# Presentation: 092673

## Slide 1

## Overview

**Reasons clinicians are reluctant to start insulin therapy**
**Reasons patients are reluctant to start insulin therapy**
**Types of insulin therapies**
**Types of insulin delivery methods **
**Initiating insulin therapy in patients**
**Strategies for patient self-monitoring**

## Case 1

**56-year-old man with continued poor glucose control. Reports for follow up.**
**PMH includes COPD, DJD & type 2 diabetes**
**Allergy: none**

## Case 1

**Medications**
**Glyburide 10 mg twice daily**
**Metformin 1 g twice daily**
**Rosiglitazone 8 mg daily**
**Aspirin 325 mg daily**
**Acetaminophen 500 mg 4 times daily as needed**
**Albuterol inhaler as needed**

## Case 1

**HbA1c- 8.9% **
**(6 mo ago- 9.0%; 1 year ago – 8.8%)**
**Creatinine 1.1mg/dl**
**AST - 55 IU/L;  ALT - 60 IU/L**
**Weight - 220 pounds, Height - 5’10”, BMI-31.5**
**Adherent to meds both by history & med records**

## Case 2

**81-year-old man presents to urgent care. He has had no medical care in 4 years. **
**Worsening fatigue, blurred vision & newly burning with urination.**
**Allergy: penicillin**
**Drinks 12 beers/day. ****Smokes 1 ppd for 47 years.**

## Case 2

**Weight - 172 pounds, Height - 5’11”, BMI - 24.0**
**Labs: HbA1c 13.2%**
**Urine protein – 2+**
**AST - 72 IU/L;  ALT - 58 IU/L**

## Target HbA1c Level

| Major Comorbidity    or 
Life Expectancy | Microvascular 
Complications
Absent/mild | Microvascular 
Complications
Moderate | Microvascular 
Complications
Advanced |
| --- | --- | --- | --- |
| Absent
 > 15 years |  < 7% | < 8% | < 9% |
| Present
5-15 years | < 8% | < 8% | < 9% |
| Marked
< 5 years  | < 9% | < 9% | < 9% |

**Target HbA1c Level**

## Target HbA1c Level

| Major Comorbidity    or 
Life Expectancy | Microvascular 
Complications
Absent/mild | Microvascular 
Complications
Moderate | Microvascular 
Complications
Advanced |
| --- | --- | --- | --- |
| Absent
 > 15 years |  < 7% | < 8% | < 9% |
| Present
5-15 years | < 8% | < 8% | < 9% |
| Marked
< 5 years  | < 9% | < 9% | < 9% |

**Target HbA1c Level**

## Target HbA1c Level

| Major Comorbidity    or 
Life Expectancy | Microvascular 
Complications
Absent/mild | Microvascular 
Complications
Moderate | Microvascular 
Complications
Advanced |
| --- | --- | --- | --- |
| Absent
 > 15 years |  < 7% | < 8% | < 9% |
| Present
5-15 years | < 8% | < 8% | < 9% |
| Marked
< 5 years  | < 9% | < 9% | < 9% |

**Target HbA1c Level**

## Clinical inertia
Clinic time constraints/                        lack of resources
Fear of hypoglycemia
Weight gain
Patient reluctance

**Clinic time constraints/                        lack of resources**
**Fear of hypoglycemia**
**Weight gain**
**Patient reluctance**

**Barriers to Starting Insulin –**
***Clinician***

## Inconvenience
Pain
False perceptions
Fear of needles
Fear of hypoglycemia

**Pain**
**False perceptions**
**Fear of needles**
**Fear of hypoglycemia**

**Barriers to Starting Insulin –**
***Patient***

## HbA1c Reduction with Treatment

| Therapy | Medication | Reduction in HbA1c |
| --- | --- | --- |
| Lifestyle changes, diet & exercise | None | 0.5 – 2.0% |
| Single oral agent | Sulfonylurea or Metformin | 1.0 – 2.0% |
| Combinations with oral agents | Sulfonylurea, Metformin
Alpha-glucosidase inhibitor
Thiazolidinedione
Exenatide | 0.5 – 2.0% |
| Insulin with other agent | Sulfonylurea, Metformin Thiazolidinedione
Pramlintide | 0.2 – 2.6% |
| Insulin | Insulin alone | >2% |

## Formulary Insulins

|  | Cost/vial |
| --- | --- |
| NPH | $ |
| Regular | $ |
| 50/50 (NPH/REG) | $ |
| 70/30 (NPH/REG) | $ |
| Insulin aspart | $$ |

## Non-formulary Insulins

|  | Cost/vial |
| --- | --- |
| Long Acting                                                                                                         |  |
| Insulin glargine | $$ |
| Insulin detemir | $$ |
| Rapid Acting |  |
| Insulin lispro | $$$ |
| Insulin glulisine | $$$ |
| Inhaled Insulin | $$$$ |

## Non-formulary Insulins

|  | Cost/vial |
| --- | --- |
| Concentrated Form |  |
| U-500 insulin | $$$$ |

## Insulin Response in Non-Diabetics

**B**

**S**

**L**

**HS**

**Insulin Effect**

**B**

**Notes:**
Slide 6-23
INSULIN TACTICS
Twice-daily Split-mixed Regimens
Twice-daily mixtures of NPH and regular insulins have been widely used for type 2 diabetes for many years. In some cases, premixed 70/30 insulin is used for this purpose. Patient profiles of insulin levels resulting from this method, as shown in this figure, do not come close to matching the normal endogenous secretory pattern, shown in the shaded background. Patients with type 1 diabetes using this “split-mixed” regimen rarely achieve reasonably good glycemic control by present standards, since they lack endogenous insulin to supplement the partially adequate profile of injected insulin. Type 2 diabetes patients who have substantial endogenous insulin may fare much better with this regimen, but may experience late morning or nocturnal hypoglycemia because of excessive levels of insulin at these times.
Berger M, Jorgens V, Mühlhauser I. Rationale for the use of insulin therapy alone as the pharmacological treatment of type 2 diabetes. Diabetes Care. 1999;22(suppl 3):C71-C75; Edelman SV, Henry RR. Insulin therapy for normalizing glycosylated hemoglobin in type II diabetes: applications, benefits, and risks. Diabetes Reviews. 1995;3:308-334.

## The Basal-Bolus Concept

**B**

**S**

**L**

**HS**

**Insulin Effect**

**B**

**Notes:**
Slide 6-23
INSULIN TACTICS
Twice-daily Split-mixed Regimens
Twice-daily mixtures of NPH and regular insulins have been widely used for type 2 diabetes for many years. In some cases, premixed 70/30 insulin is used for this purpose. Patient profiles of insulin levels resulting from this method, as shown in this figure, do not come close to matching the normal endogenous secretory pattern, shown in the shaded background. Patients with type 1 diabetes using this “split-mixed” regimen rarely achieve reasonably good glycemic control by present standards, since they lack endogenous insulin to supplement the partially adequate profile of injected insulin. Type 2 diabetes patients who have substantial endogenous insulin may fare much better with this regimen, but may experience late morning or nocturnal hypoglycemia because of excessive levels of insulin at these times.
Berger M, Jorgens V, Mühlhauser I. Rationale for the use of insulin therapy alone as the pharmacological treatment of type 2 diabetes. Diabetes Care. 1999;22(suppl 3):C71-C75; Edelman SV, Henry RR. Insulin therapy for normalizing glycosylated hemoglobin in type II diabetes: applications, benefits, and risks. Diabetes Reviews. 1995;3:308-334.

## Options for Basal Insulin

**NPH**

**B**

**S**

**L**

**HS**

**B**

**Insulin Glargine/Detemir**

**Insulin Effect**

**S**

**L**

**Notes:**
Slide 6-23
INSULIN TACTICS
Twice-daily Split-mixed Regimens
Twice-daily mixtures of NPH and regular insulins have been widely used for type 2 diabetes for many years. In some cases, premixed 70/30 insulin is used for this purpose. Patient profiles of insulin levels resulting from this method, as shown in this figure, do not come close to matching the normal endogenous secretory pattern, shown in the shaded background. Patients with type 1 diabetes using this “split-mixed” regimen rarely achieve reasonably good glycemic control by present standards, since they lack endogenous insulin to supplement the partially adequate profile of injected insulin. Type 2 diabetes patients who have substantial endogenous insulin may fare much better with this regimen, but may experience late morning or nocturnal hypoglycemia because of excessive levels of insulin at these times.
Berger M, Jorgens V, Mühlhauser I. Rationale for the use of insulin therapy alone as the pharmacological treatment of type 2 diabetes. Diabetes Care. 1999;22(suppl 3):C71-C75; Edelman SV, Henry RR. Insulin therapy for normalizing glycosylated hemoglobin in type II diabetes: applications, benefits, and risks. Diabetes Reviews. 1995;3:308-334.

## Options for Pre-meal Insulin

**Regular**

**Insulin aspart**

**B**

**S**

**L**

**HS**

**B**

**Insulin Effect**

**Notes:**
Slide 6-23
INSULIN TACTICS
Twice-daily Split-mixed Regimens
Twice-daily mixtures of NPH and regular insulins have been widely used for type 2 diabetes for many years. In some cases, premixed 70/30 insulin is used for this purpose. Patient profiles of insulin levels resulting from this method, as shown in this figure, do not come close to matching the normal endogenous secretory pattern, shown in the shaded background. Patients with type 1 diabetes using this “split-mixed” regimen rarely achieve reasonably good glycemic control by present standards, since they lack endogenous insulin to supplement the partially adequate profile of injected insulin. Type 2 diabetes patients who have substantial endogenous insulin may fare much better with this regimen, but may experience late morning or nocturnal hypoglycemia because of excessive levels of insulin at these times.
Berger M, Jorgens V, Mühlhauser I. Rationale for the use of insulin therapy alone as the pharmacological treatment of type 2 diabetes. Diabetes Care. 1999;22(suppl 3):C71-C75; Edelman SV, Henry RR. Insulin therapy for normalizing glycosylated hemoglobin in type II diabetes: applications, benefits, and risks. Diabetes Reviews. 1995;3:308-334.

## Mixtures of Pre-meal Insulins

**Mixtures of Pre-meal Insulins**

**Regular/NPH**

**Combined effect**

**B**

**S**

**L**

**HS**

**B**

**Insulin Effect**

**Notes:**
Slide 6-23
INSULIN TACTICS
Twice-daily Split-mixed Regimens
Twice-daily mixtures of NPH and regular insulins have been widely used for type 2 diabetes for many years. In some cases, premixed 70/30 insulin is used for this purpose. Patient profiles of insulin levels resulting from this method, as shown in this figure, do not come close to matching the normal endogenous secretory pattern, shown in the shaded background. Patients with type 1 diabetes using this “split-mixed” regimen rarely achieve reasonably good glycemic control by present standards, since they lack endogenous insulin to supplement the partially adequate profile of injected insulin. Type 2 diabetes patients who have substantial endogenous insulin may fare much better with this regimen, but may experience late morning or nocturnal hypoglycemia because of excessive levels of insulin at these times.
Berger M, Jorgens V, Mühlhauser I. Rationale for the use of insulin therapy alone as the pharmacological treatment of type 2 diabetes. Diabetes Care. 1999;22(suppl 3):C71-C75; Edelman SV, Henry RR. Insulin therapy for normalizing glycosylated hemoglobin in type II diabetes: applications, benefits, and risks. Diabetes Reviews. 1995;3:308-334.

## Starting Insulin

**NPH at bedtime **
**10 – 20 Units**
**Glucose testing**
**Adjust dose based on feedback**
**Maintain contact**

## Options for Insulin Adjustment

| Glucose level off-target | Change in treatment |
| --- | --- |
| Fasting glucose | Evening NPH insulin |
| Pre-supper glucose | Morning NPH insulin
Check glucose pre-lunch |
| Pre-lunch | Morning regular insulin |
| Bedtime glucose | Evening regular insulin |

## Injection Aids

**Insulin pens**
**Insertion aids (Autoject, Inject-Ease, NeedleAid)**
**Dosing devices (InnoLet)**
**Needle guides & stabilizers (Holdease, Inject Assist, Vial Syringe Guide)**
**Insulin pumps**

## Self Monitoring: Case 1

**66-year-old man with stable doses of diabetes medications x 6 months**
**HbA1c – 6.2%**
**Fasting glucose levels: 100-150 mg/dl**
**What if starts taking prednisone?**
**What if all glucose readings                 are normal, but he wants                “peace of mind?”**

## Self Monitoring: Case 2

**72-year-old man recently started on bedtime NPH insulin for fasting hyperglycemia**
**HbA1c – 7.6%**
**When should he test:**
**If fasting sugars controlled?**
**If starting exercise regimen?**

## VANTS Call

**November 2, 2006**
**2:00 pm Eastern**
**1-800-767-1750**
**Access code: 59781#**