1. LMC Diabetes Advanced Diabetes Education Workshop Presented by LMC Diabetes and Endocrinology

2. LMC Diabetes Objectives 1.Review of oral therapy for type 2 diabetes 2.Why do people start Insulin 3.Supporting a patient starting insulin 4.Types of Insulin and Titrating Insulin 5.MDI 6.Carb Counting, Insulin to Carb Ratio and Insulin Sensitivity Factor

3. LMC Diabetes Review of Oral Diabetes Medication According to CDA 2013 GPG: Monotherapy roughly reduces A1C by 0.5 to 1.5% Combination therapy may provide a drop in A1c > 1.5% The higher the A1C, the larger effect seen by the use of oral agent (s). As A1C comes closer to target, pc blood sugars become more important to keep in target

4. LMC Diabetes Why is insulin initiated? Different reasons: 1.Individuals with symptomatic hyperglycemia and metabolic decompensation should receive an initial anti-hyperglycemic regimen containing insulin 2.Maxed out on oral therapy 3.BS difficult to control with oral agents 4.Side effects from oral agents

5. LMC Diabetes Insulin Type of Insulin Starting DoseTitrationBG to use for assessment for titration Oral Meds BasalTypically 10 units (may be smaller if patient is elderly and of normal weight) 1 unit once a day, OR 2 units every 2 days until FBS target of 4.0-7.0 mmol/L is reached FBSPhysician to decide – typically d/c secretagogue and keep metformin Pre-mixed5 to 10 units once or twice daily (pre-breakfast and/or pre-supper). 1 -2 units for both injections until targets met of 4.0-7.0 mmol/L pre- breakfast and pre-dinner FBS from pre-dinner dose Pre-dinner blood sugar from AM dose Physician to decide – typically d/c secretagogue and keep metformin Basal/BolusTotal Daily Dose = 0.3 to 0.5 units/kg 40% basal insulin 20% bolus at breakfast 20% bolus at lunch 20% bolus at dinner Basal first Work towards using insulin to carb ratios and insulin sensitivity factors Basal – FBS Bolus – 2 hr pc meal blood sugars To be discontinued except metformin at times Patients should be taught how to self titrate. Regular follow ups should be performed every couple days to monitor hypoglycemia and hyperglycemia.

6. LMC Diabetes Feelings around starting insulin Common feelings: Nervous, Afraid, Angry, Guilty How to approach patients starting insulin: 1.Acknowledge their emotions – ask them how they are feeling 2.Remember what is routine for you is VERY NEW to them! 3.Explain physiologically why they are starting insulin in a sympathetic manner 4.Provide reassurance that you are there for support and provide your contact information

7. LMC Diabetes Activity Female Patient AZ comes to see you: BMI = 32, waist 101 cm Diabetes for 7 years Maxed out on triple therapy SMBG: FBS 9-11 and periodically testing throughout the day – usually around 6-8 mmol/L when they test A1C 8.2% Has tried to lose weight – lifestyle hx reveals fair-good diet with limited exercise – she is very aware of what she needs to do from a lifestyle perspective Patient is seeing the physician after you What do you think the physician will say? What do you suggest?

8. LMC Diabetes Activity Answer 1.Reinforce lifestyle changes 2.Discuss with physician initiating insulin – triple therapy is failing with A1C 8.2% 3.Physician sees patient – agrees to initiate insulin …………… (contd)

9. LMC Diabetes Basal Insulin Activity Physician suggests Levemir 10 units HS Questions: 1.Outline how you would approach the insulin start consultation? 2.Why is the patient starting insulin? 3.How should the patient titrate? 4.Approx. how long does basal insulin last in the body? 5.How can you assess if it is the right dose? 6.Where should the patient inject? 7.When should the patient test and inject? 8.What is the main side effect of insulin? 9.Where should the insulin be stored (both current and unopened)?

10. LMC Diabetes Basal Insulin Activity - Answer 1.Outline how you would approach the insulin start consultation? A: Ask AZ how she is feeling about starting insulin. Explain to her how the session will proceed : Today I am going to start you on insulin. I am here to help you through this and am always available for questions. Today we will talk about what insulin is, why you are starting insulin, the type of insulin you are starting on, how to inject, storage of insulin, driving instructions, perform a practice injection, and dose and titration instructions. Explain why she is starting insulin and the implications of having an elevated A1C Let her know when you will be checking in her with her again – 2 days from now

11. LMC Diabetes Basal Insulin Activity – Answers contd Answers to Questions: 2.Why is the patient starting insulin? A1C is 8.2% and she is maxed out on oral therapy 3.How should the patient titrate? 2 units every 2 days until FBS is <7 4.Approx. how long does basal insulin last in the body? Approx 22-26 hrs 5.How can you assess if it is the right dose? FBS

12. LMC Diabetes Basal Insulin Activity – Answers contd Answers to Questions: 6.Where should the patient inject? Best spot is abdomen; other sites: back of the upper arms, the upper buttocks or hips, and the outer side of the thighs 7.When should the patient test and inject? Test HS and FBS and inject at approx same time at night before bed 8.What is the main side effect of insulin? Hypoglycemia 9.Where should the insulin be stored (current and unopened)? Insulin currently being used room temperature; Unopened in the fridge

13. LMC Diabetes Mixed Insulin Activity Patient BR: The Endocrinologist is starting the patient on Mix 25 15 units BID. AIC was 9.2% Questions? 1.Why would a doctor start a patient on Mix 25 versus the other insulin? 2.When should the patient test and inject? 3.When should the patient change the insulin cartridge? 4.How should you titrate the insulin? 5.What dietary issues do you need to make sure they are following?

14. LMC Diabetes Mixed Insulin Activity - Answers 1.Why would a doctor start a patient on Mix 25 versus the other insulin? Need mealtime coverage as well 2.When should the patient test and inject? Before each injection and 2 hrs after breakfast and dinner and inject 10-15 minutes before the meal 3.When should the patient change the insulin cartridge? If not finished before 28 days, then every 28 days.

15. LMC Diabetes Mixed Insulin Activity - Answers 4.How should you titrate the insulin? Individualized – but 1-2 units every 2 days until pre breakfast and pre dinner blood sugars are between 4-7 mmol/L. 5.What dietary issues do you need to make sure they are following? No skipping meals, and eating appropriate portions of carbs at breakfast and lunch to avoid hypoglycemia

16. LMC Diabetes MDI Activity Patient CW: The Endocrinologist is seeing a pt with an AIC of 10.3% and plans to switch their therapy from orals to insulin. They start the patient on MDI with 6 units of Novorapid q meals and 12 units of Levemir qHS.. Questions? 1.Why would a patient benefit from MDI? 2.How do you think the patient feels? 3.How should you titrate the insulin? 4.How can you assess if it is the right dose? 5.When should the patient test and inject? 6.When does the Novorapid start to work and approximately how long does the Novorapid last in the body? 7. What basic dietary issues do you need to make sure they are following?

17. LMC Diabetes MDI Activity - Answer 1.Why would a patient benefit from MDI? Flexibility 2.How do you think the patient feels? Major lifestyle change – very nervous 3.How should you titrate the insulin? Basal first and then rapid –1-2 units at a time 4.How can you assess if it is the right dose? With testing

18. LMC Diabetes MDI Activity - Answer 5.When should the patient test and inject? Test: Always before each injection and ideally 2 hrs after each meal while titrating doses Inject: 10-15 minutes before a meal 6.When does the Novorapid start to work and approximately how long does the Novorapid last in the body? Within 10-15 min and lasts 4-5 hrs in the body 7. What basic dietary issues do you need to make sure they are following? Consistent amount of carbs at each meal from day to day

19. LMC Diabetes Insulin to Carb Ratio(IC) and Insulin Sensitivity Factor (ISF): A patient is ready to use I:C and ISF: Once a he/she has been on MDI and they are interested in adjusting their own insulin based on their food intake Insulin to carb ratio: A measurement of how much one unit of insulin for will cover a specified number of carbohydrate grams Insulin Sensitivity Factor: A measurement of how much one unit of insulin will reduce blood sugars in mmol/L

20. LMC Diabetes 4 steps to Accomplish I:C and ISF Step 1: Master Carbohydrate Counting Step 2: Calculate I:C Step 3: Calculate ISF Step 4: Put it all together

21. LMC Diabetes I:C and ISF Facts To use the I:C and ISF, patient must be on a basal and bolus regimen Only adjust the bolus insulin for I:C and ISF – never adjust basal Bolus insulin lasts 4-5 hrs in the body Very individualized and the patient is the expert! Patient must be willing to carbohydrate count Patient must be willing to work at figuring out the I:C and ISF by recording intake, insulin dosage, and testing BS ac and pc meals A ½ unit pen may help with accuracy for patients Patients may have a different I:C and/or ISF at different times of day

22. LMC Diabetes Insulin to Carb Ratio – Mastering Carbohydrate Counting Carbohydrate Counting Review: 1.What is a Carb? - Grains, fruits, milk, and sweets 2.How to figure out amount of Carbohydrates in Food: A.Beyond the Basics – ½ cup cooked pasta = 15 grams, 1 small apple = 15 grams……. B.Estimate portions: Hockey Puck (1/2 cup), Golf Ball (1/3 cup), Tennis Ball (3/4 cup), Baseball (1 cup), Deck of Cards (3 oz), 6 Dice (1 oz), 1 fist = ~ 1 cup, 2 handfuls = ~ 2 cups C.Use Food Labels – BEST WAY TO CARB COUNT Most accurate Every gram counts!

23. LMC Diabetes Carb Counting Contd Reading Food Labels contd: Subtract fibre from total carbohydrate grams Subtract Sugar alcohols from total carbohydrate grams Other facts to consider with carb counting: 1.Choose low GI (glycemic index) foods 2.Have balanced meals with protein, fat and fibre Both low GI foods and balanced meals slow down absorption of food and match the 4-5 hrs of the rapid insulin in the body

24. LMC Diabetes Activity Mr. ES is in your office… Pre-breakfast blood sugar = 6.2 Breakfast: 1 slice whole wheat toast, 1 tsp non-hydrogenated margarine, and ½ cup OJ = 30 grams carbs, patient took 2 units of insulin based on I:C of 1:15 2 hr pc blood sugar = 11.1 Pre-lunch blood sugar = 7.1 Questions? 1.Why is the 2 hr pc 11.1 and the pre-lunch 7.1? 2.What do you need to change to get better BS results?

25. LMC Diabetes Activity Answer Breakfast meal is high glycemic index and not balanced How to change the breakfast: Add protein - more balanced with carbs, protein and fat Switch orange juice to an orange – lower GI Overall the addition of protein and switch to lower GI fruit will slow down the absorption of the carbs match the rapid insulin better

26. LMC Diabetes Calculating the Insulin to Carb Ratio 1.Have at least one days worth of carb intake from your patient: Option 1: have patient bring in 3 days of typical eating Option 2: record a usual day of eating with them 2.Teach patient how to carb count and have them carb count their food record/typical day (during their session with you) 3.Record how much insulin the patient takes before each meal and before bedtime, if their blood sugars were in target when they tested (the goal is not to have them include extra insulin they use for correcting high blood sugars) Note: if patient is always high or low then use their current numbers, but keep this in mind when calculating

27. LMC Diabetes Calculating the Insulin to Carb Ratio Three methods to use for calculating the I:C: Method 1: 480 Rule 480/TTD(Total Daily Dose) _____of insulin units = _____ Method 2: Usual Carbs Actual Carbs Eaten ÷ Actual Meal Bolus Dose B= _____g Carbs ÷ _____ U insulin = 1 U for every _____ g Carbs L= _____g Carbs ÷ _____ U insulin = 1 U for every _____ g Carbs D= _____g Carbs ÷ _____ U insulin = 1 U for every _____ g Carbs Method 3: Average Carbs Average Carbs/day = ______÷ total daily bolus requirement______ = 1 unit for every _____ g Carbs

28. LMC Diabetes Which I:C method to try? 1.The patient should ask themselves – which one are they most comfortable with? 2.Allow the patient to run through a scenario using each method and see which insulin dose seems the most realistic? 3.If method 2 seems like it works – that will be the most accurate 4.If patients blood sugars are inconsistent and you dont know where to start, use method 1 5.If all 3 methods are giving different numbers, find a happy medium 6.If a patient is always high use a lower I:C then they have been using 7.If a patient is always low use a higher I:C then they have been using

29. LMC Diabetes ……and now the Insulin Sensitivity Factor Calculating the ISF: Formula: 100/TDD ___=___. Therefore, 1 unit of rapid acting insulin will BS ____ mmol/L Ie. TDD = 50 ISF = 100/50 = 2. Therefore, 1 unit of rapid acting insulin will BS by 2 mmol/L. Using the ISF: Correction Dose: (Current BG – goal BG ) ÷ ISF ____ = _____ U extra insulin to take with meal. Ie. Current BS = 12, ISF = 2 Correction Dose: (12-6 (goal BS)) ÷ 2= 3 U extra insulin to take with meal. NOTE: A GOAL BS of 6.0 is a safe target for pre-meal BS A GOAL BS of 8.0 is a safe target for a pre-meal BS but pc snack. (this is a tough concept to teach)

30. LMC Diabetes Putting the two together……. 1.Count your carbs 2.Divide carbs by your I:C Do not round 3.Test your blood sugars 4.If above target, correct BS Do not round 3.Calculate insulin units from #2 and #4 for total insulin needed at this meal Round Units of insulin based on carb intake Units of insulin based on blood sugar Total insulin units to take

31. LMC Diabetes Putting the two together……. 1.Count your carbs= 45 grams 2.Divide carbs by your I:C=45/9 =5 Units Do not round 3.Test your blood sugars=12.0 4.If above target, correct BSISF = 3 (12.0-6) / 3 =2 Units Do not round 3.Calculate insulin units from #2 and #4 for total insulin needed at this meal Round5 + 2 = 7 total units of insulin Units of insulin based on carb intake Units of insulin based on blood sugar Total insulin units to take

32. LMC Diabetes Useful Tips for IC and ISF 1.Do not correct a 2 hrs pc blood sugar as the patient will get insulin stacking and may have a hypoglycemic reaction 2.If your 2 hrs pc meal test is > 10 mmol/L – the patient has to ask themselves – what did I eat? Did I count the carbs properly? Was the food high GI? Was my meal balanced? 3.If you pre-meal blood sugar is above 4-7, did you just have a snack 2 hrs before – is this really a post meal/snack blood sugar? If so, use 8.0 as a target, not 6.0 when correcting 4.Use a half unit pen 5.Limit snacks to 15 grams of carbs or less until I:C and ISF have been figured out

33. LMC Diabetes Now that you are done…..Lets see if it works - Testing the I:C Have the patient do the following: 1.Use the I:C and ISF that you and the patient had calculated and apply it 2.Record food intake – carb amounts, including timing of meals and snacks for 3 days 3.Record insulin intake for those 3 days 4.Test 7 times/day – before each meal and 2 hrs after each meal, along with HS At next appointment, review, adjust and try again!

34. LMC Diabetes I:C AND ISF Activity Patient DS Food diary reveals: Breakfast: 1.5 cups of Special K cereal, 1 cup milk Lunch: Tuna Sandwich: 2 slices rye bread, 1 cup skim milk, Green Salad with 1 T balsamic dressing Afternoon Snack: 1 small banana, 7 soda crackers, 1 oz mozzarella cheese, Dinner: 5 oz of chicken with olive oil salt and pepper, 1 ear of corn, 1 cup broccoli, 1 small apple Activity: 1.Count the carbs 2.Any other suggestions?

35. LMC Diabetes IC AND ISF Activity Answer Patient DS Food diary reveals: Breakfast: 45 grams Lunch: 47 grams Afternoon Snack: 30 grams Dinner: 45 grams Suggestions: 1.Balance out breakfast with protein or fibre 2.Limit afternoon snack to 15 grams

36. LMC Diabetes I:C Activity Her normal dosages: 5 units bolus/meal, 18 units basal HS, TDD = 33 units Calculate all 3 methods: Method 1: 480 Rule 480/TTD _____U = _____ Method 2: Usual Carbs Actual Carbs Eaten ÷ Actual Meal Bolus Dose B= _____g Carbs ÷ _____ U insulin = 1 U for every _____ g Carbs L= _____g Carbs ÷ _____ U insulin = 1 U for every _____ g Carbs D= _____g Carbs ÷ _____ U insulin = 1 U for every _____ g Carbs Method 3: Average Carbs Average Carbs/day = ______÷ total daily bolus requirement______ = 1 unit for every _____ g Carbs

37. LMC Diabetes Activity: Calculating The I:C - Answer Patient DS dosages: 5 units bolus/meal, 18 units basal HS, TDD = 33 units Method 1: 480 Rule 480/TTD (33)U = 14.5 Method 2: Usual Carbs Actual Carbs Eaten ÷ Actual Meal Bolus Dose B= 45 g Carbs ÷ 5 U insulin = 1 U for every 9 g Carbs L= 45 g Carbs ÷ 5 U insulin = 1 U for every 9 g Carbs D= 45 g Carbs ÷ 5 U insulin = 1 U for every 9 g Carbs Method 3: Average Carbs Average Carbs/day = 135 ÷ total daily bolus requirement 15= 1 unit for every 15 g Carbs WHICH METHOD WOULD YOU USE?

38. LMC Diabetes Activity: Answer Contd Use Method 2! Now Calculate the ISF: 100/TDD _____ = ______. Therefore, 1 unit of rapid acting insulin will BS _____ mmol/L

39. LMC Diabetes Activity Contd 100/TDD 33 = 3. Therefore, 1 unit of rapid acting insulin will BS 3 mmol/L Final Summary of the I:C and ISF for the patient to use: I:C B = 9 L = 9 D = 9 ISF = 3

40. LMC Diabetes Activity Contd Scenario Questions based on the I:C of 1:9/ meal and ISF of 3 1.Lunch– premeal sugar is 8.2 mmol/L, total carb intake is 35 grams – how much insulin should she take? 2.Dinner - Pre-dinner sugar is 12.2 mmol/L – had snack 2 hrs before of an apple, total dinner carb intake is 62 grams – how much insulin should she take?

41. LMC Diabetes Activity contd – Lunch Answer 1.Grams of carbohydrates = 35g 2.Divide carbs by your I:C - 9 3.Blood Sugar = 8.3 mmol/L 4.Use ISF: (8.3 – 6)/3 = 3.Calculate insulin units from #2 and #4 for total insulin needed at this meal I would have patient have a half unit pen and take 4.5 units 3.8 0.77 4.6

42. LMC Diabetes Activity contd – Dinner Answer 1.Grams of carbs = 62g 2.Divide carbs by your I:C - 9 3.Blood Sugar = 12.2 mmol/L 4.Calculate ISF = (12.2 – 8)/3 = 3.Calculate insulin units from #2 and #4 for total insulin needed at this meal I would have the patient take 8 units 6.8 1.4 8.2

43. LMC Diabetes Other Variables to consider with insulin 1.Change in weight – weight gain requires more insulin and weight loss requires less. 2.Change in weather or season – warmer months people tend to be more active and insulin is more sensitive in warmer months; therefore, a lower TDD may be necessary. 3.Menstruation – many women will find that their need for insulin will rise in the days before their menstrual period beings. 4.Illness – a higher TDD with both larger boluses and higher basal rates is often needed to counteract this physical stress. 5.Travel – insulin may need to be adjusted when traveling over >3 time zones. 6.Problems with glucometer – may be using insufficient amount of blood, not coding, meter accuracy

44. LMC Diabetes Conclusion Insulin is a common treatment in diabetes management As the diabetes educator, it is important to be a genuine source of support for the patient Every patient is different – individualize their care and make changes accordingly With time & insulin titrations, the I:C and ISF become easier to manage and adjust Help your patients manage their blood sugar with insulin starts, titrations, and ongoing management for the ultimate goal of tighter control, and a healthier and happier lifestyle!