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Common errors in insulin therapy
 

Common errors in insulin therapy

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    Common errors in insulin therapy Common errors in insulin therapy Presentation Transcript

    • 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 assessment4. Insulin injection techniques5. Regimens of insulin treatment6. Insulin analogues7. Consequences of Insulin Therapy -Short term -Long term
    • Alternative therapy to insulin in T1DM!
    •  Omission of insulin in T1DM is SUICIDAL Never stop insulin even during sickness  Follow sick day guidelines
    • Delay in Initiation of Insulin Therapy
    • The 2 Defects of T2DM Insulin resistance Insulin deficiencyInsulin resistance alone cannot produce T2DM AJM 2000
    • Adapted from Holman RR. Diabetes Res Clin Pract 1998;40(Suppl.):S21–S25
    • 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
    • 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.
    • ADA 2012 Algorithm for T2DM
    • 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.
    • 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
    • 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
    • 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 Contraindication/intolerant to other OHA’s
    • Pre-injection Assessment is NotDone!
    • Pre- injection Assessment Injection-related concerns Psychological insulin resistance (personal failure, anticipated pain, once on insulin always on insulin)
    • Pre-injection Assessment-Dexterity problems-Cognitive capacity-Health literacy-Numeracy skills-Visual impairment-Local infections, ulcers and scars
    • How insulin should be stored ?
    • 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
    • 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 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
    •  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
    • Insulin Dose Prescription is not Properly Written!
    •  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)
    • Insulin is administered through clothing !
    •  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
    • 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 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
    • 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) 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
    • 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
    • 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
    • What should be targeted?-FPG, PPG, HbA1c or all three-Which should be the first?
    • 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.
    • HbA1c: Limitations Does not detect glycemic excursions Does not reveal hypoglycemia Cautions: ◦ Anemia ◦ Uremia ◦ EPO therapy
    • 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 analogues with premixed conventional insulin Mixing of glargine with short acting insulin Premixed insulin twice a day and glargine at bedtime
    • 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
    • Somogyi phenomenon is not Recognized?
    • Somogyi Phenomenon Post-hypoglycaemic hyperglycemia Wide swings in blood glucose profile Common cause of fasting hyperglycemia Perform 4am BG level (<80mg/dl)
    • Dawn Phenomenon is usuallyMissed!
    • Dawn Phenomenon Early morning hyperglycemia (nocturnal GH surge, increased insulin clearance) Perform BG at 4 am >80mg/dl
    • Use of Biosimilars!
    •  These preparations are structurally similar but pharmacokinetics and therapeutic efficacy are variable Biosimilars with suboptimal efficacy may induce DKA
    • 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-art The time of initiation may be variable but delay should be avoided Close monitoring should be done for hypoglycemia and weight gain
    • Thank you