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Ibrahim elebrashy.insulin therapy

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  • 1. Insulin TherapyPrimary Care Challenges and Solutions Prof. Ibrahim El EbrashyHead Of The Diabetes & Endocrinology Center Cairo University
  • 2. A1C reduction with glucose – lowering medications Oral agents A1C (%)* Sulfonylureas 1.5 Biguanides (metformin) 1.5 Glinides 1.0–1.5 Thiazolidinediones 0.8–1.0 DPP-IV inhibitors 0.5–0.9 α-Glucosidase inhibitors 0.5–0.8 Parenteral agents Insulin ≥2.5 GLP analogues 0.6 Amylin analogues 0.6*MonotherapyDPP = dipeptidyl peptidase; GLP = glucagon-like peptideNathan DM. N Engl J Med. 2007;356:437-40.
  • 3. When to Start Insulin First ADA-EASD Consensus • Severely catabolic patient • Hemoglobin A1C > 10% • FBS > 250 mg/dl (13.9 mmol/l) • Random consistently > 300 mg/dl (16.7 mmol/l)Nathan et al. Diabetes Care 2006;29: 1963-1972
  • 4. Replacement insulin therapy should mimic endogenous insulin profile in insulin-treated T2DM Endogenous insulin secretion Breakfast Lunch Dinner Ideal basal insulin Insulin (mU/l) 45 Ideal prandial insulin 30 15 0 06.00 12.00 18.00 24.00 06.00 Time (hours)Adapted from Kruszynska YT, et al. Diabetologia 1987;30:16–21.
  • 5. Why Basal insulin Early?
  • 6. Why Basal insulin Early? Treating fasting hyperglycemia lowers the entire 24-hour plasma glucose profile 400 Plasma glucose (mmol/l) 20 T2DM Plasma glucose (mg/dl) 300 15 200 Hyperglycaemia due to an increase in fasting glucose 10 100 5 Normal Meal Meal Meal 0 0 06.00 10.00 14.00 18.00 22.00 02.00 06.00Comparison of 24-hour glucose levels in control subjects vs patients with diabetes (p<0.001).Adapted from Hirsch I, et al. Clin Diabetes 2005;23:78–86. Time of day (hours)
  • 7. Reduced risk of nocturnal hypoglycaemia with insulin glargine 42% NPH 8 risk reduction 6.9 44% Insulin glargine Events per patient–year 7 risk reduction 6 5.5 p<0.001 5 p<0.001 4.0 48% 4 3.1 risk reduction 3 2.5 p<0.002 2 1.3 1 0 * ** All nocturnal Confirmed nocturnal hypoglycaemia hypoglycaemia Confirmed hypoglycaemia: *4 mmol/l (72 mg/dl); **3.1 mmol/l (56 mg/dl)Riddle M. et al. Diabetes Care 2003;26:3080–6.
  • 8. Insulin glargine reduces hypoglycemic risk versus NPH in T2DM: Meta analysis Risk of severe hypoglycaemia and severe nocturnal hypoglycemia reduced by 46% (p = 0.04) and 59% (p = 0.02), respectively, with insulin glargine Risk reduction mainly observed at night Symptomatic hypoglycaemic events Mean (CI) Overall 0.711 (0.586, 0.862); p = 0.001 Nocturnal 0.591 (0.486, 0.718); p < 0.001 Daytime 0.931 (0.771, 1.123); p = 0.455 0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 Reduced risk Increased risk Odds ratioRosenstock J, et al. Diabetes Care 2005;28:950−5.
  • 9. LANTUS-BOT: after 5 years on Insulin Glargine, 83% of patients still did not require intensification  Retrospective cohort analysis from a German database comparing the persistence of T2DM patients on basal insulin plus OADs with i patients treated with NPH plus OADs 28Pfohl M, et al. Adding insulin glargine to oral therapy in type 2 diabetes patients results in longer persistence with the treatmentregimen compared to NPH insulin. Poster presented at ISPOR 2008
  • 10. Schreiber et al: following titration, Insulin Glargine + oral antidiabetic drugs can provide sustained glycaemic control  Observational study initiated in 12,216 insulin-naïve subjects with T2DM, who added Insulin Glargine to their existing OAD treatment i The study duration was 9 months, followed by optional 20- and 32-month extension phases 29Schreiber SA et al. Diabetes Obes Metab 2007;9(1):31–38; Schreiber SA, et al. Diabetes Technol Ther 2008;10(2):121–127
  • 11. NEW THIN: switching from NPH to Insulin Glargine improves HbA1c control in real life  Retrospective analysis from a UK database analysing the switch from NPH to Insulin Glargine in patients with TD2M i 30Gordon J, et al. ADA 2009, abstract accepted
  • 12. At The EndEducation For OurPatients Is A Must
  • 13. Advice For Physicians Dont wait forever. "Patient needs insulin therapy," Dont be afraid of hypoglycaemia, but be aware of it. Consider combination therapy ( insulin + OAD ). Dont under-insulinize.
  • 14. Thank You