Insulin TherapyPrimary Care Challenges     and Solutions               Prof.        Ibrahim El EbrashyHead Of The Diabetes...
A1C reduction with             glucose – lowering medications                            Oral agents                   A1...
When to Start Insulin First      ADA-EASD Consensus      •    Severely catabolic patient      •    Hemoglobin A1C > 10%   ...
Replacement insulin therapy should mimic       endogenous insulin profile in           insulin-treated T2DM               ...
Why Basal insulin Early?
Why Basal insulin Early?                                              Treating fasting hyperglycemia lowers               ...
Reduced risk of nocturnal       hypoglycaemia with insulin glargine                                              42%      ...
Insulin glargine reduces hypoglycemic risk versus NPH in T2DM: Meta analysis   Risk of severe hypoglycaemia and severe noc...
LANTUS-BOT: after 5 years on Insulin Glargine, 83% of patients still did not require intensification                      ...
Schreiber et al: following titration, Insulin Glargine + oral  antidiabetic drugs can provide sustained glycaemic         ...
NEW        THIN: switching from NPH to Insulin Glargine                improves HbA1c control in real life                ...
At The EndEducation For OurPatients Is A Must
Advice For Physicians Dont wait forever. "Patient needs insulin therapy," Dont be afraid of hypoglycaemia, but be aware ...
Thank You
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
Ibrahim elebrashy.insulin therapy
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Ibrahim elebrashy.insulin therapy

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Ibrahim elebrashy.insulin therapy

  1. 1. Insulin TherapyPrimary Care Challenges and Solutions Prof. Ibrahim El EbrashyHead Of The Diabetes & Endocrinology Center Cairo University
  2. 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. 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. 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. 5. Why Basal insulin Early?
  6. 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. 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. 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. 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. 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. 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. 12. At The EndEducation For OurPatients Is A Must
  13. 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. 14. Thank You

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