Section 2 Insulin Therapy in Type 1 and Type 2 Diabetes 37.

Section 2

Insulin Therapy in Type 1and Type 2 Diabetes

37

Initiating Insulin Therapy• Add single dose of basal insulin– Glargine, detemir, or NPH– Usually administered at bedtime

• Use conservative starting dose– 10 units (empiric)– 0.1 to 0.2 units/kg– 0.3 to 0.4 units/kg if severe hyperglycemia

41

Initiating Insulin Therapy• Adjust dose according to fasting SMBG– Typical titration 1–2 units every few days– Treat to target range for fasting glucose• ADA: 70–130 mg/dL• AACE: <110 mg/dL

– May use product-specific titration instructions• Continue oral agent(s) at same dosage

(eventually reduce)

42American Diabetes Association Standards of Medical Care in Diabetes—2012AACE Medical Guidelines for Clinical Practice for Developing a Diabetes Mellitus Comprehensive Care Plan (2011)

Intensifying Insulin Therapy• A1C ≥7% after 2–3 months with fasting blood

glucose in target range• Perform SMBG before meals, bedtime• Add prandial (bolus) insulin based on time of

out-of-range result– Before lunch: add breakfast dose– Before dinner: add lunch dose– Before bedtime: add dinner dose

43

Intensifying Insulin Therapy• Insulin options– Insulin aspart– Insulin glulisine– Insulin lispro– Regular insulin– NPH insulin

• Dosing considerations– Typical initial dose: 4–5 units– Typical titration: 2–3 units every 2–3 days

44

Intensifying Insulin Therapy• Continue other agents?– Metformin– Thiazolidinediones (glitazones)– Sulfonylureas, glinides– α-Glucosidase inhibitors– DPP-4 inhibitors– GLP-1 receptor agonists– Colsevelam– Bromocriptine

45

• 62-year-old Caucasian woman with type 2 diabetes

• Weight: 219 lb• Medications– Insulin glargine (Lantus®)

42 units at bedtime– Metformin (Glucophage®

XR) 1,000 mg twice daily– Pioglitazone (Actos®) 45 mg

once daily46

Insulin Mini-Case 1

Fasting Prelunch Presupper Bedtime

132 186 222 310

122 172 202 282

148 184 188 257

126 170 233 239

132 192 193 228

162 189 240 306

188 192 198 298

127 176 202 264

133 188 199 312

142 213 198 300

122 192 215 297

156 186 320* 387a

121 190 188 201

137 178 206 258

47

aHad watermelon at lunch.

• How should insulin therapy be adjusted?

• Continue current medications?

48

Insulin Mini-Case 1

Pattern Management• Review SMBG data for general patterns• Identify trends– Three or more similar glucose values at the same

time each day• Discuss with patient possible causes of values

outside target– Food from previous meal?– Activity?– Insulin dose?

74

Pattern Management• Should changes in food/carbohydrate amount

or timing of intake be made?• Should physical activity be more regular,

increased, decreased?• Should the insulin regimen be adjusted?

75

• 54-year-old African American woman with type 2 diabetes

• A1C: 9.2%• Medications

– Humalog® Mix75/25TM (insulin lispro)• 16 units each morning• 10 units each evening

– Metformin (Glucophage® XR) 1,000 mg twice daily

49

Insulin Mini-Case 2

Fasting Prelunch Bedtime Comments

310 176 198 Pizza for dinner last night

333 152 142 Walked after supper

289 133 199

256 Woke up late

202 165 201

198 148 205

286 163 189

292 161 200

301 145 212

277 158 209

289 162 189

286 177 197

284 149 201

303 159 182

50

• How should insulin therapy be adjusted?

51

Insulin Mini-Case 2

Multiple InjectionInsulin Regimens

52

53

Four injections per day

American Diabetes Association. Practical Insulin: A Handbook for Prescribing Providers. 3rd ed. 2011.

Initiating Insulin in Type 1 Diabetes• Typical starting dose: 0.5–0.7 units/kg/day• Basal insulin: ½ to ⅔ of total daily dose• Bolus insulin: ½ to ⅓ of total daily dose,

divided among meals• Titrate doses as needed

56

• 19-year-old Caucasian man newly diagnosed with type 1 diabetes

• Weight: 137 lb• A1C: 11.6%• Blood glucose: 256 mg/dL• Spilling ketones

57

Insulin Mini-Case 3a

• Determine total daily dose– 0.6 units/kg/day

• Determine individual doses– 50% basal/50% bolus

58

Insulin Mini-Case 3a

Adjusting Insulin DosesOut-of-Range Result Insulin Component to Adjust

Postbreakfast/prelunch Prebreakfast rapid-acting/short-acting insulin

Postlunch/presupper Prelunch rapid-acting/short-acting insulinMorning NPH

Midafternoon Long-acting insulinMorning NPH

Postsupper/bedtime Presupper rapid-acting/short-acting insulin

Early morning Long-acting insulinEvening NPH

59American Diabetes Association. Practical Insulin: A Handbook for Prescribing Providers. 3rd ed. 2011.

Refining Insulin Doses• Correction insulin– Correction factor (insulin sensitivity factor)– Correction dose

• Insulin-to-carbohydrate ratio– Insulin to cover ingested carbohydrate

• Pattern management– Insulin doses determined or adjusted by trends in

SMBG data

60

Correction Factor• Amount of rapid-acting or short-acting insulin

needed to return an elevated blood glucose level to target level– Quantifies degree of change in blood glucose

value expected with injection of 1 unit insulin

61

Correction Factor • For the average patient, 1 unit of insulin will

lower blood glucose by 50 mg/dL– For insulin-sensitive individuals, 1 unit may lower

blood glucose by as much as 100 mg/dL– For insulin-resistant individuals, 1 unit may lower

blood glucose by as little as 25 mg/dL

62

Correction Factor• 1800 rule– 1800 ÷ total daily dose of insulin (TDD)– Example• 1800 ÷ 50 units = 36• 1 unit of rapid-acting or short-acting insulin will lower

blood glucose by 36 mg/dL

• Also 2000, 1700, 1500 rules– Higher rule value = lower risk of hypoglycemia

63

Correction Dose• Current blood glucose − target blood glucose =

amount of glucose over target• Amount of glucose over target ÷ correction

factor = correction dose

[Blood glucose now] − [Goal blood glucose]

Correction factor

64

• 19-year-old Caucasian man with type 1 diabetes

• Experiencing unexpected elevations in blood glucose due to school-related stress

65

Insulin Mini-Case 3b

• Recall TDD– 37 units/kg/day

• Determine correction factor– Use rule of 1800

• Calculate correction dose– Current blood glucose:

320 mg/dL– Blood glucose goal: 120 mg/dL

66

Insulin Mini-Case 3b

Insulin-to-Carbohydrate Ratio• Amount of rapid-acting or short-acting insulin

needed to “cover” carbohydrates in meals and snacks

• Patient may have different insulin-to-carbohydrate ratios for different meals

67

Insulin-to-Carbohydrate Ratio• How to calculate– Determine average carbohydrate grams for each

meal and snack– Divide carbohydrate grams by units of insulin

administered (with appropriate glucose control)

68

Insulin-to-Carbohydrate Ratio• Information needed– Detailed, accurate food records for at least 3 days• To determine total carbohydrate grams eaten at meals

and snacks

– Units of rapid-acting or short-acting insulin administered with each meal and snack

– Premeal and postmeal blood glucose levels

69

Insulin-to-Carbohydrate Ratio• Sample calculation– Average carbohydrate grams at dinner: 55 g– Administered 9 units rapid-acting insulin with

appropriate return of glucose to baseline– 55 g ÷ 9 units = 1 unit of insulin per 6 g

carbohydrates– Insulin-to-carbohydrate ratio 1:6

70

Insulin-to-Carbohydrate Ratio• Rule of 500– Alternate method of calculating insulin-to-

carbohydrate ratio– 500 ÷ TDD

71

• 24-year-old Hispanic woman with type 1 diabetes

• Weight: 118 lb• Uses insulin glargine

(Lantus®) 22 units once daily

• Guesses at prandial doses

72

Insulin Mini-Case 4

• Calculate the insulin-to-carbohydrate ratio– Use rule of 500– Use 0.6 units/kg/day for insulin dose

73

Insulin Mini-Case 4

76

Patient Case Claire Green

• What do Claire’s SMBG results tell you?

• What changes (if any) should Claire make?

77

Claire Green

• How should Claire adjust her insulin regimen for her night out with the girls?

78

Claire Green

Hypoglycemia

79

Hypoglycemia• Risk factors– Missed or irregular meals– Physical activity– Alcohol consumption

• Symptoms

80

81

Hypoglycemia ManagementCHECK

TREAT

CHECK

EAT

82

Insulin Therapy Updates

Emerging Insulin Regimens

Eli Lilly

• Basal Insulin Peglispro: Phase III

Eli Lilly and Boehringer Ingelheim

• Glargine biosimilar: Filed

Sanofi

• Glargine U300: Phase III• Lixisenatide + glargine: Phase III

Emerging Insulin Regimens

Novo Nordisk

• Degludec + aspart (Ryzodeg): Filed• Degludec (Tresiba): Filed• Degludec + liraglutide (IDegLira): Phase III; Filed in Europe• Faster insulin aspart (FIAsp): Phase III

Insulin’s about to get really exciting!

Questions?

84

LUNCH

85