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KISS Keep Insulin Safe and Simple is a very practical and simple way to initiate insulin and achieve optimal glycaemic control in type 2 diabetic.

KISS Keep Insulin Safe and Simple is a very practical and simple way to initiate insulin and achieve optimal glycaemic control in type 2 diabetic.

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Kiss Kiss Presentation Transcript

  • KISS :KEEP INSULIN SAFE AND SIMPLE
    • Dr. RISHIKESAN K.V,
    • VENNIYIL MED.CENTRE, SHARJAH
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    • “ Less than optimal glycemic control during the early years of diabetes has a lasting detrimental effect on the development and progression of complications, even after better glycemic control is established later in the course of the disease.”
    Adapted from White, N et al, J Pediatr. 2001 Dec; 139(6): 804-12 .
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  • DCCT/EDIC
    • METABOLIC MEMORY
    • THE GOOD CONTROL THAT YOU HAVE FIVE OR SIX YEARS CREATES A METABOLIC MEMORY IN OUR PATIENTS , AND THEY TEND TO HAVE LESS MACROVASCULAR COMPLICTIONS LATER ON.
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  • First commercial insulin
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  • BANTING-1891-1941 & BEST-1899-1978 Orthopod who became a physiologist and died in air crash in Newfoundland while on wartime mission Together they isolated insulin and Banting won the Nobel Prize in 1923 knighted in 1934
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  • Initiating insulin in T2DM
    • Life style change and OAD ,will be initially effective.
    • About 50% will require insulin within 6 yrs.of Dsis.
    • Starting insulin is not hard,not risky, and does work.
    • A simple six- step guide to initiate insulin therapy.
  • STEP 1
    • Is the pts.A1C on target?
    • Higher the A1C, greater the microvascular risk
    • [UKPDS].
    • A1C above 7% and certainly above 8% should prompt consideration of insulin Therapy.
    • A1C value reflects the overall avg.BGL(24H/d
    • over several wks.)
  • A1C
    • BGL( mmol/L) = 2A1C – 6 OR
    • BGL (mg% ) = (A1C X 35.6 ) – 77.3.
    • Following this formula A1C 8% = BGL 10mmol/L.
    • Ideal/Target A1C < 6.5%.
    • A1C = FBS+ PPBS.
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  • Lower A1C level Reduces the Risk of Complications DCCT * KUMAMOTO * UKPDS Each 1% fall in A1C results in 20-30% RRR in microvascular compln
  • Long-term Complications of Diabetes Mellitus
    • Diffuse Atherosclerois
      • AMI
      • CVA
      • PVD
        • Hypertension
      • Renal failure
      • Diabetic retinopathy/blindness
      • Gangrene
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  • HbA 1c and Microvascular Complications Relative Risk 15 13 11 9 7 5 3 1 HbA 1c , % 7 8 9 10 11 12 Neuropathy Nephropathy Retinopathy
  • Every 1% HbA 1c Increase Above Goal Elevates the Risk of Diabetic Complications Increase in Any Diabetes-Related Endpoint Increase in Risk of Myocardial Infarction (MI) Increase in Risk of Stroke Increase in Risk of Microvascular Complications Incidence of Diabetes- Related Complications (%) +21% +37% +12% +14% Adapted from Stratton et al. BMJ . 2000;321:405-412.
  • Lower A1C level Reduces the Risk of Complications DCCT * KUMAMOTO * UKPDS Each 1% fall in A1C results in 20-30% RRR in microvascular compln
  • Good Glycemic Control (Lower HbA 1c ) Reduces Incidence of Complications DCCT Research Group. N Engl J Med . 1993;329:977-986. Ohkubo Y et al. Diabetes Res Clin Pract . 1995;28:103-117. UKPDS 33: Lancet . 1998;352:837-853. HbA 1c Retinopathy Nephropathy Neuropathy Macrovascular disease DCCT 9  7% 63% 54% 60% 41%* Kumamoto 9  7% 69% 70% – – UKPDS 8  7% 17-21% 24-33% – 16%* * not statistically significant
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  • Chris Rhodes Ph.D. PNRI, Seattle, WA. TYPE 2 DIABETES – A QUESTION OF BALANCE PERIPHERAL INSULIN RESISTANCE BETA CELL MASS AND FUNCTION NON DIABETIC STATE BETA CELL MASS AND FUNCTION PERIPHERAL INSULIN RESISTANCE DIABETIC STATE
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  • STEP 2 Co morbidity/Life style/Co Rx.
    • CHECK life style; insulin Tx is not a substitute for healthy life style.
    • Overwt/obese/underactive/overeating individuals likely to gain wt. and may not get glycaemic control.
    • Many pts.gain wt. because of the good control of glycosuria with insulin.
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  • WALKING MORE BUT NOT ENOUGH
    • Many of us are busy all day
    • Exhausted physically & mentally by evening
    • Feel relaxed in front of TV with the remote
    • Majority of the adults are not engaging in regular physical activity
    • We might find we had walked fewer than 3000 steps during the day
    • Walking suits most people and walking with a companion makes it enjoyable
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  • Lifestyle
  • The long term goal might be 30- 40 minutes or 10000 steps per day WALK MORE ,WALK EACH DAY AND WALK MORE EACH WEEK
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  • Lifestyle
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  • WT.GAIN IN TYPE 2 DM
    • Improved glycaemic control >>> decreased glycosuria ( 2kg / 1% decrease inA1C )
    • Prandial boluses , independent of glycaemia
    • OADs – SUs /Glitazones & stopping metformin
    • Premixed insulins – hypos caused by the short acting components >>> wt. gain
    • Overuse of insulin >>> hypos >>> hunger symptoms.
  • The Wrong Insulin
    • Some docs hope ONE SIZE WILL FIT ALL and use premixed insulins .
    • In clothing XL will fit all , but not comfortably or elegantly.
    • A rational approach – to start with 10 units of basal insulin at night and continue OAD
    • Eventually many require bolus insulin for better glycaemic control
  • METFORMIN ADVANTAGE
    • Improves insulin sensitivity
    • Cardiovascular protection / demonstrated decrease in coronary events.
    • As monotherapy for 6 months >>> wt.loss of 2-3 kg.
    • Net wt. advantge of 4-6 kg.
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  • EAT LESS AND WALK MORE.
    • SECONDARY CAUSES FOR HIGH BLOOD SUGAR.
    • A. Medications –
    • OCP
    • STEROIDS
    • THIAZIDES
    • BETABLOCKERS
    • PHENYTOIN
    • ANTIPSYCHOTICS
    • GLUCOSAMINE
  • SEC.CAUSES Conts….
    • B. Med. Conditions
    • UTI/ ASYMPTOMATIC
    • DENTAL INFECTIONS
    • HYPERTHYROIDISM
    • OCCULT MALIGNANCY
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  • DIABETES PROGRESSION
    • With progression of disease capacity of beta cells to secrete insulin decreases.
    • Body”s capacity to respond to insulin also decreases.
    • When insulin resistance exceeds insulin secretory capacity PREDIABETES strts.
    • Diabetes progressively worsens with time,
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  • INSULIN SECRETION FAILS
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  • FIRST PHASE INSULIN SECRETION
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  • BETA CELL FUNCTION
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  • T2DM –NATURAL HISTORY
  • FAILURE OF SU AND SECRETAGOGUES.
    • These agents – DAONIL, AMARYL, STARLIX, NOVONORM,DIAMICRON etc. will not work if there is insufficient insulin.
    • Insulin sensitisers like GLITAZONE and METFORMIN may be effective.
    • Glucophage/ Actos alone or in combination
    • worthwhile.
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  • STEP 3. WHICH BASAL INSULIN
    • In general ONCE DAILY BASAL INSULIN
    • plus continuing OAD is the preferred option because of good glycaemic control, less wt . gain and lesser hypoglycaemia .
    • Basal Insulins - 2 types
    • Intermediate acting
    • Long acting
  • INTERMEDIATE ACTING
    • ISOPHANE INSULIN-
    • 12- 24 Hour s duration- human origin,cloudy .
    • Available as vials, cartridges and disposible pen injectors.
    • Brands – Humulin NPH
    • Protaphane.
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  • LONG ACTING INSULIN
    • 24- 36 Hrs. duration
    • Analogue nsulin ,clear soln.available as pen injectors, cartridges and vials.
    • Brands
    • LEVEMIR
    • LANTUS
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  • Insulin Glargine : Structure Insulin Glargine : 21 A -Gly 30 B a-L-Arg-30 B b-L-Arg-insulin Metabolites : M1-21 A -Gly-insulin M2-21 A -Gly-des-30 B -Thr-insulin Substitution Extension A-chain B-chain 1 5 10 15 20 Asn 1 5 10 15 20 25 30 Arg Arg Gly
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  • BASAL INSULINS
    • PROS AND CONS OF ANALOGUE
    • PROS
    • consistent profile
    • often single daily dose
    • lesser hypos
    • no mixing or resuspension
  • CONS analogue
    • *slower response to dose changes
    • *may be confused with bolus insulin as both are clear solution
    • *cannot mix with bolus insulin
    • *glargine may sting when injected.
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  • New Long Acting Insulin (Glargine Insulin)
    • Lantus is a new type of long acting insulin that has no peaks
    • Mimics physiological insulin (basal)
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  • STEP 4. DOSE TITRATION
    • START WITH 10 UNITS
    • ADJUST THE DOSE TWICE WEEKLY TO REACH THE TARGET FBS OF < 6 mmol/L (110 mg%)
    • When BGL is well above target, increase by larger amounts than when BGL is close to target.
    • Adjust dose every 2-3 days
  • INITIATION&TITRATION
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  • FESTINA LENTE- HASTEN SLOWLY
    • Increasing the dose too fast may cause hypos and wt.gain
    • Adjusting the dose slowly could mean many months to achieve optimal control
    • Once the fasting BGL is on target, check the evening preprandial BGL.
    • If the second preprandial not on target add a second dose of basal insulin( 10 units)
  • SWITCHING FROM ISOPHANE TO ANALOGUE BASAL INSULIN
    • If switching from once daily isophane to QD Basal use same units
    • If switching from BID isophane to QD Basal start at 80%
    • If a premix insulin is used, calculate the new dose on the amount of isophane in the mix
    • Consider a 10% dose redn.in case of severe hypos in the past
  • STEP 5. SHOULD OAD BE STOPPED&/OR BOLUS INSULIN STARTED
    • Should OAD be stopped – stopping OAD means less number of tabs. but may also mean more of insulin units OR a second dose of insulin.
    • SUs MAY NO LONGER BE EFFECTIVE
    • INSULIN SENSITISERS WILL CONTINUE TO WORK .
    • THE RISK OF SERIOUS ADV.EFFECTS INCREASES-lactic acidosis & fluid overload
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  • What is the patient”s A1c?
    • If any difference between avg.BGL and that predicted by the A1C –
    • 1. inaccurate/inadequate measurements and
    • recording
    • 2.occasionally pts. may not record high or
    • low values.
  • HIDDEN HYPERGLYCAEMIA
    • Avg.BGL and A1C accurate, Preprandial BGLs are on target and A1C off target , check
    • PPBGLs and during the night( eg. 3.00am), for
    • hidden hyperglycaemia.
    • Check BGLS before lunch and before HS to check for morning and evening post prandial hyperglycaemia.
  • MORNING HYPERGLYCAEMIA
    • In both people with and without diabetes BGL falls during the night and the increase in the early hours of morning – can be a problem in diabetics (DAWN PHENOMENON)
    • There are three classic patterns of morning hyperglycaemia
    • *** INSULIN RUN OUT
    • **** THE BOUNCE
    • ***** POOR CONTROL
  • HOW TO TACKLE POST PRANDIAL HIGHs?
    • Review the glycaemic load of that particular meal.
    • A dietitian will be able to advise on glycaemic load and on strategies to reduce post prandial glycaemia.
    • If changes in CHO intake are not needed, practical, or effective then add QUICK ACTING INULIN in addition to BASAL INSULIN
  • Glycemic Index for Food
    • Not all carbohydrates are created equal when compared to their effects on plasma glucose.
    • Glycemic Index is an attempt to measure the differences in the amount of glucose converted in the plasma from various foods.
    • Glycemic Index ranks foods according to their ability to raise blood sugar.
    • Low Glycemic Index foods release their glucose to the bloodstream slowly, over a prolonged period of time.
    • High Glycemic Index foods release theirs all at once.
    Food Glycemic Index Glucose 100 Honey 91 Brown Rice 88 Corn Flakes Cereal 83 Wheat Bread 72 Table Sugar 64 Banana 61 Sweet Corn 58 Oatmeal Cookies 57 Sweet Potato 50 Orange Juice 49 Macaroni 46 Ice Cream 38 Milk 34 Peanuts 10
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  • FOODS THAT MUST BE AVOIDED
    • SWEETS , ICE CREAMS , FRUIT SUGAR
    • CAKES , PASTRIES , SWEET BISCUITS
    • CHOCOLATES, SOFT DRINKS
    • CONDENSED MILK , CREAM AND MOLASSES
  • Sweet food
  • Sweet food
  • Fat food
  • Meat
  • FOODS TO BE CONSUMED IN LIMITED AMOUNTS
    • CUT DOWN YOUR INTAKE OF SALT, RED MEAT, POULTRY, EGGS, COFFEE AND TEA
    • THESE SHOULD BE ESPECIALLY AVOIDED WHEN YOU HAVE AN EMPTY STOMACH
    • OTHER EXAMPLES: PASTA,COCONUT, HONEY,PALM SUGAR,YOGHURT
  • BENEFICIAL FOODS
    • FIGS, POMEGRANATES,CITRUS FRUITS
    • VEGETABLES SUCH AS CABBAGE, BROCCOLI, SPINACH, CARROTS, BEET RADISH, GARLIC, ONION, CEREALS CUCUMBER, LETTUCE, TOMATO, WHOLE GRAIN FOODS, SPROUTS AND GRAINS SUCH AS BENGAL GRAM AND CHICK PEAS
  • Cereals
  • Vegetables
  • Vegetables
  • Raw vegetables
  • Vegetables
  • Vegetables
  • Fish
  • BOLUS INSULINS
    • A Quick acting bolus insulin in case of on target preprandial BGL, but off target A1C and
    • post prandial BGL
    • BOLUS INSULINS
    • Traditional and
    • Analogues bolus insulins
  • CHARACTERISTICS OF BOLUS INSULIN
    • A. Rapid acting/very quick acting-
    • #Onset 5- 15 min. Peak 30-90 min. Durn 4-6 hrs 1. INSULIN ASPART(NOVORAPID) clear soln. analogue insulin available as vials, cartridges and pens
    • 2.INSULIN LISPRO(HUMALOG) available as vials and cartridges for use in pens.
  • BOLUS INSULIN conts…..
    • B.Short acting/Quick acting insulin-
    • #Onset 30-60 min. Peak 2-3 hrs. Durn 8-10 hrs
    • NEUT. INSULIN (ACTRAPID/ HUMULIN R)
    • #Human insulin ,clear soln.available as vials and cartridges for use in pen injectors
    • #Both analogue and Human insulins are clear soln. but each has its pros and cons
  • Human Neutral Bolus Insulin
    • May act too slowly to control post prandial HYPER and may act for so long so that HYPO before the next meal becomes a risk
    • For pts. on analogue basal insulin , neutral human bolus insulin may be better to control the blood glucose before the next meal esp.
    • if the next meal is more than 6 hrs.after the bolus insulin
  • Analogue Bolus Insulin…
    • Faster in starting and stopping and may control post prandial HYPER with lesser risk of HYPO.
    • However the analogue may increase the risk of HYPO if the meal is not eaten promptly or if enough CHO is not eaten with meal( steak and salads)
    • Rapid acting insulin may RUN OUT before next.meal causing preprandial HYPER
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  • Humalog/Novolog versus Regular
    • Rapid acting insulins: Start in 10min Peak in 1-2h Gone in 3.5-4h
    • Regular insulin: Starts in 30min Peaks in 3-4h Gone in 6-8h
  • Isophane Basal and Quick acting Bolus…….
    • Is a good choice for better control of next preprandial HYPER and immediate post prandial HYPER.
    • Eg. Humulin NPH at HS and Humalog OR Novorapid as preprandial bolus insulins
    • Anlogue Basal and short acting neutral insulin
    • is also a rational choice.
    • Eg. Lantus/ Levemir at HS and human actrapid as bolus insulins
  • What dose of Bolus insulin?
    • Choosing the initiating dose is easy.
    • Use 1/3 of the corrresponding morning or evening basal insulin dose
    • The usual recipe is 2/3 basal and 1/3 bolus.
    • Adjust the starting dose according to the BGL profile
    • FESTINA LENTE-not too slow and not too fast. GET IT JUST RIGHT
  • BOLUS INSULIN TITRATION
    • Increase the dose by 20% if BGL are well off target and by 10%when they are closer to target.
    • Don’t aim too low
    • The major side effect of quick acting insulin is HYPOS and WT.GAIN ( wt.gain because of assoc. hunger symptoms)
    • Hypos less likely in T2DM than in IDDM pt.
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  • BGL POFILE ON BASAL PLUS BOLUS INSULIN SCHEDULE
    • INSULIN INJECTION
    • 1.Morning Basal
    • 2.Morning Bolus
    • 3.Evening Bolus
    • 4.Bed time Basal
    • ON TARGET BGL
    • Evening preprandial(pre dinner)
    • Mid-day preprandial (prelunch)
    • Pre bed time
    • Fasting (pre brakefast)
  • INSULIN Rx PROGRAM
  • TROUBLE SHOOTING INSULIN PROBLEMS
    • FIRST FIX THE FASTING – Is BED TIME insulin needed?
    • THEN TACKLE THE TEA – Is BRAKE FAST insulin needed?
    • FIND THE HIDDEN HYPERS- Is a PRE MEAL bolus needed?
    • AND CHECK THE A1C – Is the A1C on target ?
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  • STEP 6. ARE PROBLEMS WITH INSULIN LIKELY?
    • Two classes of potential problems-
    • 1.MEDICAL
    • coping with injn. and monitoring techniques (both pts.& doctors) AND risk of hypos and wt.gain (pts)
    • 2. PSYCHOLOGICAL ( both the pts.&doctors)
  • MEDICAL PROBLEMS
    • Any pts.except a very few can manage to administer their own insulin or monitor their BGL using injectors/pens and glucometers.
    • For these few a relative ,carer or visiting nurse could help.
    • BASAL INSULIN injn.& PREPRANDIAL BGL measuremnts are the most important daily activities
  • PSYCHOLOGICAL PROBLEMS ?Causes
    • PATIENTS
    • *insulin therapy will be painful and difficult
    • *fear of wt. gain and hypoglycaemia
    • * end of the road , diabetes worse
    • *employment/dependency
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  • PSYCHOL.INSULIN RESISTANCE -? Causes
    • DOCTORS
    • *pts do not want insulin therapy
    • * difficult, extra time needed
    • * pts need referrals
    • * hypos and wt gain
    • * insulin therapy will not work and costly
  • PSYCHOLOGICL INSULIN RESISTANCE
    • Many doc and their pts prefer to delay insulin therapy until it is ABSOLUTELY ESSENTIAL.
    • Neither wants to take the bold step; the problems of starting insulin are immediate and obvious to both. The problems of not starting are more remote and less obvious
  • HOW TO RESOLVE THE CONCERNS?
    • @To demonstrate that inj. are virtually painless
    • with a DRY inj
    • @Introduce the person to a successful pt
    • @Explain that the risk of hypo is remote(1/20 th
    • that in type1)
    • @Explain that eating less and walking more will limit or prevent wt. gain
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  • EMPLOYMENT AND INSURANCE
    • Some concerns are less easy to resolve :
    • some employers /insurance do discriminate
    • against people with diabetes and access to some jobs is more difficult.
    • Overall ,though ,insulin doesn’t limit opportunity
    • much
  • CONCLUSIONS
    • WHY INITIATE INSULIN THERAPY
    • *maintain near normal glycaemia when oral agents cannot
    • *reduce strain on beta cell
    • * improve insulin resistance and correct glucotoxicity
    • * minimize long term complications-microvascular/macrovascular
    • *improve QOL
  • INSULIN IS NOT……
  • Initiate insulin therapy sooner rather than later, and treat to target
    • Insulin works
    • Insulin is good
    • Insulin is your friend
    • KISS approach really works
  • A PATIENT MIGHT SAY
    • I FEEL GREAT.
    • I DON’T NEED DAYTIME NAPS
    • IF I HAD KNOWN HOW EASY IT WAS TO
    • START INSULIN ,I WOULD HAVE DONE IT
    • YEARS AGO
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  • THANK YOU THANK YOU VERY MUCH