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Insulin initiation intensification inoutpatient
Ketut SuastikaUniversitas Udayana Den
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OutlinesPresentation structure
Diabetes is a progressive disease and is increasing
in prevalence
The mapping of insulin treatment based recent guidelines
Insulin Initiaton and Intensification from latest update study (A1
Conclusion
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212000171 million1
2030
552 millio
2011
366 million2
Diabetes is a global diseaseEstimated global prevalence of diabetes
1! "ild! Diabetes Care. 2#! 2$%1#$&1'!2! International Diabetes ederation!IDF Diabetes Atlas! ifth *dition! 211
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1! Adapted from% +amlo&,alsted -A. *delman /0! Clincial Diabetes 20001(2)% http%334ournal!diabetes!org3clinicaldiabetes3v1n2
2D!" Progressive loss of insulinsecretion #it$ increasing insulin resistance1
Impaired
glucose tolerance
%ndiagnosed
diabetes
Insulin
&no#n
diabetes
Insulin Postpra
'asting
!icrovascular complications
!acrovascular complications
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Diabetes is a progressive disease
Type 2 diabetes (T2D5) progression is characterised by decline in beta&c
and 6orsening insulin resistance1
7etting to. or maintaining. target ,bA1clevels in T2D5 re8uires intensifie
over time2
1! onseca 0A! Br J Diab Vasc Dis2%/2! 9athan D5. et al! Diabetes Care2:2%1:&2
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Diabetes being a progressive disease t$at is incin prevalence
T2D5 results in a progressive loss of insulin secretion 6ith incre
resistance1
-y 2. ID predicts ''2 million people 6orld6ide 6ill have dia
Diabetes is the fourth most common diagnosed chronic condition
5any people 6ith diabetes do not have good glycaemic control(
1! +amlo&,alsted -A. *delman /0! Clincial Diabetes 20001(2)% http%334ournal!diabetes!org3clinicaldiabetes3v1n223pg!htm
2! International Diabetes ederation!IDF Diabetes Atlas! ifth *dition! 211! -runton! Curr Med Res Opin2112$;'&$2
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OutlinesPresentation structure
Diabetes is a progressive disease and is increasing
in prevalence
The mapping of insulin treatment based recent guidelines
Insulin Initiaton and Intensification from latest update study (A1
Conclusion
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(e# position statement of t$e )D) and E)*D onmanagement of $+pergl+cemia in t+pe 2 diabete
Inzucci SE, et al. Diabetologia. 2012
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(e# )D),E)*D Position on *e-uential Insulin*trateg+ in +pe 2 Diabetes
(on.Insulin/egimes
asal Insulin Onl+ess 'leible!ore 'leible
Conv!ore 8onvenientess 8onvenient
Inzucci SE et al. Diabet!l!"ia. 20#2. $ %u&prec't et al. Intensi(icati!n t! t! bip'asic insulinaspart )0*+0. Int J Clin ,ract 200-
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@atient Centered Approach
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9$at is t$e optimal target b)1clevel:
7oals of optimum ,bA1clevels%
7ood glycaemic control
5inimise development and progression of microvascularand macrovascular complications
b)1c
;70
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Insulin can be initiated at an+ time
Traditionally. insulin has been reserved as the last line of ther
H,o6ever. considering the benefits of normal glycemic status
can be initiated earlier and as soon as possible
Inade-uateifest+le
1 O)D 2 O)D
I(II)E I(*%I(
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OutlinesPresentation structure
Diabetes is a progressive disease and is increasing
in prevalence
The mapping of insulin treatment based recent guidelines
Insulin Initiaton and Intensification from latest update study (A1
Conclusion
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o# to start asal Insulin /tart 6ith basal insulin (Insulin Detemir) 1 < or .1&.2 < per Gg
=nce daily in4ection. anytime in4ection but in same time per each d
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*imple Dose titration #it$ evemir
@atients 6ho e>perienced hypoglycemia reduced their daily dose by unit
'P= target range70.?0 mg,d
'P= ;70 mg,d @3A mmol,B
'P=C?0 mg,dl @50 mm,B
!ean 3.da+ 'P= @mg,dB
!aintaindose
units
'P= target rangeA0.110 mg,d
'P= ;A0 mg,d @ mmol,B
'P=C110 mg,d @61 mmol,B
londe et al Diabetes Obes Metab 200? 11@6B"623.631
Increase
3 units
Decrease3 units
evemirF Dose itration =uidelines"3.0.3 )lgorit$m
/tart 6ith evemir 1 < or .1&.2 < per Gg --
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evemirF,=largine ead.to.ead"*imilar Profiles in +pe 2 Diabetes
Time (h)
GleinGlein = et al! Diab Obes Metab 2$ :%2:&2::
7luco
seinfusionrate
(mg3Dg3min)
0 2 4 6 8 10 12 14 16 18 20 22
0
0.5
1.0
1.5
2.0
2.5
3.0
!#
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evemir reduces nocturnal $+pogl+caemia b+ up65< compared to (P
,'illis1si&i3as. Clin 'er 2004/256#07#84-95#/ Riddle et al 200). Diabetes Care/ 24 6##7 )05014/ Asa3ura et al 2005. E:pert Opin ,'ar&ac!t'er/ #0 6-7 #18/ ;anel ; et al 2005. J Diabetes1
In
In
In
+elative+isD
+iddleet al. 2 @hillis&Tsimias et al. 2;
-29% -44% -53% -65%
9@, vs! glargine 9@, vs! detemir
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o# to Intensif+
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reatment t$erapies for +pe 2 diabetes
Adapted (r!& Racca' et al. Diabetes Metab Res Re= 200+/2)28+.
ifest+le !etformin
.ot$erO)D or=P.1
agonists
asalInsulin
(Once-dailytreat-to-target)
PremiedInsulin
(!ice dailyreat totarget)
asal
Insulin("asal # 1 or2 $randial)
asalInsulin
("asal # $randial
b)1c470< b)1c470
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o normalise blood glucose bot$ 'P= and PP=must be reducedH
Adapted (r!& M!nnier > et al. Diabetes Care 200)/2455#98
PP'P
50< 55
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