Insulin in Primary Care Dr Saqib Mahmud, MRCP(UK), MRCGP

Introduction Prevalence of DM in UK-2.2 million. Prevalence of DM in UK-2.2 million. 90%-T2DM 90%-T2DM Diabetic epidemic predicted to reach 300million by 2025 Diabetic epidemic predicted to reach 300million by 2025 Increased incidence of T2DM due to ageing population, sedentary life style & obesity Increased incidence of T2DM due to ageing population, sedentary life style & obesity T2DM results from insulin resistance & abnormal insulin secretion T2DM results from insulin resistance & abnormal insulin secretion

Insulin resistance Failure of peripheral tissues to respond or use insulin  prevents insulin signalling to the liver to reduce glucose production  hyperglycaemia hyperglycaemia

Abnormal insulin secretion Early phase  loss of rapid release of stored insulin in response to food Early phase  loss of rapid release of stored insulin in response to food Late phase  newly manufactured insulin becomes impaired  hyperglycaemia Late phase  newly manufactured insulin becomes impaired  hyperglycaemia

New approach to T2DM Mx Our approach has dramatically changed during the past few years Our approach has dramatically changed during the past few years Historically insulin was owned by health care professionals & self management of insulin was discouraged Historically insulin was owned by health care professionals & self management of insulin was discouraged Now, self management is actively encouraged with patient education & self adjustment on the start of therapy Now, self management is actively encouraged with patient education & self adjustment on the start of therapy Patients make the informed choice Patients make the informed choice

UKPDS Demonstrated beyond doubt  improved glycaemic control reduces microvascular complications Demonstrated beyond doubt  improved glycaemic control reduces microvascular complications T2DM runs a progressive course – 4% decline in beta cell function T2DM runs a progressive course – 4% decline in beta cell function Most patients will eventually need insulin to counteract beta cell failure Most patients will eventually need insulin to counteract beta cell failure Insulin is widely under used & frequently delayed particularly in primary care Insulin is widely under used & frequently delayed particularly in primary care

Reluctance to insulin Rx Stems from lack of confidence Stems from lack of confidence Practice factors Practice factors Patient factors Patient factors Insulin initiation interpreted as Rx failure rather than natural progression of disease Insulin initiation interpreted as Rx failure rather than natural progression of disease Current NHS developments are likely to expect insulin initiation largely in the primary care in future Current NHS developments are likely to expect insulin initiation largely in the primary care in future

Glycaemic control Various guidelines including UKPDS recommend HbA1c <7.5% Various guidelines including UKPDS recommend HbA1c <7.5% NICE - HbA1c b/w 6.5 to 7% NICE - HbA1c b/w 6.5 to 7% NSF Diabetes – HbA1c <7.5% NSF Diabetes – HbA1c <7.5% QoF target – HbA1c < or = 7.4% QoF target – HbA1c < or = 7.4%

Indications for Insulin initiation To maintain glucose control as beta cell failure progresses To maintain glucose control as beta cell failure progresses Progressive rise in HbA1c >7.5% despite max OHAs Progressive rise in HbA1c >7.5% despite max OHAs Osmotic symptoms Osmotic symptoms Sudden weight loss & intense tiredness Sudden weight loss & intense tiredness Painful peripheral neuropathy & diabetic Amytrophy Painful peripheral neuropathy & diabetic Amytrophy Episode of DKA Episode of DKA

Indications - continued MI (DIGAMI study) MI (DIGAMI study) Pregnancy Pregnancy Development of complications – most urgent need for insulin Development of complications – most urgent need for insulin

Barriers to initiate insulin Practice factors Reluctance to use insulin in T2DM Reluctance to use insulin in T2DM Reluctance by GPs to become involved in insulin initiation Reluctance by GPs to become involved in insulin initiation Traditionally insulin introduction was seen as a last resort Traditionally insulin introduction was seen as a last resort Need for referral to secondary care Need for referral to secondary care

Patient factors – reluctance to insulin Major barrier – widespread fear of self injecting / fear of needles Major barrier – widespread fear of self injecting / fear of needles Fear of hypoglycaemia- overestimate of risk Fear of hypoglycaemia- overestimate of risk Inability to deal with insulin- handle equipment, adjust dose Inability to deal with insulin- handle equipment, adjust dose Feeling of loss of health- insulin is seen as ‘beginning of the end’ Feeling of loss of health- insulin is seen as ‘beginning of the end’ Weight gain- levels off with time in most, counteracted by combining metformin, may not occur in some Weight gain- levels off with time in most, counteracted by combining metformin, may not occur in some

Patient factors - misconceptions Becoming ‘addicted to insulin’- once they start will be unable to stop it even if it does not suit them Becoming ‘addicted to insulin’- once they start will be unable to stop it even if it does not suit them Punishment for those who fail on other Rx Punishment for those who fail on other Rx Insulin causes ‘ill health’– usually from observations of others (particularly when insulin was introduced too late) leading to death or complications to follow Insulin causes ‘ill health’– usually from observations of others (particularly when insulin was introduced too late) leading to death or complications to follow ‘Live for today’- some prefer to live with increased risk of complications ‘Live for today’- some prefer to live with increased risk of complications Physical barriers – vision & dexterity Physical barriers – vision & dexterity

Assessing if insulin is appropriate Is the patient on max doses of OHAs with HbA1c>7% Is the patient on max doses of OHAs with HbA1c>7% Can the patient cope with daily injections or hypoglycaemia Can the patient cope with daily injections or hypoglycaemia Are the long term complications likely to occur in the patients life time Are the long term complications likely to occur in the patients life time Does the patient need an LGV or PCV license to work Does the patient need an LGV or PCV license to work Is the patient clinically obese Is the patient clinically obese

Common insulin regimes Once daily – basal with OHAs, eg; glargine or levemir Once daily – basal with OHAs, eg; glargine or levemir Twice daily pre-mixed insulins, eg; Novomix 30 Twice daily pre-mixed insulins, eg; Novomix 30 Multiple injections ( basal / bolus ) eg; glargine or levemir / novorapid – basal, once a day. Bolus, at meal times-tds Multiple injections ( basal / bolus ) eg; glargine or levemir / novorapid – basal, once a day. Bolus, at meal times-tds

Once daily- Basal with OHAs (glargine/ levemir) suitable for; Over weight& insulin resistant Over weight& insulin resistant Reluctant to start insulin Reluctant to start insulin Unable to inject themselves Unable to inject themselves Optimizing control is not vital but hypoglycaemia is unacceptable Optimizing control is not vital but hypoglycaemia is unacceptable Initiate at 10u or 0.2u/kg – dinner/bedtime, titrate dose 3-7 days Initiate at 10u or 0.2u/kg – dinner/bedtime, titrate dose 3-7 days Pre-breakfast BG levels are good indicators of their effectiveness Pre-breakfast BG levels are good indicators of their effectiveness

Twice daily pre-mixed insulins – good choice for; Fairly regular lifestyles, eat similar amounts at similar times each day Fairly regular lifestyles, eat similar amounts at similar times each day When OHAs are no longer sufficient to control BG levels after meals (becoming insulin depleted) When OHAs are no longer sufficient to control BG levels after meals (becoming insulin depleted) Eg;0.4x70kg=28u, start with 60% of this dose=16u, split 50/50 Eg;0.4x70kg=28u, start with 60% of this dose=16u, split 50/50 8 units am/pm titrate dose 8 units am/pm titrate dose

Multiple injections (basal/bolus) suitable for; Who need flexibility because of erratic life style, shift work, regular travelling across time zones, regular sport Who need flexibility because of erratic life style, shift work, regular travelling across time zones, regular sport Who need to optimize BG control b/c of complications, illness or wound Who need to optimize BG control b/c of complications, illness or wound Median daily dose s u/kg body wt Median daily dose s u/kg body wt Eg;0.4x70kg=28u Eg;0.4x70kg=28u 1/3 rd of total daily dose basal 1/3 rd of total daily dose basal 2/3 rd remaining bolus divide b/w 3 main meals 2/3 rd remaining bolus divide b/w 3 main meals

Conclusion Most individuals with T2DM will require insulin eventually due to disease progression and beta cell failure Most individuals with T2DM will require insulin eventually due to disease progression and beta cell failure Patients should be informed of this at initial diagnosis and not allowed to believe that need for insulin is a result of failure on their part to control the disease Patients should be informed of this at initial diagnosis and not allowed to believe that need for insulin is a result of failure on their part to control the disease