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Practicalities of intesive insulin therapy to optimase diabetes control

Ewa Pańkowska MD, PhD Warsaw, Poland

At least four injections per day At least four glucose

measurements per day.

Outcomes: Less microvascular complications More severe hypoglycemia events

Intensive Insulin Therapy

DCCT, NEJM, 1993

20 years ago…

{as a first choice regime for persons

with type 1 diabetes

Flexible, Intensive Insulin TherapyFIIT

ISPAD recommendation,ADA recommendation,PDA recommendation

10 years ago…

British Medical Journal; 2002;

Conclusion: Skills training promoting dietary freedom improved quality of life and

glycaemic control in people with type 1 diabetes without worsening hypoglycemia

What FIIT means?

Tsukuda, K. DT&T, 2009

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The tools and the algorythmin FIIT

Multiple daily injection vs continuous subcutaneous insulin infusion

1. There are a lot of evidences that CSII improves metabolic control (HbA1c) comparing to MDI method. Is that True or False?

2. Insulin pump therapy significantly decreases risk of severe hypoglycemia events. True or False?

questions:

The comparison between MDI and CSII.Are there relevant differences

for metabolic control

6.00 10.00 12.00 15.00 18.00 20.00 22.00 24.00 3.00 6.00 10.00 12.0060

80

100

120

140

160

180

MDI CSI

Time

glyc

emia

mg/

dl

Pańkowska, E, ADA 2011

00.10.20.30.40.50.60.70.80.9

11.1

P<0,05

P<0,05

Basal insulin IU/kg/d Total daily dose IU/kg/d

MDICSII

Parallel day – to – day study

Mealtime insulin• Regular insulin• Rapid acting

analogue Basal insulin:

• NPH• Long acting analogue

Delivering insulin:• subcutaneous and

shots administartion

Mealtime insulin• Rapid acting analogue

Basal insulin: • Rapid acting analogue

Delivering insulin:• Subcutaneus and

continuous administartion

* NPH – Isophane insulin (intermediate-acting)

Number of injection/month average: 120-150

Insulin depot in subcutaneous tissue

basal insulin dose - 20 IU

Logbook as a form of injected insulin dose registration

Number of injection/month average: 8-10

Insulin depot in subcutaneous tissue

Basal: 20 IU/day - 0,8 IU/h

Electronic memory as a form of delivered insulin dose registration

Basal insulin Once or twice a

day Insulin dose

adaptation once or twice per day

If injected, cannot be revoked

Basal function: Insulin dose adaptation

every hour or every half an hour

Possibility of suspension of basal insulin administration

Possibility of keeping different basal insulin profile in electronic memory – Basal Profiles

Possibility of adaptation of basal insulin for current needs - Temporary basal rate

Bolus function:• One shot of insulin (RI or

analogue) before the meal

• One meal – one shot of insulin

• One kind of insulin shooting

Correction insulin: combine with meal insulin in one injection

Bolus function: Three kinds of boluses:

Normal (for Carbohydrates) Extended (for Fat-protein) Multiwave (for Mixed)

Possibility of programming one meal bolus as a multi-bolus (before, during and after a meal)

Correction insulin: programmed separately

The schema of insulin dosing in FIIT

Total daily dose

50% Meal insulin

15% lunch

20% dinner

50% Basal insulin

15% Breakfas

t

?

Patient’s age Diabetes duration ( years) C-petid residual secretion BMI Concomitant disease and hormonal

therapy

The factors influence basal insulin dose

Patient’s age and duration of diabetes

1 248 patients with T1DM on insulin pumps

The Percentage of basal insulin

Age Average SD

Preschooler 34.09 15.93

Prepubertal 43.13 12.48

Pubertal 47.43 12.44

Danne T., Diabetologia, 2008

Age Average SD

Preschooler 20.9 9.2

Prepubertal 26.1 12.50

Pubertal 31.8 12.00

Pańkowska E.. Pediatric Diabetes, 2008

Duration of diabetes and C-peptide residual secretion

C-peptide and percentage of basal insulin in TDD

The basal to bolus proportion related to C-peptide

Pańkowska E., Pediatric Diabetes, 2008

* p<0,05

*

Basal insulin patterns

Basal insulin dose in children and adolescents

0

0.5

1

1.5

2

01:00 04:00 07:00 10:00 13:00 16:00 19:00 22:00

Insu

lin U

/Hr

preschooler 1-6 ys, 0,2-0,3j/g Prepubertal 7-12 ys , 0,4-0,5j/g

pubertal, 13-18 ys; 0,9-1,0 j/g

0

0.5

1

1.5

2

01:00 04:00 07:00 10:00 13:00 16:00 19:00 22:00

Insu

lin U

/Hr

0

0.5

1

1.5

2

01:00 04:00 07:00 10:00 13:00 16:00 19:00 22:00

Insu

lin U

/Hr

5years old girl with diabetes from 2 years .Basal insulin 6-10% of TDD

15 years old girl with diabetes from 10 ys

Basal insulin 30-45%of TDD

Anna , 7 years old Diabetes for second year of life5 years duration, c-peptide naiveAsthma bronchialeHb1c- 6,5% ( average)

Case report

Blood glucose and insulin applaying pl-insmadz.pdf

Case report

14 years old boy, Diabetes duration 4 years, HbA1c 7,0%

The blood glucose profile and insulin applying Paweł.pdf

Temporal basal rate and sick days

the proportion of basal to bolus insulin can be ranged from 10% to 60%

Meal daily plan are flexible in term of meal’s size, timing for breakfast, lunch and dinner and meal nutrients contains .

Dual wave boluses/multiwave are applied by patients in their daily care.

Basal rate is lower during a day than night hours,

Summary

Tailoring insulin programming

in pump therapy is one of the

way in getting recommended

metabolic control.

Conclusion