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NHS T1DM Slide Deck - Part One Clean.pptx
- 1. Type 1 Diabetes Mellitusand Insulin Clinical Virtual Session 5 Midlands Foundation Pharmacy Training Programme 2024/2025
- 2. 2 Time Item 13:00-14:00 ProtectedLearning Time 14:00-14:30 Welcome & Introduction to T1DM, treatment regimens & insulin dose calculations Hazel Forde, Specialist Pharmacist Diabetes & Endocrinology, Cambridge University Hospitals Trust. The expert speaker will introduce the topic and guide you through calculating doses of insulin, insulin regimens and how pharmacokinetics influences choice of insulin. There will be interactive polls for trainee participation. 14:30-15:15 Large Group Based Learning : Case Studies Hazel Forde, Specialist Pharmacist Diabetes & Endocrinology, Cambridge University Hospitals Trust. 15:15-15:30 Break 15:30-15:45 Technology Changes in Diabetes Hazel Forde, Specialist Pharmacist Diabetes & Endocrinology, Cambridge University Hospitals Trust. The expert speaker will facilitate discussion using interactive polls. 15:45-16:45 Large Group Based Learning: Case Studies Hazel Forde, Specialist Pharmacist Diabetes & Endocrinology, Cambridge University Hospitals Trust. 16:45-17:00 Registration, Evaluation and Close Agenda •During the session we will be discussing the case studies that you were provided with as pre-work. •The expert speaker will ask for contributions from each ICS to provide answers for each of the questions. •Some contribution is expected from all members of the ICS across the session. •When you are speaking, please switch your camera on and unmute your mic. •Begin by introducing yourself and stating which trust you work at. •Please keep your mic muted when you have finished speaking.
- 3. 3 Learning Outcomes Evaluatethe differences between Type 1 and Type 2 DM Explore the symptoms of diabetic emergencies Evaluate the pharmacological measures that can be employed with consideration of evidence base for the management of diabetic emergencies including Diabetic Ketoacidosis (DKA) and Hyperosmolar hyperglycaemic state (HHS) Evaluate glucose monitoring for patients and trends to adjust insulin doses and understand how the pharmacokinetic profile influences choice of insulin Explore the use of insulin biosimilars and medication safety in reducing insulin errors After the clinical session, you should be able to:
- 4. 4 Introduction to Type 1Diabetes Mellitus
- 5. 5 Type 1 Type2 • Autoimmune disease • Immune system destroys the insulin-producing beta cells in the pancreas over several months • Symptoms appear quickly • By the time the symptoms of diabetes present, there are no functioning beta cells left and no insulin is being produced • Can occur at any age (but symptoms often first show in childhood) • A mixture of insufficient insulin production and insulin resistance • No single cause, but there are many risk factors (e.g. obesity, smoking, genetics, physical inactivity) • Symptoms develop slowly (may or may not show symptoms) • Generally seen in older patients or those with multiple co-morbidities Type 1 vs Type 2 Diabetes Mellitus
- 6. 6 Type 1 DiabetesMellitus • ~ 8 % of people with diabetes have Type 1 Diabetes Mellitus (T1DM) • Cause still not fully understood, but autoimmune destruction of beta cells • Complex mix of genetic and environmental factors • 1 in 20 chance of developing T1DM if close family member with T1DM (1 in 300 chance in general population) • Can occur at any age • Roughly ¼ diagnosed as adults • Babies cannot have type 1 diabetes – diagnosis of diabetes in < 6 months is neonatal diabetes (not an autoimmune condition, but instead caused by a change in a gene which affects insulin production) • Majority diagnosed aged 10-14 years
- 7. 7 Symptoms Polyuria Polydipsia Weight loss Blurredeyesight Genital itching and thrush Tiredness Wounds slow to heal Increased hunger
- 8. 8 Other autoimmune conditions Addison’s disease Coeliac disease Autoimmune thyroid disease Vitiligo Well established linkbetween T1DM and other autoimmune conditions
- 9. 9 Side note –LADA/type 1.5 diabetes • LADA = Latent Autoimmune Diabetes in Adults • Also known as type 1.5 diabetes due to having characteristics of both T1DM and T2DM • Usually diagnosed in people aged 30-50 years • Symptoms: polyuria, polydipsia, tiredness, weight loss • Symptoms tend to appear more slowly than T1DM but more obvious and more quickly compared to T2DM • People with LADA tend to have a healthy weight • 4–12% of people who initially receive a T2DM diagnosis actually have LADA • Diagnosis: test for autoantibodies that are usually found in patients with T1DM (autoimmune response) • Treated initially with metformin, and then insulin added. Research is ongoing about how best to classify and manage LADA
- 10. 10 Monitoring NICE NG17 • Supportadults with type 1 diabetes to aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower to minimise the risk of long-term microvascular complications. HbA1c measured every 3-6 months • Advise adults with type 1 diabetes to aim for: • a fasting plasma glucose level of 5–7 mmol/litre on waking and • a plasma glucose level of 4–7 mmol/litre before meals at other times of the day • a plasma glucose level of >8 mmol/litre before bedtime • Advise adults with type 1 diabetes who choose to test after meals to aim for a plasma glucose level of 5–9 mmol/litre at least 90 minutes after eating • Blood glucose measured minimum QDS for patients using insulin
- 11. 11 Monitoring NICE NG17 • Supportadults with type 1 diabetes to aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower to minimise the risk of long-term microvascular complications. HbA1c measured every 3-6 months • Advise adults with type 1 diabetes to aim for: • a fasting plasma glucose level of 5–7 mmol/litre on waking and • a plasma glucose level of 4–7 mmol/litre before meals at other times of the day • a plasma glucose level of >8 mmol/litre before bedtime • Advise adults with type 1 diabetes who choose to test after meals to aim for a plasma glucose level of 5–9 mmol/litre at least 90 minutes after eating • Blood glucose measured minimum QDS for patients using insulin
- 12. 12 Treatment Lifelong treatment withinsulin Aim to maintain blood glucose as tightly within range as possible Currently no cure (although some patients may be eligible for a pancreas transplant)
- 13. 13 Epidemiological extrapolation showingthe benefit of a 1% reduction in mean HbA1c UKPDS: Tight Glycaemia Control Reduces Complications HbA1c 1% * p<0.0001 ** p=0.035 37% Deaths related to diabetes * Microvascular complications e.g., kidney disease and blindness * Heart attack * Amputation or fatal peripheral blood vessel disease * Stroke ** 12% 21% 14% 43% Stratton IM et al. UKPDS 35. BMJ 2000; 321: 405–412
- 14. Large amounts of insulin released in responseto food. Steady trickle throughout the day. How is insulin released by a healthy pancreas? The healthy pancreas releases insulin in a glucose-dependent manner = • The higher the blood glucose, the more insulin is released from the pancreas • Very low blood glucose = insulin release stops Aim is to mimic normal insulin production i.e. background insulin at all times with an increase in insulin secretion at times of eating
- 15. 15 Insulin safety Most typesof insulin are available in a range of devices • Pre-filled pens • Cartridges which must be inserted into a compatible reusable pen device • Multi-dose vials (e.g. to fill an insulin pump) which must be accessed with a needle and calibrated insulin syringe
- 16. 16 Insulin safety Insulin cartridgesand pre-filled pens must NEVER be accessed with a needle and syringe as this can lead to significantly inaccurate dosing and potentially fatal overdose
- 17. • Basal-bolus regimen:once or twice daily basal (background) insulin with bolus (mealtime) insulin. • Pre-mixed regimen: twice daily pre-mixed biphasic insulin. • DAFNE (Dose Adjustment For Normal Eating): a flexible basal-bolus regimen, in which mealtime doses are calculated by the patient. • Pump: a continuous subcutaneous infusion of rapid acting insulin delivered by programmable pump. Insulin as a medicine – insulin regimens
- 18. Insulin pharmacokinetics Type ofinsulin Time to onset Time to peak Duration of action Ultra rapid acting <5 minutes 45 mins – 2.5 hours 4 hours Rapid acting 15 minutes 1-3 hours 3-5 hours Short acting 30-60 minutes 2-4 hours 6-8 hours Intermediate acting 1-2 hours 4-12 hours 16-20 hours Long acting 1-3 hours No peak 20+ hours (Tresiba 48hrs) Pre-mixed biphasic 15 minutes 1-4 hours 12-16 hours
- 19. 19 Fiasp ® Lyumjev® Novorapid ® Trurapi ® Humalog ® Admelog ® Actrapid ® Humulin S ® Humulin I ® Insulatard ® Levemir ® Lantus ® Abasaglar ® Semglee ® Toujeo ® Tresiba ® Humulin M3 ® Novomix 30 ® Humalog Mix25 ® Humalog Mix50 ®
- 20. 20 Insulin Quick Reference& Golden Rules Chart - 2023 Version 5 Developed by NUH Diabetes Team (Review June 2026) Insulin Name Schedule of administration Usual Regimen Duration of Action Available forms Picture of Prefilled pen Key: V = Vial, C = Cartridge, P = Prefilled pen, I = Innolet # Never omit insulin in Type 1 diabetics Rapid Acting Apidra® (glulisine) With/up to 15 mins after meal Given at meal times. Patient will usually also be on once or twice daily longer acting insulin 1.5 - 4 hours V, C, P FiAsp® (faster acting aspart) 3 - 5 hours V, C, P NovoRapid® (aspart) 3 - 5 hours V, C, P Trurapi (aspart) 3 -5 hours V, C, P Humalog® (lispro) 2 - 5 hours V, C, P Admelog (lispro) 2 -5 hours V, C, P Short Acting ActRapid® 15 - 20 mins before meal 7 - 8 hours V N/A Humulin® S 6 - 12 hours V, C N/A Medium Acting Insulatard® (Human Insulin - Isophane (NPH)) Not directly related to meal times Once or Twice daily. Usually at bedtime &/or breakfast. Usually used in combination with quick acting insulin pre-meals 24 hours V, C, I Humulin® I 22 hours V, C, P Long Acting (basal) Abasaglar® (glargine*) 24 hours C, P Lantus® (glargine*) 24 hours V, C, P Levemir® (detemir) 24 hours C, P , I # Never abbreviate units Semglee® (glargine*) 24 hours p Full guidelines available on the intranet & app Toujeo® (300unit/ml glargine*) 30 hours p Tresiba® (degludec) 42 hours C (100unit/ml only), P Mixed/Biphasic Humalog® Mix 25 With/up to 15 mins after meal Twice daily, usually pre-breakfast and evening meal. Rarely once a day. NEVER at bedtime. Humalog Mix 50 may be three times a day with meals. 11 - 20 hours V, C, P Humalog® Mix 50 12 -19 hours C, P NovoMix® 30 24 hours C, P Humulin® M3 15 - 20 mins before meal 22 hours V, C, P Hypurin® Porcine 30/70 24 hours V, C N/A * Glargine is available as four brands, Lantus, Abasaglar, Semglee and Toujeo. They are not interchangable - PRESCRIBE BY BRAND # Take care with similar sounding names #Always administer using an insulin syringe or pen device #Use 25/50 Rule where possible
- 21. 21 Adapted from theJBDS DKA Guideline Dose Calculation Method A – Calculate Total Daily Dose using patient weight • The average person requires 0.5 to 0.75 units/kg/day. • Use 0.75 units/kg/day for those thought to be more insulin resistant i.e. teens, obese. • In frail older individuals, CKD 4 or 5, severe hepatic failure or new diagnosis type 1 use 0.3 units/kg/day. Method B – Calculate Total Daily Dose using VRIII Add up the amount of insulin given over the past 6 hours, then divide by 6 to give hourly requirement, then X 20 (not 24 to reduce the risk of hypoglycaemia). e.g. Patient had 12 units over the past 6 hours. 12 ÷ 6 = 2 units/hour 2 x 20 = 40 units/day For both methods For Basal-Bolus regimen: Give 50% of the dose as the basal and divide the other 50% across the three meals e.g. 72kg person requiring 36 units = basal insulin 18 units, bolus insulin 6 units with meals For Twice Daily Mixed Insulin: JBDS advise starting with two thirds of total daily requirements in the morning and one third in the evening. Some patients may need a different split (consider eating patterns etc.) Important factors to note: This is a rough estimate and there are a number of factors which can affect insulin sensitivity (weight, age, activity levels etc.) People with insulin resistance can require much higher doses. People can have higher insulin requirements in acute illness (e.g. sepsis). IT IS SAFER TO START WITH A LOWER DOSE AND TITRATE UP There are 2 main methods for calculating insulin doses in patients (method A is preferred)
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- 23. 23 Case Study One Samis a first year history student at University. He went to his GP after a 5-day history of tiredness, thirst and frequent urination. When tested his BG was 18 mmol/L Additional information: Weight: 74kg Age: 18 years Living in catered accommodation and he plays football once a week 1. What is the likely diagnosis? 2. What additional tests would you want to complete? 3. Sam should start on insulin. What would you consider when choosing a regimen/insulin? 4. Prescribe an insulin regimen for Sam 5. How would you advise Sam to inject his insulin? 6. What blood glucose range should Sam aim for? 7. Counsel Sam on hypoglycaemia and its management?
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- 25. 25 A few dayslater Sam returns to the clinic for follow-up. He has been injecting his insulin without problem and is getting used to testing. The purpose of today’s clinic is to give him more information about his diabetes. 1.Counsel Sam on the “Sick Day Rules” 2.Can Sam continue to drive? Sam hasn’t been to his usual football game this week as he wasn’t sure of the rules around exercise and diabetes. 3. Should people with type 1 diabetes exercise? 4. What effect can exercise have on blood glucose levels? 5. Do people with type 1 diabetes need a special diet? 6. Can people with type 1 diabetes drink alcohol? Case Study Two A few days later Sam returns to the clinic for follow-up. He has been injecting his insulin without problem and is getting used to blood glucose testing. Sam hasn’t been to his usual football game this week as he wasn’t sure of the rules around exercise and diabetes. The purpose of today’s clinic is to give him more information about his diabetes. 1. Counsel Sam on the “Sick Day Rules” 2. Can Sam continue to drive? 3. Should people with type 1 diabetes exercise? 4. What effect can exercise have on blood glucose levels? 5. Do people with type 1 diabetes need a special diet? 6. Can people with type 1 diabetes drink alcohol?
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