Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Premix insulin regimens haffizabad 22 02 2012

1,705 views

Published on

basic insulin regimens

Published in: Health & Medicine
  • Be the first to comment

Premix insulin regimens haffizabad 22 02 2012

  1. 1. In the Name of ALLAH, EverBeneficent, Infinitely Merciful
  2. 2. 07/15/12 2
  3. 3. 07/15/12 3
  4. 4. 07/15/12 4
  5. 5. HOW TO DIAGNOSE DIABETES?07/15/12 5
  6. 6. TREATMENT TARGETS07/15/12 6
  7. 7. Efficacy of Monotherapy in Type 2 Diabetes Agent HbA1c reduction Fasting glucose % Reduction (mg/dl) Sulphonylurea 1.5 - 2.0 60 - 80 Metformin 1.5 - 2.0 60 - 80 Pioglitazone 0.6 - 1.9 50 - 80 Alpha Gucosidase 0.5 - 1.0 20 - 30 inhibitor07/15/12 7 Bonnie Kimmel, MD and Silvio E. Inzucchi, MD Clinical Diabetes 23:64-76, 2005
  8. 8. Current FDA Approved Combination Therapy Options in Type 2 Combination Additional Additional Lowering of Lowering of FBG HbA1c (mg/dl) SU + MTF 1.5 – 2.0 60 – 80 SU + TZD 1.0 – 1.5 40 – 60 MTF + TZD 0.6 – 0.8 20 – 40 SU + AGI 1.0 – 1.5 20 – 40 07/15/12 8Bonnie Kimmel, MD and Silvio E. Inzucchi, MD Clinical Diabetes 23:64-76, 2005
  9. 9. Staged DiabetesManagement at IDC * 07/15/12 9Mazze, Strock, Simonson, Kendall, Cuddihy, Bergenstal. SDM Quick Guide 5th Edition, International Diabetes Center, 2009
  10. 10. Stages of Type 2 Diabetes— UKPDS 100 75 β-Cell Function (%) 50 IGT Postprandial Type 2 Type 2 Diabetes 25 Hyperglycemia Diabetes Type 2 Phase III Phase I Diabetes Phase II 0 -12 -10 -6 -2 0 2 6 10 14 Years From Diagnosis07/15/12 H. Diabetes Review. 1999;7:139. Lebovitz 10
  11. 11. 07/15/12 11
  12. 12. 07/15/12 12
  13. 13. The Miracle of Insulin Patient J.L., December 15, 1922 Februray 15, 192307/15/12 13
  14. 14. UKPDS: decreased risk of diabetes-related complications associated with a 1% decrease in A1C Observational analysis from UKPDS study datacorresponding to a 1% decrease in HbA1C Any Percentage decrease in relative risk diabetes- Diabetes- All Peripheral Micro- related related cause Myocardial vascular vascular Cataract endpoint death mortality infarction Stroke disease† disease extraction 12% 14% 14% * 19% 21% 21% ** ** ** ** ** 37% † Lower extremity amputation or fatal peripheral vascular disease 43% *P = 0.035; **P < 0.0001 ** 07/15/12 **Adapted from Stratton IM, et al. UKPDS 35. BMJ 2000; 321:405–412. 14
  15. 15. What are the anabolic effects of Insulin?Stimulates entry of amino acids into cells,enhancing protein synthesisEnhances fat storage (lipogenesis) and preventsmobilization of fat for energy (Lipolysis andKetogenesis)Stimulates entry of glucose into cells for utilization asenergy sourcePromotes storage of glucose as glycogen in muscle andliver cells (glycogenesis) 07/15/12 15
  16. 16. When should Insulin be used in Type 2 diabetes mellitus? “The Magnificent Seven”07/15/12 16
  17. 17. When should Insulin be used in Type 2 diabetes mellitus? 1. Type 2 diabetes not controlled with maximal doses of Oral Hypoglycaemic agents What do you mean by maximal doses of OHAs? Metformin 2500/3000mg a day + Glipizide 20mg/glibenclemide15-20mg/day Gliciazide 320mg/ Glimepride 6-8mg/day + Rosiglitazone 8mg/ Pioglitazone 45mg/day07/15/12 17
  18. 18. When should Insulin be used in Type 2 diabetes mellitus? 2. Type 2 diabetes during periods of physiological stress (surgery, infection) Continue OHAs simultaneously. Stop metformin in case of severe infections or impending reduction in renal perfusion07/15/12 18
  19. 19. 07/15/12 19
  20. 20. 07/15/12 20
  21. 21. 07/15/12 21
  22. 22. When should Insulin be used in Type 2 diabetes mellitus? 3. gestational diabetes Metformin may be continued Discontinue other medications07/15/12 22
  23. 23. 07/15/12 23
  24. 24. Indications of Insulin therapy? 4. Use of parenteral nutrition or high-caloric supplements07/15/12 24
  25. 25. Indications of Insulin therapy?5. Diabetic ketoacidosis (DKA)/Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)07/15/12 25
  26. 26. Indications of Insulin therapy? 6. Progressive complications: proliferative retinopathy/maculopathy, progressive or painful neuropathy For rapid control and tighter adjustment07/15/12 26
  27. 27. Indications of Insulin therapy? 7. Chronic Renal Failure For all above a creatinine of 4.0mg/dl Cutoffs for other OHAs:- Metformin: 1.5mg/dl Glimeperide/Glibenclemide: 2.0mg/dl Glipizide: 2.5mg/dl Pioglitazone/Rosiglitazone: 4.0mg/dl07/15/12 27
  28. 28. Normal Pancreas ‘Bolus’ Insulin (Meal Associated) Insulin Effect Basal Insulin (~0.5-1.0 U/hr) Insulin is released in response to varying blood07/15/12 glucose levels and hypoglycemia does not occur 28
  29. 29. How does one classify the types of insulin?♦ Generally classified according to peak effect and duration of action♦ Rapid acting/lispro /aspart/glulisine♦ Short acting: regular.♦ Intermediate acting: NPH.♦ Long acting(basal) lantus. /levimer.♦ Premixed:(30/70), (50/50), (75/25)07/15/12 29
  30. 30. What are the types of Insulin ?• Short acting : Regular insulin• Intermediate acting NPH insulin• Analogs rapid acting : Lispro, Aspart /glulisine Long acting : Glargine/levimer07/15/12 30
  31. 31. Insulin Time Action Curves Rapid-Acting: Lispro (Humalog®), Aspart (NovoLog®), Glulisine (Apidra®) Relative Insulin Effect Short-Acting: Regular (Humulin® R, Novolin® R) Intermediate: NPH (Humulin® N, Novolin® N) Long-Acting: Glargine (Lantus®) Detemir (Levemir®) 0 2 4 6 8 10 12 14 16 18 20 Time (Hours)Bergenstal, “Effective insulin therapy,” International Textbook of Diabetes Mellitusvol 1. 3rd ed, Chichester NY, John Wiley and Sons, Inc., 2004:995-1015. 07/15/12 31
  32. 32. What are the types of insulin regimens?• Premixed regimen• Split mix regimen• Basal bolus regime (multidose)• Bedtime dosing alone (NPH/Lente/Glargine)• Infusion07/15/12 32
  33. 33. Premixed insulin AVAILABLE PREPRATIONS • Premixed(30/70): Regular: 30 % NPH : 70% • Premixed (50/50): lispro 50% NPL 50% • Premixed Analogs Biphasic insulin aspart (30/70) 30% : Aspart 70% : protaminated aspart07/15/12 33
  34. 34. 07/15/12 34
  35. 35. 07/15/12 35
  36. 36. 07/15/12 36
  37. 37. Basic Insulin Regimen: Split-Mixed Regimen or Premix Endogenous insulin Regular NPH B L D HS B07/15/12 37
  38. 38. Basic Insulin Regimen: Split-Mixed Regimen or Premix • Does not Endogenous insulin mimic normal Regular physiology NPH Hyperglycemia • Requires meal consistency • Snacking may result in weight gain • Hypo- and B L D HS B hyperglycemi07/15/12 a 38
  39. 39. Insulin Therapy Regimens ♦Usual starting dose: 0.5-1.0 unit/kg/day07/15/12 39
  40. 40. Premixed insulin • Dose adjustment: • The fasting sugar depends on the night dose of insulin • The post breakfast sugar depends on the morning dose of insulin • Rough calculation increase the insulin by one unit to reduce the sugars by 25mg/dl07/15/12 40
  41. 41. Self Monitoring is crucial Glucometers At least 6-8 times a week ideally07/15/12 41
  42. 42. Premixed insulin Advantages • more accurate dosing • lesser injections • Pen devices administer premixed forms Disadvantages • Fine tuning may not be possible • Strict meal pattern • Nocturnal hypoglycemia • May need “diet changes for insulin” rather than “insulin changes for diet”07/15/12 42
  43. 43. Starting insulin in type 2 diabetes - patient on full dose OHA • Continue the OHA • Start on insulin (approx 0.2-0.4 U/kg/day,morning 2/3, evening 1/3) • Reassess control with SMBG & titrate dosage07/15/12 43
  44. 44. TIMING OF INJECTION• 70/30 30 MINUTES BEFORE BREAKFAST AND SUPPER• NOVO MIX 70/30• HUMALOG MIX 25/75 5—15 MINUTES• BEFORE BREAKFAST AND SUPPER07/15/12 44
  45. 45. ADVANTAGES• SIMPLE AND EASY TO USE ;draw A SINGLE DOSE OF A COMBINATION OF INSULIN IN ONE SYRINGE• MINIMUM INSULIN DOSING THAT PROVIDES 24-HOUR INSULIN COVERAGE• HUMALOG MIX 75/25 INSULIN OR NOVO MIX 70/30 INSULIN CAN BE TAKEN 5-15 MINUTES BEFORE A MEAL07/15/12 45
  46. 46. DISADVANTAGES• 70/30 INSULIN ;SHOULD WAIT 30 MINUTES AFTER INSULIN INJECTION BEFORE EATING THE MEAL• FIXED RATIO OF INTERMEDIATE AND SHORT OR RAPID ACTING INSULIN MAY NOT CONTROL BLOOD GLUCOSE LEVELS• CAN NOT ADJUST INTERMEDIATE- ACTING INSULIN COMPONENT WITHOUT ADJUSTING THE SHORT OR RAPID ACTING INSULIN COMPONENT07/15/12 46
  47. 47. DISADVANTAGES• CAN NOT ADJUST REGULAR INSULIN,INSULINASPART, OR INSULIN LISPRO FOR VARIATION IN FOOD INTAKE, BLOOD GLUCOSE LEVELS OR EXERCISE• MUST TAKE INSULIN AND EAT MEALS ABOUT THE SAME TIME EVERY DAY MUST EAT ACONSISTANT AMOUNT OF CARBOHYDRATES AT EACH MEAL FROM DAY TO DAY• LEAST FLEXABLE OF ALL REGIMENS07/15/12 47
  48. 48. INDICATIONS• PATIENTS WITH LIMITED CAPABILITIES• PATIENTS WHO ARE UNWILLING TO INTENSIFY REGIMEN• INITIAL REGIMEN AFTER DIAGNOSES TO LEARN AND ADAPT TO INJECTIONS• TYPE 2 DIABETES07/15/12 48
  49. 49. 07/15/12 49
  50. 50. STARTING DOSE• 2/3 TOTAL DAILY DOSE BEFORE BREAKFAST ,1/3 TOTAL DAILY DOSE BEFORE SUPPER• 0.5—1.0 U/KG/DAY07/15/12 50
  51. 51. Pre-mix (70/30)• Gaps in insulin coverage• Poor long-term control• Failure to match endogenous secretion pattern• Dawn phenomenon• Increased glycaemia07/15/12 51
  52. 52. Can Oral hypoglycaemic agentsbe continued at the same time with insulin? • Metformin Best continued if renal function is normal. May reduce insulin requirements by 15-30%. • Adjunctive weight reducing effect • Thiazolidinediones • May be continued with insulin. • Can reduce insulin requirements from 15-60% • Major issue of weight gain, accentuated by insulin: 7.5%. 15%>5kg.07/15/12 52
  53. 53. Can Oral hypoglycaemic agentsbe continued at the same time with insulin? • Sulphonylureas • Glimeperide: doses of 2-4mg a day have a peripheral GLUT-4 activity reducing insulin requirement by 10-20%. • Glipizide and Glibenclemide can reduce insulin requirements by 5-15%. • Unpredictable- recommended previously in those with high C-peptide levels07/15/12 53
  54. 54. Summarizing……..Insulin administration is suitably as premixed fashion formost type 2 diabetes. Split-mix may be required in asubset.The neccessity of self blood glucose monitoring as aaccessory is emphasized. 07/15/12 54
  55. 55. Aggressively Titrated Premix 70/30+Met+Pio Met+PioBaseline A1C 8.1±1.0 7.9±0.9EOS A1C 6.5±1.0 7.8±1.2Percentage of Patients WithA1C (EOS)<7.0% 76.3 24.1≤6.5 59.1 11.5≤6.0 33.3 2.3≤5.5 14.0 0FPG (mg/dl) 130±50 162±41 07/15/12 55 Raskin et al. Insulin 2007;2 (suppl A):S11
  56. 56. Comparison of Common Insulin Regimens*Variable Glargine* NPH1 Premix2,3 Detemir4Efficacy Insulin WorksHypoglycemia† 1.0 1.4X 2.5-5.0X 1.0Insulin Dose 1.0 1.0 1.5-2.0X 1.6-2.1XWeight Gain 1.0 1.0 1.5X 0.7-1.0X* Normalized to glargine; sponsored comparator trials† Confirmed hypoglycemia1 Riddle MC et al. Diabetes Care 2003;26:3080-30862 Janka HU et al. Diabetes Care 2005;28:254-259 07/15/123 Raskin P et al. Diabetes Care 2005;28:260-265 564 Rosenstock J et al. ADA 2006; Abstract 555-P
  57. 57. Sunday, July 15, 2012 57
  58. 58. 07/15/12 58
  59. 59. 07/15/12 DR MAXUD DIABETOLOGIST 59
  60. 60. 07/15/12 60
  61. 61. 07/15/12 61

×