14:00 - 16:00 WS #15: Insulin Masterclass - Advanced 16:30 - 18:30 WS #21: Insulin Masterclass - Advanced (Repeated) Dr David Kim Endocrinologist and General Physician Waitemata DHB and Apollo Specialist Clinic Albany Auckland Mr Rab Burtun Diabetes Nurse Specialist Waitemata DHB Waitakere Hospital Auckland
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Dr David Kim Mr Rab Burtun - GP CME North/Thur_room2_1401-Rab... · 2018-06-09 · Case 2: Ms A Date Insulin am Lunch Bed Bef Bkfast Bef Lunch Bef Dinner Bef Bed Mon Protaphane 48
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• Added Apidra 3 units pre-breakfast and pre-lunch
• Persistent high CG’s (~10-15) at pre-lunch/dinner -Titrated fron 4 units to 6 units
• BS low bef bed so reduced the dinnertime Apidra
• BS too low fasting reduced the lantus to 46 units
Case 2: Ms ADate Insulin am Lunch Bed Bef
BkfastBef Lunch Bef Dinner Bef Bed
MonProtaphane 48 8.9 12.4 8.2 14.5
Tues 8.2 13.1 7.9 18.2
Wed 10.2
Thurs
52 yr old woman with T2DM for 23 yrs, chronic poor control, HbA1c >80 for over a year
Metformin 1g TDS + on basal insulin since 5 years ago –Protaphane at bedtime, dose gradually increased to 48 units
Long history of patchy compliance, occasional CG testing, mostly fasting 8 - 15, pre-dinner 10 - 20 mmol/L
Ms Blood sugar Diary
Case 2 Mrs A• Simplify Metformin to
1.5g BD
• Switched insulin to premix (NovoMix30) –20 units pre-breakfast and 20 units pre-dinner
• Got her to test CG’s more intensively; pre-breakfast and pre-dinner, with a follow up phone call the following week
• Increase morning Novomix to 24 units continue 20 units at dinner
Date Insulin Breakfast
Dose
Dinner
Dose
CG
Bef
Breakfast
CG Bef
Lunch
CG Bef
Dinner
CG Bef bed
Mond Novomix
30/70
20 units 20 units 7.2 10.2 10.4 9.3
Tues 8.5 10.8 11.1 9
wed 8.9 12.2 13.7 8.9
Thurs 7.5 11.6 14 9.7
Friday Novomix
30/70
24 20 7.2 7.8 7.6 8.9
6.8
Steroids
Case 3 Mrs P
• 67 yrs old lady on metformin 1 gm bd + Gliclazide 80 mg bd + lantus 26 units nocte
• Fairly well controlled Hba1c of 62 mmols
• Recently started on Prednisone 15 mg for COPD since then BS gone crazy!!!
SteroidsCase 3 Mrs P
• Stop Gliclazide
• Start on 4 units of Novorapid then titrate up
• Add 3 units of Novorapid at lunch titrate
Case 4 Mr BD
• Mr BD 65 yrs old ,BMI 39 fairly Insulin resistant,Type 2 for 12 yrs ,fairly well controlled on Metformin 1 gm tds + Gliclazide 80 mg bd +Lantus 45 units nocte.
• Hba1c was around 60-65 mmols for the last few yrs until 3 months ago Hba1c gone up to 89mmols since Metformin was reduced to 500 mg od
• Due to declining renal function eGFR now 17 ml/min
Case 4 Mr BD• Continue metformin 500
mg OD
• Stop Gliclazide
• Start 4 units of Apidra with Breakfast and dinner
• Titrate Insulin dose until BS stabilises
• Ended up on Apidra 6 units amm, 4 units at lunch and 6 units at dinner
• Lantus reduced to 40 units nocte .
Insulin doses in T2D
• Requirements depend on insulin (body) resistance
• Duration of DM will affect remaining beta cell function
• Correct dose of insulin is when you achieve target blood sugars.
Insulin doses in T2D
When might changes need to be made?
• Hypos
• BGLs consistently > 15 mmol/L
• Illness
• Steroids/medications causing hyperglycaemia
• HbA1c not on target
Pen needles
• 4-5 mm– Children
– Most adults
– No pinch technique
– All patients need to prime their insulin needle with insulin BEFORE EVERY injection regardless of insulin type or frequency of injections (THIS IS A SAFTEY ISSUE)
INJECTION SITES
• The abdomen is generally the preferred injection site.
06/06/2018 Rab Burtun,Diabetes Nurse Specialist
Needle Reuse and injection pain
• In order to significantly reduce the discomfort of the injection, thinner, shorter and sharper insulin needles have been developed. Repeated use however can impact the performance and safety of the needle by:
• ➞ Removing the lubricant primarily responsible for painless or near painless injections
• ➞ Damaging the needle tip, from mild bending to hook-like distortion of the entire tip
• Photographs showing the type of damage that can occur with needle reuse:*
• Both loss of lubricant and tip damage will result in pain and discomfort during the
• injection.• * Photographs from Dieter Look and Kenneth Strauss study: “Nadeln