intensive insulin therapy

Blood Glucose Monitoring• To adjust the insulin treatment • To detect or confirm hypoglycemia or severe hyperglycemia • To adjust treatment to the circumstances of daily life using an in

• Optimize diabetes management

• Assist you in initiating insulin in your office

– When to start insulin therapy?

– Insulins, doses, delivery options

– Patient training

Challenges in Initiating Insulin?

– Discomfort with insulin

• Lack of knowledge and experience

– Fear of needles

Type 2 Diabetes: Double Impairment

• Impaired ß cell function:

Type 1 & 2 Diabetes: Key Concepts

• Minimizing the complications of diabetes requires:

– Early diagnosis and treatment of diabetes

– Maintaining HbA1C level < 7%

• Achieving HbA1C < 7% requires control of post-prandial and fasting hyperglycemia

CDA Guidelines (for glycemic control)

Steps to Glycemic Control

• Establish glycemic objectives

– Target fasting and post-prandial glycemia

• Diet counseling with exercise component

• Diabetes education for every patient

• Pharmacological treatment; oral and insulin

Patient Counselling Topics

A Review symptoms and treatment of

A Hypoglycemia

• Definition: Glycemia < 3.8 mmol

• Patients may experience hypoglycemia at different glycemic levels

– Speech disorder – Behavioural disorder – Drowsiness

– Coma – Convulsions

Preventing Hypoglycemia

• Check BG 4-6 times per day

• Carry glucose tablets

• Have Glucagon Kit available

Preventing Hypoglycemia

• Test before driving and ideally 1 hour later

(target: over 5.5 mmol/L)

• Perform two SMBG 30 minutes apart prior to bedtime (confirming rising or falling BG)

• When drinking alcohol, perform SMBG hourly

• With exercise, perform SMBG pre- and exercise

post-• If hypoglycemia episodes persist, raise target glucose levels

Preventing Hyperglycemia and DKA

• Monitor BG 4-6 times per day

• Use Correction Boluses when appropriate

Hyperglycemia Treatment Guidelines

The Key to Preventing DKA

B Patient Training

• Training by a multidisciplinary team at DEC is IDEAL for:

– Diet counseling

– Education on the injection sites

– Education on the various injection devices

– Evaluation of the patient’s support network

• Other resources may exist for training, i.e retail pharmacy

C Blood Glucose Monitoring

• To adjust the insulin treatment

• To detect or confirm hypoglycemia or severe

hyperglycemia

• To adjust treatment to the circumstances of daily life using an insulin scale prescribed by the

attending physician

• To improve patient safety and increase motivation

to comply with treatment

Ideal Testing Frequency

Injection Tools and Options

• Durable delivery devices

– NovolinSet® (NPH, Toronto, 30/70 )– Humulin® N

Advancing Insulin Therapy Through

Device Innovation

We are trying to duplicate how the pancreas works in

releasing insulin for someone who doesn’t

have diabetes Goal of Insulin Therapy

Non-diabetic Insulin and Glucose

Glucose (mmo/L)

Peak 7 hr

Novolin®ge NPH Humulin® N

Intermediate

Vial and cartridge

Start 30-60 min.

Peak 4 hr

Novolin®ge Toronto Humulin® R

Short-acting

(regular)

Vial and cartridge

Start < 15 min.

Aspart (NovoRapid®) Lispro (Humalog®)

Rapid-acting

Vial and cartridge

Insulin PreMixes

• Regular + intermediate

– Novolin® 10/90, 20/80, 30/70, 40/60, 50/50– Humulin® 30/70, 20/80

Normal Blood Glucose Levels

Blood Glucose (mmols)

Normal Blood Glucose Levels

Blood Glucose (mmols)

www.diabetesclinic.c 28

Two injections/day

Blood Glucose (mmols)

8am noon 6pm 2am 4am 8am

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Three injections/day

Blood Glucose (mmols)

8am noon 6pm 2am 4am 8am

Time

R or H + N in

AM

R or H at Supper N before bed

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Four injections/day

Blood Glucose (mmols)

8am noon 6pm 2am 4am 8am

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Continuous Infusion

Blood Glucose (mmols)

8am noon 6pm 2am 4am 8am

2-Limitations of Regular Human

Insulin

• Slow onset of activity

– Should be given 30 to 45 minutes before meal

• Inconvenient for patients

• Long duration of activity

Adherence to Injection Recommendation (Canada)

Dissociation of Regular Human

Objectives for the Development of Acting Insulin Analogues

Short-• Modify time action to address

– Postprandial hyperglycemia

– Hypoglycemia

• Improve safety and convenience

Whats’ new in type 1 diabetes

treatment?

• Insulin analogues

• Physiological insulin replacement

• Aggressive “intensive” management

– 4 injections per day

– Insulin infusion pumps

– Continuous glucose monitoring systems

– Integrated technologies for monitoring control

Non-diabetic Insulin and Glucose

Glucose (mmo/L)

NovoRapid® (insulin aspart)

Time-Action Profile

Onset: 10-20 minutes Maximum effect: 1-3 hours Duration: 3-5 hours

Rapid-acting insulin analogue

We are trying to duplicate how the pancreas works in

releasing insulin for someone who doesn’t

have diabetes Goal of Insulin Therapy

Insulin Therapy Options

– 0.5 units/kg = total daily dose

– 4x/day 40% NPH @ hs and 60% rapid acting analogue ac meals

– For patients with significant complications (i.e renal failure, foot infections, CVD, etc…)

In someone without diabetes, the

pancreas delivers a small amount of insulin continuously to cover the body’s

non-food related insulin needs.

Basal Insulin

The amount of insulin required to

cover the food you eat.

Fast-acting or Short-acting (clear) insulin works as a

Bolus Insulin

Bolus Insulin

Why count carbs?

• More precise way of measuring the impact of a meal on blood sugar

• Lets you decide how much insulin is needed to “cover” the meal

• Greater flexibility -eat what you want, when you want to eat it

Fine Tuning: Bolus Doses

• Carbohydrate counting or pre-determined meal portion

• Individualized insulin to carbohydrate dose

or insulin to meal dose

• Adjust bolus based on post-meal BGs or

next pre-meal BG

Fine Tuning: Basal Rate

• Monitor BG pre-meal, post-meal, bedtime, 12am, and 2-4am

• Test fasting BG with skipped meals

• Adjust nighttime basal based on

2-4am and pre-breakfast BG

• Adjust basal by 0.1 u/hr to avoid over-correction

Novolin®ge 30/70

Time-Action Profile

Premixed insulin

Onset: 0.5 hour Maximum effect: 2-12 hours Duration: 24 hours

30/70 - Twice/day

Dosage Changes

• Change insulin dose so that peak of action

corresponds to most abnormal value (pre-meal)

• If all values are abnormal - start with fasting

glycemia followed by lunch, supper and bedtime

• Change the dose by increments of 1-4 U

• Not more than twice/week

• Monitor for PATTERNS in hypoglycemia

NovoRapid ® Penfill ®

Rapid-acting human insulin analogue (insulin aspart)

Novolin ® ge Toronto Penfill ®

Short-acting insulin (insulin injection, human biosynthetic)

Novolin ® ge NPH Penfill ®

Intermediate-acting Insulin (insulin injection, human biosynthetic)

Onset: 10-20 minutes Maximum effect: 1-3 hours Duration: 3-5 hours

Onset: 0.5 hour Maximum effect: 1-3 hours Duration: 8 hours

Onset: 1.5 hours Maximum effect: 4-12 hours Duration: 24 hours

Full Range of Novo Nordisk Insulins

Follow-Up: The Patient’s Role

Every Day

• Check BG 4-6 times a day,

and always before bed