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Insulin Conundrums
Veronica Green
*p < 0.0001 **p = 0.021
Epidemiological extrapolation showing benefit of a 1% reduction in mean HbA1c with a mean duration of diabetes of 10 years
Ris
k re
du
ctio
n (
%) as
soci
ated
with
a
1%
low
er
Hb
A1c
43%
Amputation or death due to
peripheral vascular disease
*
*
21%
Any diabetes- related endpoint
*
37%
Microvascular complications
*
14%
Myocardial infarction
*
19%
Cataract extraction
16%
**
Heart failure
5. Stratton IM et al. BMJ 2000; 321: 405–412.
-40
-30
-20
-10
0
Risk reductionRisk reduction for each 1% reduction in HbA1c in type 2
diabetes
Standard approach to the management of Type 2 diabetes
Lifestyle Changes
Diet and Exercise
Oral Monotherapy
Oral Combination+glipins +
Oral + exenatide / +
Insulin
Treatment intensification
V Green Byetta workshop 2
When to start insulin?
NICE
• Hba1c >7.5%• Use NPH od/bd• Or long acting
analogue if– Hypoglycaemia– Can’t do it themselves– Otherwise would need
BD basal+orals
• Hba1c >9%• Use BD biphasic• Use analogue mix if
– Marked post prandial raise
– Need to inject immediately pre-meals
– hypos
NICE 2009
Or Not
• NPH ½ price of analogue long acting insulin but
• 20% variability in absorption with each injection
• iFriedburg SJ, Lam YWF, Blum JJ, Gregerman RI.
2006. Insulin absorption: a major factor in apparent insulin resistance and the control of type 2 diabetes. Metabolism. 55(5) 614-619
Who is Afraid of What?
Taking the Fear out of Taking the Fear out of Insulin Injections Insulin Injections
Doctor’s FearsWill I do my patient any good?
Will they put on more weight?
Will their complications worsen?
Will it make a difference to the blood glucose levels?
Nurse’s FearsCan this person learn to inject?
Is it going to make a difference?
Am I able and competent to do this?
What if something goes wrong?
What insulin to use?
Patient’s FearsWill this make me a drug addict?
What about my lifestyle?
My diabetes mild, I don’t need insulin
Needle phobia
Fear of hypos
Needles
Injection sites
Effect on Lifestyle
• Find out about work, social life BEFORE deciding on a regime
• Adapt the regime about the life not the other way round.
Insulins
Rapid Acting Analogues
• Work almost straight away
• Last 3-5 hours
• Used pre/post prandially
• NovoRapid , Humalog, Apidra
Short Acting Insulins
• Act 30 minutes post injection
• Last 6-8 hours
• Given pre prandially
• Actrapid or Humulin S
Intermediate Acting Insulins
• Act after 1-2 hours
• Last 12-14 hours• Given
morning/evening or bedtime
• Insulatard or Humulin I
Pre Mixed Insulins
• Act after 30 minutes, last 12-14 hours
• Given morning and evening pre meal
• Mixtard, Humulin M
• Mixed analogues – NovoMix 30, Humalog Mix 25, 50
Long Acting Analogues
• Act immediately
• Last 18-24 hours
• Given am or pm
• Lantus or Levemir
Classification
• Mild – can be treated by the person themselves without help
• Moderate – Need help in treating, but are conscious
• Severe – Pt unable to help themselves, need of hospital care
Symptoms
Neuro-glycopenic• Confusion• Drowsiness• Speech difficulty• Poor coordination• Atypical behaviour• Diplopia
Autonomic• Sweating / pale• Palpitations• Shaking (tremor)• Hunger
Other signs
• Malaise• Headache• Hemiplegia
(particularly in the elderly)
• Person may have individual signs e.g. numb lips
Nocturnal hypoglycaemia 1
• Effects 30-40% of all diabetics
• Can be slept through
• The person may only be aware the next morning that they have had a hypo
Nocturnal hypos 2
• Nightmares / vivid dreams
• Waking up unrested• Waking up with a
headache• High fasting sugar
(often alternating with OK ones)
Hypo Unawareness
• Loss of bodily warning signs
• Can cause severe hypos
• Caused by– Running very tightly– Frequent hypos– Duration of diabetes
Glucose Sensor ProfileModal Day
-5.0
0.0
5.0
10.0
15.0
20.0
12:00 AM 4:00 AM 8:00 AM 12:00 PM 4:00 PM 8:00 PM 12:00 AM
Time
Glu
cose
Con
cent
ratio
n (m
mol
/L)
10-Sep-02
11-Sep-02
12-Sep-02
13-Sep-02
72 hour continuous glucose monitoring
PhysiologyBG<3
Neuroglycopenic symptoms
Autonomic symptoms
Treat with glucoseRelease of glucagon, + stress
hormones
Glucogenolysis, gluconeogenesis (liver/kidney)
Raise in BG
Treatment
• 20g glucose
• Back up long acting carbohydrate
• Find the cause
• Adjust medication if required
Causes
• Too much insulin / OHA
• Too little food
• Timing of injection in relation to food
• Alcohol
• Exercise
• Injection site problems
• Hot weather
Lipohypertrophy
Case Histories