycemia

FAts Intake should be limited Saturated fat is the primary determinant of LDL Trans fats increase LDL & lower HDL - limit as much as possible

Initial MNT guidelines Consume 3 meals/day, not skip meals Meals no more than 4-6 hrs. apart Set maximum carbohydrate intake per meal Avoid regular soda, fruit juice, sport drinks, choose water Food label - focus on serving size & total carbs Men: gms carbs., Women: gms

Barriers to insulin Hypoglycemia Weight gain Psychological Barriers Lipodystrophy Allergic reactions Glargine insulin associated with cancer risk

IN Summary

Insulin is very effective but underused in T2DM ☤ ☤ ☤ ☤ ☤ Insulin can be used earlier in disease and as an adjunct to oral medications Transition to insulin should not be regarded as a failure by patient or provider Primary care providers should be familiar with indications for insulin, insulin regimens used & side effects Adequate support for patients is key to transitioning and the success of treatment

"Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around." ~ Leo Buscaglia ~ ♡♡ ♡♡ ♡