Say Yes to InsulinMentorship Program Initiating insulin Kick-off meeting      林文玉醫師              金磚 20120827
Insulin use was inadequately    delayed
Before Starting Insulin, Patients Spend an Estimated 10 Years                             Above Target        10          ...
Progressively declining beta cell function in T2D                                         ‘waiting for failure’           ...
The impact of glycemic control on complications The majority of people with type 2 diabetes fail to reach       recommende...
No HbA1C Threshold in Type 2 Diabetes                        80                                  Myocardial infarction    ...
June 2012 vol. 7, issue 6
“Clinical Inertia”                                 Failure to advance therapy when required                             La...
Clinical Inertia: “Failure to advance therapy when required”                                Percentage of Subjects advanci...
Clinical Inertia: “Failure to advance therapy when required”                              4207 Person-Years of Followup   ...
Treatment Algorithm for Type 2                        Diabetes in Adults*                                               Ed...
What should I tell people with Type 2             diabetes about insulin?    ‘Most people with Type 2 diabetes eventually ...
Progression of Type 2 diabetes relates to           declining islet -cell function while insulin                   insensi...
Progression to Type 2 diabetes usually involves afailure of insulin secretion in people who are already                   ...
What should I tell people      with Type 2 diabetes about insulin?      ‘If you need insulin, it doesn’t mean you failed. ...
UKPDS: Islet -cell function and the progressive              nature of diabetes                         100               ...
What should I tell the person with Type 2              diabetes who needs     insulin, but doesn’t want to take it?‘Insuli...
How should I start insulin therapy for my      patients with Type 2 diabetes?• According to the IDF Global Guideline for T...
Treat-to-Target: addition of detemir or NPH                                to oral therapy                       475 Peopl...
What are the problems associated with                insulin therapy?• Weight gain is usual as glycosuria is reduced• Hypo...
Conclusions• Due to declining -cell function, insulin therapy will be necessary  for most patients with Type 2 diabetes• I...
Kick off meeting
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Kick off meeting

  1. 1. Say Yes to InsulinMentorship Program Initiating insulin Kick-off meeting 林文玉醫師 金磚 20120827
  2. 2. Insulin use was inadequately delayed
  3. 3. Before Starting Insulin, Patients Spend an Estimated 10 Years Above Target 10 35 Months* 27 Months* 9.1 Metformin 9 8.8 monotherapy Sulfonylurea 8.2 monotherapy 8 7.6 7.7A1C % 7.1 7 ADA goal 6 05 First HbA1c on Best HbA1c on Last HbA1c before treatment treatment switch or addition Modified: Monotherapy switched to another agent or additional agent added. *Mean number of months until a new or additional treatment was started Adapted from Brown JB, et al. Diabetes Care 2004;27:1535–40
  4. 4. Progressively declining beta cell function in T2D ‘waiting for failure’ Insulin ±oral drugs Dual for lowering 100 Lifestyle Monotherapy therapy blood glucose 10 ß-cell function (%) 9 8 HbA1c (%) 7 6 HbA1c 5 ß-cell function 0 0 0 Time >15 (years)Adapted from: Heine RJ et al. BMJ. 2006;333:1200-1204.
  5. 5. The impact of glycemic control on complications The majority of people with type 2 diabetes fail to reach recommended goals for glycemic control1 Intensive glucose control is associated with long-term reductions in long-term diabetes complications—the legacy effect 17% 15% 15% 13% 9% p=0.01 p=0.01 p=0.01 p=0.007 p=0.04 Diabetes Myocardial Microvascular Death Any diabetes death infarction disease (any cause) endpoint 1. Del Prato, et al. Int J Clin Pract Suppl 2007;157:47-57 2. Holman et al, NEJM 2008;359:1577-1589
  6. 6. No HbA1C Threshold in Type 2 Diabetes 80 Myocardial infarction Epidemiologic Adjusted Microvascular endpoints Data from the incidence per UKPDS 60 1000 person years (%) ADA Goal 40 20 ? 0 5 6 7 8 9 10 11 Updated mean HbA1C (%)Stratton IM, et al. BMJ. 2000;321:405-412. 6
  7. 7. June 2012 vol. 7, issue 6
  8. 8. “Clinical Inertia” Failure to advance therapy when required Last HbA1C Value Before Abandoning Treatment 10 9.6% 9.1% 9 8.8% 8.6% 8 % Mean HbA1C at ADA Goal last visit1 7 Sulfonylurea Diet/Exercise Combination Metformin 2.5 years 2.9 Years 2.2 Years 2.8 Years1Brown et al. The Burden of Treatment Failure in Type 2 Diabetes. Diabetes Care 27: 1535-1540, 2004 10
  9. 9. Clinical Inertia: “Failure to advance therapy when required” Percentage of Subjects advancing when HbA1C > 8% At Insulin Initiation, the average patient had: 100 • 5 years with HbA1C > 8% • 10 years with HbA1C > 7% 80 %Age of Subjects 66.6% 60 44.6% 35.3% 40 18.6% 20 0 Diet Sulfonylurea Metformin CombinationBrown et al. The Burden of Treatment Failure in Type 2 Diabetes.Diabetes Care 27: 1535-1540, 2004 11
  10. 10. Clinical Inertia: “Failure to advance therapy when required” 4207 Person-Years of Followup At Insulin Initiation, patients who had failed combination therapy • Had a median HbA1C of 9.9% “The high median HbA1C that preceded the initiation of insulin in our population is particularly troubling and suggests that there are substantial barriers to its Initiation”Cook et al: Glycemic Control continues to deteriorate after Sulfonylureas Are Addedto Metformin Among Patients with Type 2 Diabetes. Diabetes Care 28: 995-1000, 2005 12
  11. 11. Treatment Algorithm for Type 2 Diabetes in Adults* Education/Nutrition/Exercise Goals met FPG/SMBG goals not met after 1 month Follow-up Every 3 Start Initial Oral Monotherapy to 6 Months or Early Dual Oral Therapy Therapy adequate Goals not met after 3 months Continue Therapy Initiate/Modify Dual HbA1c Every 3 to 6 Months Therapy Therapy adequate Goals not met after 3 to 6 months Continue Dual Therapy Add Evening Insulin or Third Oral Agent; HbA1c Every 3 to 6 Months Consider Referral to Endocrinologist Goal: FPG/SMBG <6.5 mmol/L; HbA1C <6.5%†*Modified Texas Diabetes Council Algorithm. Feld S. Endocr Pract. 2002;8(suppl 1):40-82.†American College of Endocrinology. 13
  12. 12. What should I tell people with Type 2 diabetes about insulin? ‘Most people with Type 2 diabetes eventually need insulin because their own production of insulin falls off with time and they therefore inevitably become insulin deficient’• Diabetes is caused by a progressive failure of insulin production in people who are usually insulin insensitive (overweight)
  13. 13. Progression of Type 2 diabetes relates to declining islet -cell function while insulin insensitivity is unchanged Time to need glucose-lowering medication 2–4 years 5–7 years -Cell 60 Insulin 60 8–10 yearsfunction sensitivity(%) 40 40 20 20 0 0 0 2 4 6 0 2 4 6 Years from diagnosis Levy J et al. Diabet Med. 1998;15:290-296
  14. 14. Progression to Type 2 diabetes usually involves afailure of insulin secretion in people who are already insulin insensitive 500 400 (insulin response mU/l) Insulin secretion 300 Normal – compensated insulin resistance Normal Normal 200 IGT 100 Diabetes 0 0 1 2 3 4 5 Insulin sensitivity (glucose requirement mg/kg/min) Adapted from Weyer C et al. J Clin Invest. 1999;104:787-794
  15. 15. What should I tell people with Type 2 diabetes about insulin? ‘If you need insulin, it doesn’t mean you failed. Tablets cannot control blood glucose forever, because they don’t stop the problem of your own declining insulin production getting worse’• Islet -cell dysfunction worsens over time, regardless of therapy
  16. 16. UKPDS: Islet -cell function and the progressive nature of diabetes 100 Time of diagnosis 80(% of normal by HOMA) Islet -cell function 60 40 Pancreatic function = 50% of normal 20 0 10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 Years HOMA = homeostasis model assessment Holman RR. Diab Res Clin Pract. 1998;40(suppl):S21-S25; UKPDS. Diabetes. 1995;44:1249-1258
  17. 17. What should I tell the person with Type 2 diabetes who needs insulin, but doesn’t want to take it?‘Insulin will not make your diabetes worse. In fact, it will help control your glucose, so you’ll have fewer complications and you’ll feel better.’• Strict glycaemic control reduces the risks of both microvascular and macrovascular complications• People who start insulin usually feel much better for it
  18. 18. How should I start insulin therapy for my patients with Type 2 diabetes?• According to the IDF Global Guideline for Type 2 Diabetes – Insulin is the most effective way of reducing hyperglycaemia – Insulin can be started as a basal insulin alone or with premix insulin – Start insulin when glucose control on maximum tablets >7.5 % (HbA1c) – Begin at low dose but titrate up rapidly in first month IDF. Global Guideline for Type 2 Diabetes. 2005
  19. 19. Treat-to-Target: addition of detemir or NPH to oral therapy 475 People with Type 2 Diabetes on 1 or 2 Oral Agents Glycaemic Control Hypoglycaemia (events pt-yr-1)Baseline HbA1c 8.5% 8.6% 0.0 12 -0.5 HbA1c 8 -1.0 NPH -1.5 4 detemir -2.0 -1.8% -1.9% P=NS 0Final HbA1c 6.6% 6.8% 5.0 6.0 7.0 8.0 9.0 NPH insulin HbA1c (%) Insulin detemir Hermansen K et al. Diabetes Care. 2006;29:1269-1274
  20. 20. What are the problems associated with insulin therapy?• Weight gain is usual as glycosuria is reduced• Hypoglycaemia will occur in some people – education is needed• Failure of dose titration to get adequate glucose control• Worsening of control as islet β-cell failure progresses• These risks can be minimized by – use of insulin analogues in those with problems – using basal insulin only when starting at lower HbA1c – appropriate education on eating and physical activity – active and continuing support for dose titration – intensification of insulin regimens over following years
  21. 21. Conclusions• Due to declining -cell function, insulin therapy will be necessary for most patients with Type 2 diabetes• Insulin effectively lowers HbA1c, thereby reducing the risks of both micro- and macrovascular complications• IDF Global Guidelines recommend starting insulin when glucose control on maximum tablets >7.5 % (HbA1c)• To maintain target glucose levels in the long-term, many patients will require intensive insulin therapy (basal + bolus insulin) in combination with an insulin sensitizer
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