Seminar presentation on how to start insulin preparations in type 2 Diabetes mellitus (DM) and discussion of new insulin preparations

1. I N D I V I D U A L I Z E D
A P P R O A C H &
I N S U L I N E
P R E PA R AT I O N S
S TA R T I N G I N S U L I N I N D M I I
D R . TA R I Q E L - M A S H H A R A W I

2. E V E N T U A L LY R E Q U I R E I N S U L I N T H E R A P Y
M O S T PAT I E N T S W I T H T Y P E 2 D I A B E T E S M E L L I T U S

3. D M T Y P E I I A S S O C I AT I O N S :
1 . I N S U L I N R E S I S TA N C E ,
2 . B E TA - C E L L D Y S F U N C T I O N , A N D
3 . D E C R E A S E D I N S U L I N S E C R E T I O N .

4. What measure The efficacy of therapy ?
How Therapy can be individualized?
What is an appropriate target?

5. How Therapy can be individualized?

7. • (AACE) supports a hemoglobin A1c goal of less than
6.5% for otherwise healthy
• (ADA) & European Association for the Study of
Diabetes (EASD) & European Society Of
endocrinology recommends a higher hemoglobin A1c
target of less than 7% for most adults with type 2
diabetes mellitus

8. I N T E N S I V E V S S TA N D A R D G L U C O S E C O N T R O L R E G I M E N S

9. 1 1 , 1 4 0 PAT I E N T S ; AV E R A G E H E M O G L O B I N A 1 C L E V E L S
6 . 5 % V S 7 . 3 %
Action in Diabetes and Vascular Disease
(ADVANCE)

10. 1 0 , 2 5 1 PAT I E N T S ; AV E R A G E H E M O G L O B I N A 1 C L E V E L S
6 . 4 % V S 7 . 5 %
Action to Control Cardiovascular Risk in Diabetes
(ACCORD):

11. 1 , 7 9 1 PAT I E N T S ; AV E R A G E H E M O G L O B I N A 1 C L E V E L S
6 . 9 % V S 8 . 4 % . 8
Veterans Affairs Diabetes Trial (VADT)

12. F E B 2 0 1 6 E U R O P E A N S O C I E T Y O F E N D O C R I N O L O G Y
After adjustment for HbA1c, there was no
difference in mortality between insulin users and
patients that remain on oral glucose lowering
agents. These findings are in accordance with
results from the VADT study.
“Time to insulin initiation and long term effects of initiating insulin in people with type 2 diabetes
mellitus: the Hoorn Diabetes Care System Cohort Study. “

13. 86.5
optional for patients with
- a long life expectancy,
- short duration of diabetes,
- low risk of hypoglycemia,
and
- no significant
cardiovascular disease.
a history of
- severe hypoglycemia,
- limited life expectancy,
- advanced microvascular or
macrovascular complications,
- extensive comorbid conditions,
and
- long-standing diabetes.

14. The AACE and ADA are moving away from one-size-fits-
all and toward
I N D I V I D U A L I Z E D R E C O M M E N D AT I O N S

15. • Step 1: Is Insulin Indicated? / Total requirement?
• Step 2: basal Insulin
• Step 3: basal-bolus regimen
• - Total bolus 50 % : before each meal
• - Total bolus 10% : before main meal
• Step 4: Complex regimen -> Premixed insulins/ pump

16. A B S O L U T E
I N D I C AT I O N S
I N S U L I N
Ketoacidosis or catabolic symptoms,
ketonuria
Newly diagnosed type 2 diabetes with
pronounced hyperglycemia (glucose ≥
300 mg/dL or hemoglobin A1c ≥ 10.0%)
with or without severe symptoms
Uncontrolled type 2 diabetes mellitus
despite using one, two, or more oral
antidiabetic drugs or glucagon-like
peptide 1 (GLP-1) receptor agonists
Gestational diabetes
Preference for insulin.

17. R E L AT I V E
I N D I C AT I O N S
I N S U L I N
Hospitalized for surgery or
acute illnesses
Advanced renal or hepatic
disease
Inability to afford the cost or
tolerate the side effects of oral
antidiabetic drugs and GLP-1
receptor agonists.

22. 108
total daily dose of insulin of
0.1 to 0.2 units/kg
a higher dose of
0.2 to 0.3 units/kg

23. The dose can be titrated once or twice weekly if the
fasting glucose is above the target level
(usually < 130 mg/dL).
If hypoglycemia develops (glucose < 70 mg/dL), the
insulin dose should be reduced by 10% to 20%.

24. • Step 1: Is Insulin Indicated? / Total requirement?
• Step 2: basal Insulin
• Step 3: basal-bolus regimen
• - Total bolus 50 % : before each meal
• - Total bolus 10% : before main meal
• Step 4: Complex regimen -> Premixed insulins/ pump

26. G L A R G I N E A N D D E T E M I R V S N P H
Because glargine and detemir offer better
pharmacokinetic properties, less variability in
response, and less risk of hypoglycemia, they are
preferred over NPH.

28. G L A R G I N E A N D D E T E M I R
“glargine and detemir are similar in efficacy and
safety”

29. G L A R G I N E A N D D E T E M I R
detemir often needs to be injected twice daily, in a
higher dose, and is associated with less weight
gain

31. B
L
S
Hours
Dose
B A S A L I N S U L I N

32. • Step 1: Is Insulin Indicated? / Total requirement?
• Step 2: basal Insulin
• Step 3: basal-bolus regimen
• - Total bolus 50 % : before each meal
• - Total bolus 10% : before main meal
• Step 4: Complex regimen -> Premixed insulins/ pump

33. B
L
S
Hours
Dose
B A S A L I N S U L I N
Post prandial insulin > target

34. B
L
S
Hours
Dose
B A S A L I N S U L I N
Post prandial insulin > target
> 0.5 units/kg

35. B
L
S
Hours
Dose
B A S A L I N S U L I N
HgbA1C > goal ; controlled FBS
HgbA1C > 10

36. B
L
S
Hours
Dose
B A S A L I N S U L I N 50%

37. B
L
S
Hours
Dose
B A S A L I N S U L I N
10%

38. • Step 1: Indicated? / Total requirement?
• Step 2: basal Insulin
• Step 3: basal-bolus regimen
• - Total bolus 50 % : before each meal
• - Total bolus 10% : before main meal
• Step 4: Complex regimen -> Premixed insulins/
pump

39. P R E M I X E D I N S U L I N S
Premixed combinations of long- and short-acting
insulins in ratios of
50% to 50%, 70% to 30%, or 75% to 25%

40. P R E M I X E D I N S U L I N S
considered in patients who cannot adhere to a
complex insulin regimen.

41. – J O H N N Y A P P L E S E E D
basal, premixed, mealtime plus basal, and mealtime).

42. P R E M I X E D I N S U L I N S
basal insulin group: weight gain was less
premixed insulin group : hypoglycemic episodes,
hemoglobin A1c reduction was similar between
the different groups

43. • Step 1: Is Insulin Indicated? / Total requirement?
• Step 2: basal Insulin
• Step 3: basal-bolus regimen
• - Total bolus 50 % : before each meal
• - Total bolus 10% : before main meal
• Step 4: Complex regimen -> Premixed insulins/ pump

45. I N S U L I N P U M P
in terms of glycemic control and hypoglycemia
CSII was similar to multiple daily insulin injections

47. N E W I N S U L I N P R E PA R AT I O N S

49. Technosphere oral-inhaled insulin (Afrezza)
(FDA)-approved in 2014.
absorbed much more rapidly into the circulation
shorter duration of biologic activity

50. I N H A L E D I N S U L I N
efficacy and safety

51. I N H A L E D I N S U L I N
Equivalent to less HbA1c reductions
lower risk of hypoglycemia

52. I N H A L E D I N S U L I N
should not be used by smokers, patients with
chronic lung disease (such as asthma and chronic
obstructive pulmonary disease), and those with
acute episodes of bronchospasm. or at risk for
lung cancer

53. I N H A L E D I N S U L I N
Baseline and follow-up spirometry needs to be
implemented for those using inhaled insulin to
exclude clinically significant changes in forced
expiratory volume in 1 second

54. I N H A L E D I N S U L I N
Baseline and follow-up spirometry needs to be
implemented for those using inhaled insulin to
exclude clinically significant changes in forced
expiratory volume in 1 second

55. I N H A L E D I N S U L I N
Dosing via single-use cartridges of 4-, 8-, or 12-unit
composition

56. – J O H N N Y A P P L E S E E D
“Type a quote here.”

57. C O N C E N T R AT E D I N S U L I N
S E C O N D G E N E R AT I O N I N S U L I N S

58. • insulin glargine U-300 (Toujeo)
• insulin degludec (Tresiba)

60. TA R I Q . M A S H @ G M A I L . C O M

61. D R . TA R I Q E L M A S H H A R A W I
https://www.linkedin.com/in/drtariq
tariq.mash@gmail.com