Canadian Diabetes Assocaition Clinical Practice Guidelines Pharmacotherapy in Type 1 Diabetes Chapter 12 Angela McGibbon, Cindy Richardson, Cheri Hernandez, John Dornan

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Pharmacotherapy in T1DM Checklist USE basal-bolus insulin regimens or continuous subcutaneous insulin infusion TAILOR insulin regimens to the individual’s treatment goals, lifestyle, diet, age, general health, motivation, hypoglycemia awareness status, and ability for self- management COUNSEL about the risk, prevention and treatment of insulin-induced hypoglycemia 2013

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Types of Insulin for Use in T1DM

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Serum Insulin Level Time Analogue Bolus: Apidra, Humalog, NovoRapid Human Basal: Humulin-N, Novolin ge NPH Analogue Basal: Lantus, Levemir Human Bolus: Humulin-R, Novolin ge Toronto

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Insulin Therapy in Type 1 Diabetes BASAL – BOLUS REGIMEN Bolus insulin at meal times + basal insulin once or twice a day OR CONTINUOUS SUBCUTANEOUS INSULIN INFUSION “insulin pump therapy” with continuous subcutanous infusion of insulin via a catheter

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Must Counsel About Hypoglycemia Must counsel all patients with type 1 diabetes about hypoglycemia: recognition, treatment, prevention Assess risk factors for severe hypoglycemia Assess for hypoglycemia unawareness and treat accordingly See guideline Chapter 14

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 1 1.To achieve glycemic targets in adults with type 1 diabetes, basal-bolus insulin regimens or the use of CSII as part of an intensive diabetes management regimen should be used [Grade A, Level 1A]

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 2 and 3 2.Rapid-acting insulin analogues, in combination with adequate basal insulin, should be used instead of regular insulin, to minimize the occurrence of hypoglycemia, improve A1C [Grade B, Level 2] and achieve postprandial glucose targets [Grade B, Level 2] 3.Rapid acting insulin analogues (aspart or lispro) should be used with CSII in adults with type 1 diabetes [Grade B, Level 2]

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 4 4.A long-acting insulin analogue (detemir, glargine) may be used as the basal insulin [Grade B, Level 2] to reduce the risk of hypoglycemia [Grade B, Level 2], for detemir; [Grade C, Level 3], for glargine], including nocturnal hypoglycemia [(Grade B, Level 2), for detemir ;(Grade D, Consensus), for glargine].

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 5 5.All individuals with type 1 diabetes should be counseled about the risk and prevention of insulin- induced hypoglycemia, and risk factors for severe hypoglycemia should be identified and addressed [Grade D, Consensus].

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 6 6.In individuals with hypoglycemia unawareness, the following strategies may be used to reduce the risk of hypoglycemia and to attempt to regain hypoglycemia awareness: – Increased frequency of SMBG, including periodic assessment during sleeping hours [Grade D, Consensus] – Less stringent glycemic targets with avoidance of hypoglycemia for up to 3 months [Grade C, Level 3 ] – A psychobehavioural intervention program (blood glucose awareness training) [Grade B, Level 2]

guidelines.diabetes.ca | BANTING ( ) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA Clinical Practice Guidelines – for professionals BANTING ( ) – for patients