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Common Errors in InsulinTherapy         Anil Bhansali    Department of Endocrinology        PGIMER, Chandigarh
Insulin Therapy1.   Alternative therapy to insulin in T1DM2.   Delay in initiating insulin therapy3.   Pre-injection asses...
Alternative therapy to insulin in T1DM!
 Omission of insulin in T1DM is           SUICIDAL Never stop insulin even during             sickness   Follow sick da...
Delay in Initiation of Insulin Therapy
The 2 Defects of T2DM Insulin resistance Insulin deficiencyInsulin resistance alone cannot produce  T2DM                ...
Adapted from Holman RR. Diabetes Res Clin Pract 1998;40(Suppl.):S21–S25
Previous Algorithm – Type 2                        Inadequate non-                     pharmacologic therapy              ...
Standard Approaches to Therapy Result in               Prolonged Exposure to Elevated Glucose                   10%    Die...
ADA 2012 Algorithm for T2DM
American Association of Clinical Endocrinologists:                      algorithm for patients with T2DM                  ...
When to Add insulin?   At the initial diagnosis   Failure of maximal doses of monotherapy   Failure of submaximal doses...
At the Diagnosis of T2DM Severely symptomatic FPG>250 mg/dl RPG >300mg/dl HbA1c >10% Presence of ketosis BMI < 23 Kg...
ORIGIN study       N Engl J Med 2012; 367:309-318
Add InsulinPatient on two OHA’s FPG > 130 mg/dl PPG > 180 mg/dl HbA1c >8.5% Tighter control is desired Contraindicati...
Pre-injection Assessment is NotDone!
Pre- injection Assessment Injection-related concerns Psychological insulin resistance  (personal failure, anticipated pa...
Pre-injection Assessment-Dexterity problems-Cognitive capacity-Health literacy-Numeracy skills-Visual impairment-Local inf...
How insulin should be stored ?
Injection Storage Store insulin in use at room  temperature (15-25oC) and discard 30  days after initial use Short actin...
Injection Technique is not Properly Advised!
Injection Technique Re-suspension of cloudy insulin is  essential (Rolled 20 cycles) Needle length 4-6 mm Site of injec...
 Ensure the correct insulin syringe with  correct strength of insulin (40U vial  with 40U syringe) Insulin pen should be...
Insulin Dose Prescription is not Properly Written!
 Inadvertent use of abbreviations Inj Reg insulin 4U Route of administration is not  mentioned Site of administration ...
Insulin is administered through clothing                     !
 Pre- and post-injection site  assessment is not possible The needle becomes unsterile and  can cause infection Skin pi...
Insulin is Administered just Prior to               Meal!
 Lag time between insulin administration  and meal  -30-45 min for conventional insulin  (Hexamer to monomer)  -5-10 min ...
Short acting insulin is used twice orthrice a day without intermediate or         long acting insulin!
This strategy will never control fastinghyperglycemia as short acting insulin acts only for                    4-6 hrs.
Characteristics of Currently          Available InsulinInsulin         Onset of    Peak action(h)   Duration(h)           ...
Insulin Regimens   Basal-bolus    (3 prandial and one/two NPH or Glargine)   Only Basal    (NPH or Glargine or Detemir)...
Insulin Regimens  Fasting hyperglycemia  -NPH  -Glargine at bed time  -Detemir Post-prandial hyperglycemia  -Regular ins...
What should be targeted?-FPG, PPG, HbA1c or all three-Which should be the first?
Basal vs Post-Prandial                                       Hyperglycemia – A1c                                          ...
HbA1c: Limitations Does not detect glycemic excursions Does not reveal hypoglycemia Cautions:    ◦ Anemia    ◦ Uremia  ...
Short acting and Long acting Analogues       are Indiscriminately Used!
 Short acting analogues used as i.v  infusion for the treatment of  hyperglycemic emergencies Use of short acting analog...
Distinctive Uses of Analogues Short acting analogues  -School going children  -Pregnancy with diabetes  -Busy executives ...
Somogyi phenomenon is not      Recognized?
Somogyi Phenomenon Post-hypoglycaemic hyperglycemia Wide swings in blood glucose profile Common cause of fasting  hyper...
Dawn Phenomenon is usuallyMissed!
Dawn Phenomenon Early morning hyperglycemia    (nocturnal GH surge, increased insulin    clearance)   Perform BG at 4 am...
Use of Biosimilars!
 These preparations are structurally  similar but pharmacokinetics and  therapeutic efficacy are variable Biosimilars wi...
Consequences of Insulin Therapy
Immediate HypoglycemiaShort term  -Weight gain  -Worsening of retinopathy and   neuropathyLong term  -Malignancy
Insulin-Induced Hypoglycemia Major barrier Common with  -Advanced duration of disease  -Concurrent OHA’s  -Older age, DKD
Conclusions Diabetes is an insulin deficient  disorder, hence it should be repleted Insulin administration is a state-of...
Thank you
Common errors in insulin therapy
Common errors in insulin therapy
Common errors in insulin therapy
Common errors in insulin therapy
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Common errors in insulin therapy

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Transcript of "Common errors in insulin therapy "

  1. 1. Common Errors in InsulinTherapy Anil Bhansali Department of Endocrinology PGIMER, Chandigarh
  2. 2. Insulin Therapy1. Alternative therapy to insulin in T1DM2. Delay in initiating insulin therapy3. Pre-injection assessment4. Insulin injection techniques5. Regimens of insulin treatment6. Insulin analogues7. Consequences of Insulin Therapy -Short term -Long term
  3. 3. Alternative therapy to insulin in T1DM!
  4. 4.  Omission of insulin in T1DM is SUICIDAL Never stop insulin even during sickness  Follow sick day guidelines
  5. 5. Delay in Initiation of Insulin Therapy
  6. 6. The 2 Defects of T2DM Insulin resistance Insulin deficiencyInsulin resistance alone cannot produce T2DM AJM 2000
  7. 7. Adapted from Holman RR. Diabetes Res Clin Pract 1998;40(Suppl.):S21–S25
  8. 8. Previous Algorithm – Type 2 Inadequate non- pharmacologic therapy 2 Oral 3 Oral 4 Oral* Oral agent agents agents agents Add insulinAdapted from Mudaliar S et al. In: Ellenberg and Rifkin’s Diabetes Mellitus, 6th ed. New York, NY:Appleton and Lange; 2003:531-557. *-Indian scenario
  9. 9. Standard Approaches to Therapy Result in Prolonged Exposure to Elevated Glucose 10% Diet/Exercise Sulfonylurea or Combination Insulin Metformin Therapy Monotherapy 9.6%Mean A1C at Last 9% 9.0% 8.6% Visit 8% 7% ADA Goal <7% 6% Diagnosis 2 3 4 5 6 7 8 9 10 Years At insulin initiation, the average patient had:  5 years with A1C >8%  10 years with A1C >7% Psychological Insulin Resistance(PIR) Brown JB, et al. Diabetes Care. 2004;27:1535-1540.
  10. 10. ADA 2012 Algorithm for T2DM
  11. 11. American Association of Clinical Endocrinologists: algorithm for patients with T2DM Drug-naïve patients Initiate monotherapy HbA1c 6%–7% Metformin, TZD, secretagogues, DPP-4 inhibitors, α-glucosidase inhibitors HbA1c 7%–8% Initiate combination therapy Secretagogue + metformin, TZD, or α-glucosidase inhibitorLifestyle Changes TZD + metformin DPP-4 + metformin or TZD Secretagogue + metformin + TZD Fixed-dose combinations Insulin HbA1c 8%–10% Intensify combination therapy To address fasting and postprandial glucose levels HbA1c >10% Initiate / intensify insulin therapy Patients currently As above pharmacologically Exenatide may be combined with oral therapies in patients treated not achieving goals DPP-4=dipeptidyl peptidase-4; T2DM=type 2 diabetes mellitus; TZD=thiazolidinedione AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. Endocr Pract. 2007; 13 (Suppl 1): 16–34.
  12. 12. When to Add insulin? At the initial diagnosis Failure of maximal doses of monotherapy Failure of submaximal doses of 2 OHA’s Failure of maximal doses of 2 OHA’s Failure of submaximal doses of triple therapy
  13. 13. At the Diagnosis of T2DM Severely symptomatic FPG>250 mg/dl RPG >300mg/dl HbA1c >10% Presence of ketosis BMI < 23 Kg/m2 Cardiac / renal / hepatic dysfunctions Critically ill patients
  14. 14. ORIGIN study N Engl J Med 2012; 367:309-318
  15. 15. Add InsulinPatient on two OHA’s FPG > 130 mg/dl PPG > 180 mg/dl HbA1c >8.5% Tighter control is desired Contraindication/intolerant to other OHA’s
  16. 16. Pre-injection Assessment is NotDone!
  17. 17. Pre- injection Assessment Injection-related concerns Psychological insulin resistance (personal failure, anticipated pain, once on insulin always on insulin)
  18. 18. Pre-injection Assessment-Dexterity problems-Cognitive capacity-Health literacy-Numeracy skills-Visual impairment-Local infections, ulcers and scars
  19. 19. How insulin should be stored ?
  20. 20. Injection Storage Store insulin in use at room temperature (15-25oC) and discard 30 days after initial use Short acting analogue,Lispro, in use should be stored at 40 C after use Currently unused vials/refill cartridges should be refrigerated Never freeze the insulin
  21. 21. Injection Technique is not Properly Advised!
  22. 22. Injection Technique Re-suspension of cloudy insulin is essential (Rolled 20 cycles) Needle length 4-6 mm Site of injection should be looked for lipohypertrophy or any bruise/blisters Recommend use of alcohol swabs or cotton ball dipped in water for cleaning Injection site : Abdomen < thigh <arm
  23. 23.  Ensure the correct insulin syringe with correct strength of insulin (40U vial with 40U syringe) Insulin pen should be primed with two units of insulin as the first step Insert the needle at 90o to the skin fold and count till 10 before pulling the needle out Needle site should not be massaged Injection site should be rotated
  24. 24. Insulin Dose Prescription is not Properly Written!
  25. 25.  Inadvertent use of abbreviations Inj Reg insulin 4U Route of administration is not mentioned Site of administration is not written Time of administration is missing Premixed insulin strengths are not mentioned (25:75, 30:70, 50:50)
  26. 26. Insulin is administered through clothing !
  27. 27.  Pre- and post-injection site assessment is not possible The needle becomes unsterile and can cause infection Skin pinch-up may not be correct through clothing Fiber from the cloth could enter the skin and cause irritation
  28. 28. Insulin is Administered just Prior to Meal!
  29. 29.  Lag time between insulin administration and meal -30-45 min for conventional insulin (Hexamer to monomer) -5-10 min for short acting analogues Time of administration of long acting analogues -Preferably at bed time, usually at fixed time -If early morning hypoglycemia, then administer in morning
  30. 30. Short acting insulin is used twice orthrice a day without intermediate or long acting insulin!
  31. 31. This strategy will never control fastinghyperglycemia as short acting insulin acts only for 4-6 hrs.
  32. 32. Characteristics of Currently Available InsulinInsulin Onset of Peak action(h) Duration(h) action(h)NPH 1-3 4-10 10-20Glargine 2-4 No peak 20-24Detemir 2 No peak 16-24Regular 0.5-1 2-3 5-8Lispro/aspart 0.1-0.25 0.5-1.5 3-5Lispro 25/75 0.25-0.5 5.8 12-24Aspart 30/70 0.17-0.33 2.4 ± 0.8 12-24
  33. 33. Insulin Regimens Basal-bolus (3 prandial and one/two NPH or Glargine) Only Basal (NPH or Glargine or Detemir) Premixed twice a day (30:70 either conventional or analogues) Premixed twice a day + one regular insulin at Lunch One regular or short acting analogues to control post-prandial hyperglycemia One dose of premixed insulin before major meals
  34. 34. Insulin Regimens Fasting hyperglycemia -NPH -Glargine at bed time -Detemir Post-prandial hyperglycemia -Regular insulin -Short acting analogues -Premixed Predinner hyperglycemia -NPH, Glargine, Detemir at morning -Premixed before lunch, if it is a major meal ‘Global hyperglycemia’ -Basal and bolus
  35. 35. What should be targeted?-FPG, PPG, HbA1c or all three-Which should be the first?
  36. 36. Basal vs Post-Prandial Hyperglycemia – A1c Uncontrolled Diabetes HbA1c 8% Basal hyperglycaemia 300 contributes ~2% Post-prandial Plasma glucose (mg/dL) hyperglycaemia contributes HbA1c ~1% 200 Post-prandial hyperglycaemia Fasting hyperglycaemia 100 Normal HbA1c ~5% 0    6 B 12 L 18 D 24 6 Time of day (h)B=breakfast; L=lunch; D=dinner.Adapted from Riddle MC. Diabetes Care. 1990;13:676-686.
  37. 37. HbA1c: Limitations Does not detect glycemic excursions Does not reveal hypoglycemia Cautions: ◦ Anemia ◦ Uremia ◦ EPO therapy
  38. 38. Short acting and Long acting Analogues are Indiscriminately Used!
  39. 39.  Short acting analogues used as i.v infusion for the treatment of hyperglycemic emergencies Use of short acting analogues with premixed conventional insulin Mixing of glargine with short acting insulin Premixed insulin twice a day and glargine at bedtime
  40. 40. Distinctive Uses of Analogues Short acting analogues -School going children -Pregnancy with diabetes -Busy executives -Gastroparesis Long acting analogues -Elderly subjects -Targeting HbA1c <6.5% -Inability to inject multiple injections
  41. 41. Somogyi phenomenon is not Recognized?
  42. 42. Somogyi Phenomenon Post-hypoglycaemic hyperglycemia Wide swings in blood glucose profile Common cause of fasting hyperglycemia Perform 4am BG level (<80mg/dl)
  43. 43. Dawn Phenomenon is usuallyMissed!
  44. 44. Dawn Phenomenon Early morning hyperglycemia (nocturnal GH surge, increased insulin clearance) Perform BG at 4 am >80mg/dl
  45. 45. Use of Biosimilars!
  46. 46.  These preparations are structurally similar but pharmacokinetics and therapeutic efficacy are variable Biosimilars with suboptimal efficacy may induce DKA
  47. 47. Consequences of Insulin Therapy
  48. 48. Immediate HypoglycemiaShort term -Weight gain -Worsening of retinopathy and neuropathyLong term -Malignancy
  49. 49. Insulin-Induced Hypoglycemia Major barrier Common with -Advanced duration of disease -Concurrent OHA’s -Older age, DKD
  50. 50. Conclusions Diabetes is an insulin deficient disorder, hence it should be repleted Insulin administration is a state-of-art The time of initiation may be variable but delay should be avoided Close monitoring should be done for hypoglycemia and weight gain
  51. 51. Thank you
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