Roller Coaster of Insulin Therapy Rationale for insulin therapy in type 2 diabetes

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The South African Journal of Diabetes & Vascular Disease presents: Problems and challenges in patients with type 1 diabetes.

Larry A Distiller
Centre for Diabetes and Endocrinology
Johannesburg

http://www.diabetesjournal.co.za

Published in: Health & Medicine
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Roller Coaster of Insulin Therapy Rationale for insulin therapy in type 2 diabetes

  1. 1. Problems and challenges in patients with type 1 diabetes. Larry A Distiller Centre for Diabetes and Endocrinology Johannesburg
  2. 2. Type 1 Diabetes <ul><li>Type 1 DM is, in essence, a simple hormone deficiency state…… </li></ul><ul><li>Beta cell destruction results in Insulinopenia. </li></ul><ul><li>Exogenous Insulin is freely available. </li></ul>Replace this missing hormone In concept, no different from hypothyroidism, HRT etc.! So what’s the problem?
  3. 3. Redefining the “problem” of diabetes Diabetes the “Illness” : Patient has symptoms of hyperglycemia Symptoms treated Patient no longer ill! Able to continue “normal” lifestyle with minimum disruptions. Achieved with blood glucose <15mmol/l
  4. 4. Redefining the “problem” of diabetes <ul><li>Diabetes the “Risk Factor” : </li></ul><ul><li>The need to achieve as good glycaemic control as possible (HbA1 c <7%) to avoid microvascular (and possibly macrovascular) complications. </li></ul>
  5. 5. <ul><li>Targets for glycaemic control are set. </li></ul><ul><li>HbA1c <7% </li></ul><ul><li>FPG 4.4-6.7 mmol/l </li></ul><ul><li>PPG <10mmol/l </li></ul><ul><li>But are seldom achieved </li></ul><ul><li>WHY? </li></ul>
  6. 6. THEORETICAL BARRIERS TO CONTROL Patient Barriers Age Gender Educational level Past experience with diabetes Race Ethnicity Socioeconomic status Attitudes Personality Energy Level Physical Health Mental Health Religion Emotional State Past Experience with diabetes education Stress Education Barriers Vision Profession Values Knowledge Skills Attitude Personality Gender Energy Level Experience Flexibility Ethnicity Religion <ul><li>Environmental Barriers </li></ul><ul><li>Stress </li></ul><ul><li>Educational Method </li></ul><ul><li>Reimbursement </li></ul><ul><li>Physical Setting </li></ul><ul><li>Part of country </li></ul><ul><li>Weather </li></ul><ul><li>Family </li></ul><ul><li>Friends </li></ul><ul><li>Work </li></ul><ul><li>Culture </li></ul><ul><li>Problems re: </li></ul><ul><li>Nutrition </li></ul><ul><li>Exercise </li></ul><ul><li>Medication </li></ul><ul><li>Foot Care </li></ul><ul><li>Emergencies </li></ul>
  7. 7. The Treatment of the Patient with type 1 diabetes changed forever following the DCCT. <ul><li>This change was preceded by and made possible by the advent of three things: </li></ul>
  8. 8. The foundation of modern diabetes management SHGM Pen Devices/CSII Diabetes Nurse Educator Intensive management of type 1 diabetes
  9. 9. Allows for <ul><li>Patient self-empowerment </li></ul><ul><li>Better acceptance of diabetes & its treatment through better patient counseling, education and understanding </li></ul><ul><li>Self-adjustment of insulin doses </li></ul>
  10. 10. Goals of Insulin Therapy <ul><li>To achieve blood glucose profiles as close to the euglycaemic range as possible. </li></ul><ul><li>Target : HbA1c <7% </li></ul><ul><li>To provide as much flexibility as possible. </li></ul><ul><li>To ensure the best quality of life. </li></ul><ul><li>And at the same time to minimize hypoglycaemia </li></ul><ul><li>This is best done by mimicking normal insulin secretion as closely as possible </li></ul>
  11. 11. Know & Understand your Insulins <ul><li>Types </li></ul><ul><li>Onset of Action </li></ul><ul><li>Onset & Duration of Peak Action </li></ul><ul><li>Total Duration of Action </li></ul>
  12. 12. Know Your Patient ! <ul><li>Each person is as unique as a fingerprint </li></ul><ul><li>Age / self care ability </li></ul><ul><li>Coexisting conditions </li></ul><ul><li>Type & duration of diabetes </li></ul><ul><li>Exercise </li></ul><ul><li>Meal plan </li></ul><ul><li>Medications / alcohol </li></ul><ul><li>Complications etc… </li></ul>
  13. 13. Your Client Must Also Understand the Insulin <ul><li>First: Listen </li></ul><ul><li>Counsel – it is not a normal human activity to stab oneself repeatedly </li></ul><ul><li>Educate </li></ul><ul><li>Regular review & follow-up </li></ul>
  14. 14. Decide <ul><li>Which Insulin Regimen? </li></ul><ul><li>Which Insulins? </li></ul><ul><li>What expectations? </li></ul><ul><li>The patient cannot be dictated to, but must be a partner in the decision process. </li></ul><ul><li>The more frequently one injects, the more flexibility in life-style. </li></ul>
  15. 15. Helping Your Patient Choose a Regimen <ul><li>You get what you pay for! </li></ul><ul><li>“ Pay” 4 -5 injections </li></ul><ul><li>“ Buy” flexibility, quality of life, improved control </li></ul><ul><li>“ Pay” 2 injections </li></ul><ul><li>“ Buy” control only with regimented lifestyle and strict dietary habits </li></ul>But in the end the PATIENT must make the choice. It is he/she, not you, who has to live with it!
  16. 16. And how low to go? <ul><li>The lower the HbA1c, the tighter the control, the higher the risk of hypoglycaemia. </li></ul><ul><li>In most patients, the fear of hypoglycaemia in the short term exceeds the fear of long-term complications </li></ul><ul><li>So how low should we go? </li></ul><ul><li>Is a target HbA1c of <7% acceptable for everyone? </li></ul>
  17. 17. Should the Risk of Hypoglycaemia modify our Treatment? Yes Age (<8yrs: >60yrs CVD Advanced Complications Hypo Unawareness Job-Risk Sleeping alone Etc. No Young Healthy Aware Fit Compliant Most patients in the middle !
  18. 18. And what about SHGM <ul><li>FAQ </li></ul><ul><li>How often? </li></ul><ul><li>When? </li></ul><ul><li>What does it mean? </li></ul><ul><li>“ The answer, my friends, is blowing in the wind” </li></ul>
  19. 19. There are four kinds of ‘testers” <ul><li>Those who won’t </li></ul><ul><li>Those who don’t </li></ul><ul><li>Those who do – by “rote”. </li></ul><ul><li>Those who do with purpose . </li></ul>
  20. 20. Those who won’t <ul><li>These patients refuse to test </li></ul><ul><li>or </li></ul><ul><li>Test 2-3 times a month – a pointless exercise </li></ul><ul><li>or </li></ul><ul><li>Prefabricate test results </li></ul>
  21. 21. Those who don’t <ul><li>Test only when they “feel bad”, to confirm low or high blood glucose levels. </li></ul><ul><li>Seldom test when they “feel alright”. </li></ul><ul><li>Not a cost-effective exercise and largely a waste of time </li></ul>
  22. 22. Those who do – by “rote” <ul><li>These patients test 4 times a day, often obsessively, but do nothing whatsoever about the results. </li></ul><ul><li>They seem to believe that either: </li></ul><ul><ul><ul><li>Testing regularly makes them “good diabetics” </li></ul></ul></ul><ul><ul><ul><li>Regular home glucose monitoring is therapeutic </li></ul></ul></ul>
  23. 24. Those who do with purpose <ul><li>Two groups: </li></ul><ul><li>Fixed dose insulin therapy </li></ul><ul><li>Functional Insulin therapy </li></ul>
  24. 25. Fixed dose insulin therapy <ul><li>May be on twice daily or multiple injection regimen </li></ul><ul><li>Insulin dose is fixed – no attempt to anticipate, no adjustment with meals. </li></ul><ul><li>In these patients “pattern testing” is recommended. </li></ul><ul><li>Test 2-3 times a day at different times. </li></ul><ul><li>Adjust insulin every 2-3 days . </li></ul>
  25. 26. Functional Insulin therapy <ul><li>Carbohydrate-counting </li></ul><ul><li>Regular before meal adjustments </li></ul><ul><li>Corrective doses </li></ul><ul><li>The ideal situation </li></ul><ul><li>Test 4+ times a day meaningfully </li></ul>
  26. 27. Rules of Testing <ul><li>No amount of sophistication is going to allay the fact that all your knowledge is about the past and all your decisions are about the future. </li></ul><ul><li>-Ian E Wilson </li></ul><ul><li>Set Targets: the patient must know what glucose levels are satisfactory, which are too high and which are too low. </li></ul><ul><li>Avoid hypoglycaemia. Lowest level recommended should be ≥4 mmol/l. </li></ul>
  27. 28. Rules of Testing <ul><li>And above all: </li></ul><ul><li>Always ask “why?” </li></ul><ul><ul><ul><li>Why am I too high </li></ul></ul></ul><ul><ul><ul><li>Why am I low? </li></ul></ul></ul><ul><ul><ul><li>Why is my blood glucose normal? </li></ul></ul></ul><ul><li>And learn from past mistakes </li></ul>
  28. 29. Don’t Try to Change History ! <ul><li>Do not adjust insulin retrospectively </li></ul><ul><li>History cannot be changed </li></ul><ul><li>Pre meal / pre-bed results help to indicate adequacy of previous dose </li></ul>
  29. 30. <ul><li>The iniquitous </li></ul><ul><li>The horrible </li></ul><ul><li>The vicious </li></ul><ul><li>The evil </li></ul><ul><li>Sliding Scale </li></ul><ul><li>“ Overcorrecting” almost as bad </li></ul>Above all, avoid
  30. 31. Take a little extra insulin Take less insulin Take a bit more insulin Take even less insulin Take even more insulin Miss insulin Panic! Take really big dose My sugar is “up and down and I just can’t control it” Target range Hypo!
  31. 32. To achieve targets of glycemic control <ul><li>SHGM is an essential tool </li></ul><ul><li>Scientific dose adjustments must be based on valid data </li></ul><ul><li>Therefore need: </li></ul><ul><ul><li>Blood glucose meter </li></ul></ul><ul><ul><li>Well kept diary </li></ul></ul><ul><ul><li>And/or download capability </li></ul></ul><ul><li>SBGM is NOT therapeutic </li></ul><ul><li>ACTION based on results IS </li></ul>

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