Case Studies on Insulin Initiation Nicole McGrath 2013

Case 1 52 year old woman, type 2 diabetes for 10 yrs, BMI 32 (87kg) On Metformin 850mg mane, 1700mg nocte; Gliclazide 80mg bd Regularly picks up scripts; assures you she is taking Not testing BG HbA1c 70 mmol/mol What to do?

Case 1 Discussion Increase Gliclazide to 160mg bd Start home BG testing BG elevated: Fasting around 10 Before evening meal 12 2 hours after evening meal 13 What next?

Case Study 1 - Mrs J Age 52. BMI 32 (87kg). HbA1c: 70mmol/mol Currently on: Metformin 850mg mane, 1,700mg at dinner, Gliclazide 160mg BD.   Blood glucose (mmol/L) Slide 10 00:05:17:20 Stop so that group can discuss the case study 00:06:00:02 How would you start Mrs J. on insulin?

Case Study 1 - Mrs J. NZGG: Start Isophane 8-10 units at bedtime. Continue orals – consider reduction of Gliclazide to 80mg BD. Give the patient instruction to self-adjust insulin dose. Likely doses to achieve red line: Isophane 30-35 units nocte Gliclazide 160mg bd Metformin 850mg mane, 1700mg evening meal Rick 00:06:00:24 Cut to Slide 11 00:06:14:10 Bring up red line 00:06:37:22 Stop slide 00:07:37:05 Cut to Rick

Case Study 2 – Mrs T: Age 74. HbA1c 75mmol/mol (9%) , Currently on: Prednisone 5mg/day for Rheumatoid Arthritis and maximal OHA therapy. Blood glucose (mmol/L) Slide 16 00:12:12:04 Cut to Rick 00:13:05:13

Case Study 2 – Mrs T. As you can see… high glucose levels rising during the day but dropping over night. Consider: 10 units of isophane at breakfast and adjust the dose as required. Good fasting achieved with 15 units but…. Red line still suboptimal so change to 15 units of Pre-mixed insulin breakfast Penmix 30 / Humulin 30/70 Slide 17 00:13:07:02 Bring up red line 00:13:34:05 Cut to Rick 00:13:41:02 .

Case 3: 66 yr old male with COPD On Metformin 1gm bd, Glipizide 5mg bd; HbA1c 57 mmol/mol Needs course of Prednisone for exacerbation COPD Prednisone 40mg daily 5 days then 20mg 5 days Fasting Pre-lunch Pre-dinner 6.8 12.6 17.2 7.1 13.8 18.0

PATHWAY FOR MANAGING HYPERGLYCAEMIA SECONDARY TO STEROIDS FOR CLIENTS WITH COPD (on HealthPoint) Whilst on 40 mg Prednisone Test BSLs at least tds OHAs –increase usual mane dose by 100% e.g. usual mane dose Gliclazide 80mg –increase to 160mg If patient is maximised on OHAs: transient hyperglycemia can sometimes be tolerated for a short period. Alternatively, a morning dose of Penmix 30/70 (usually 0.2 units/kg body weight) can be given during steroid treatment. Some patients may need to be commenced on ongoing insulin

Blood glucose (mmol/L) Case Study 4 - Mr L. Age 62. BMI 27 (78kg) HbA1c 68mmol/mol. Currently on: maximal OHA therapy. Blood glucose (mmol/L) Slide 14 00:09:34:22 Cut to Rick 00:10:15:04

Case Study 4 – Mr L. High fasting and post-prandial BG: basal insulin with current OHA will treat fasting hyperglycaemia but not post meal BG elevations Suggest Premixed insulin: As lunch not so much of an issue, Novomix 30 or Humalog 25: Start 15 units bd (0.2 units/kg/dose) Stop sulphonylurea Slide 15 00:10:15:13 Bring up red line 00:10:36:00 Cut to Rick 00:11:08:06

Blood glucose (mmol/L) Case Study 5 - Mr K. Age 64. HbA1c 75mmol/mol (9%). Currently on: maximal OHA therapy. Blood glucose (mmol/L) Slide 12 00:07:40:03 Cut to Rick 00:08:17:12

Case Study 5 – Mr K. Mr K’s blood glucose is particularly high after his main meal (dinner). Consider 10–12 units of pre-mixed insulin (Humalog Mix25 or Novomix30) at dinner. Slide 13 00:08:26:23 Bring up red line 00:08:59:02 Cut to Rick 00:09:06:11

Case 6: 55 yr old male, BMI 35 (116kg), known diabetes 4 yrs, Hba1c 85 No home BG testing Long gaps between prescription requests Prescribed Metformin 1gm bd, Gliclazide 160mg bd Microalbuminuria, background retinopathy, hypertension

Case 6 Option 1 advice on diet, exercise, taking medication warn of possible adverse consequences; increase Metformin to 1500mg bd; Start BG testing and reporting back to nurse

Case 6 Option 2: 3 month F/U HbA1c 76: Has achieved good reduction with compliance but HbA1c still suboptimal and not testing much Fasting BG 10, Pre-dinner 13 Glargine in addition to Metformin and Gliclazide a reasonable option Starting dose: 0.2 units / kg / day: Weight 116kg: start 24 units daily (morning or night) Insulin self-adjustment in conjunction with weekly contact with nurse

Case 6 Option 3: Accept failure of OHA Prescribe pre-mixed insulin bd He eats 2 meals per day: brunch and dinner NovoMix 30 or Humalog Mix 25: 24 units bd Could well need to double that Stop sulphonylurea, continue Metformin Provide insulin self-adjustment handout or ask pt to increase each dose by 2 units every 3 days until BG 4-8 Hopefully practice nurse will be able to contact him weekly to support/supervise

Case 7: 37 year old female, BMI 45 (weight 128kg); diabetes 3 years HbA1c 85 Prescribed Metformin 1gm bd; Gliclazide 160mg bd and appears to be taking them Not testing BG Sleep Apnoea

Case 7 Option 1 Weight loss essential: Refer to dietitian for consideration of Optifast Refer for consideration Bariatric Surgery Pioglitazone in addition to Metformin and Gliclazide Repeat HbA1c in 3 months

Case 7 Option 2 Accept weight loss/exercise not achievable Consider insulin, although insulin resistance will mean large doses necessary Eats 3 meals per day and snacks in the evening Penmix 30 or Humulin 30/70: 26 units bd, stop sulphonylurea Insulin self-adjustment: may need to increase by > 4 units each time if BG remain very high Will probably need 60 units bd if she doesn’t change her diet/weight

Case 8: 41 yr old male, BMI 27 Diabetes 8 yrs, on Metformin 1500mg bd, Gliclazide 160mg bd, Pioglitazone 45mg daily Truck driver HbA1c 62 mmol/mol Microalbuminuria, erectile dysfunction, retinopathy BG: fasting 9, pre-dinner 10 Requires heavy traffic licence medical certificate Patient feels he is doing as much as he can re diet, exercise

Case 8 Needs insulin but want to minimise effect on driving Isophane at night 10 units Increase by 2-4 units every 3 days to achieve fasting BG < 7 Continue OHA NB. LTSA do not generally require specialist reports for type 2 patients on insulin