Insulin Initiation In Primary Care

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Insulin Initiation In Primary Care

• Dr Arla Ogilvie Endocrinologist Watford General
  Hospital
• West Herts Hospitals NHS Trust

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Does the Patient Need Insulin?

• ?Is it appropriate for the patient to be managed
  in Primary Care?
• ?Sufficient
• Knowledge
• Skills
• Support
• Time
• Confidence
• ? Have all other factors relating to control been
  addressed

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Insulin Resistance.3Types
Patient
Metabolic
Doctor
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Before you start

• Understand the patient
• Is insulin necessary?
• Factors in poor control
• Diet and ex
• Compliance with Rx
• Health beliefs
• Fears
• Hypoglycaemia
• Weight gain
• Occupation

• Understand the insulin
• Type and regime
• Once daily oral agents
• Twice daily premix
• (Basal bolus???)
• Starting dose
• Patient EDUCATION
• TIME for follow up
• Dose titration
• Regular review and support

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Setting Individual Goals

• Optimise blood glucose control
• Keep patient asymptomatic
• Prevent long term complications
• Avoid hypoglycaemia
• Preserve Quality of Life
• Safety is paramount!

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Self-monitoring of blood glucose

• Monitoring glucose is essential for safe and
  successful insulin treatment
• It guides dose adjustment
• It allows patients to see the impact of
  behaviours and diet on glucose
• Patients MUST know how to monitor glucose
• The most important aspect of self-monitoring is
  that the patients DO something with the results

Diabetes UK. http//www.diabetes.org.uk/hcpreports
/primary_recs.pdf, 2005 National Diabetes
Support Team. http//www.cgsupport.nhs.uk/downloa
ds/NDST/Factsheet_Glucose_Self_Monitoring.pdf,
2005NICE. http//www.nice.org.uk/page.aspx?o3688
2, 2005. Owens D et al. Diabetes and Primary Care
20046816
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Once-daily basal insulin

• Duration depends on the insulin
• Insulin analogues may provide 24-hour cover
• Intermediate isophane preparations (Insulatard
  and Humulin I) may only be active for 8 18
  hours and have a more pronounced peak activity

Insulin activity
Time (824 hours)
Insulin
Schematic representation
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Benefits of a once-daily basal insulin regimen

• One injection per day
• Useful for patients reluctant to start insulin
  treatment
• Works best for morning hyperglycaemia
• Useful where someone else has to administer
  insulin
• May help overcome fear of starting insulin
• Some basal insulin injections may provide a
  weight benefit1

1.Philis-Tsimikas A et al. Clin Ther
200628156981
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Limitations of once-daily basal insulin regimen

• Does not provide insulin for post-meal glucose
  surges
• Assumes patient can produce sufficient insulin to
  cover these mealtime requirements
• Requires a fairly strict, predictable diet
• Dosing during the day is inflexible and so
  patients need to intake similar calories each
  day

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How Much?

• TYPE 2
• Nocte Isophane insulin Insulatard or Humulin I
• Start 10units Metfomin and Sulphonylurea
  (Glitazone)
• Titrate once or twice weekly

• Newer agents
• Gliptins
• GLP1 Analogues
• Are NOT licensed
• To be given with
• insulin

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Easy Dose Adjustment for Once Daily Basal Insulin

• The 3 0 3 Rule
• After Initiation
• Adjust insulin every 3 days
• Based on fasting glucose
• If average glu gt 7 increase by 3 units
• If glu lt 4mmol/l decrease by 3 units

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Premixed insulin

• Basal Rapid acting component
• Possible regimens
• Once daily with largest daily meal (usually
  dinner)
• Twice daily with dinner and breakfast
• Three times daily, with each meal

Insulin activity
Brkfast
Lunch
Dinner
Bedtime
Mixtard 30 may need snacks Wait 30 mins between
injecting and eating
Novomix 30 No snacks needed Inject and eat
immediately
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Benefits of a premixed insulin regimen

• Targets mealtime glucose
• Can be initiated as one injection per day to
  familiarise patient with injecting (Most need
  twice daily)
• Second or third injections of same insulin can be
  added if necessary to optimise control
• Need fairly regular lifestyles, Eat similar
  amounts at similar times

1. Garber AJ et al. Diabetes Obes Metab
200685866
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Analogue basal-bolus therapy
Rapid insulin
Rapid insulin
Rapid insulin
Rapid-acting insulin
Long-acting insulin
Long-acting insulin
Insulin activity
Breakfast
Lunch
Dinner
Bedtime
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Benefits of a basal-bolus insulin regimen

• Closest to natural insulin production by the body
• Not necessary for majority of Type 2
• May be needed for those who have erratic
  mealtimes, work variable shifts
• Gives more flexibility over type of food and when
  it can be eaten
• Suited to those who are highly motivated
• Need to monitor 4 times daily to optimise doses

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Insulin with or without oral agents?

• Oral agents can be continued when once daily
  basal insulin is initiated
• It is recommended that metformin is continued
  where possible in T2 DM
• Stop Sulphonylurea with premixed insulin
• Glitazones can be used with insulin usually
  where intolerant to metformin. Oedema may be a
  problem

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Commencing Insulin Therapy

• Ensure patient can blood glucose monitor and
  understands BG targets
• Assess patient for suitable device
• Educate patient regarding
• Storage, timing and action of insulin.
• Device use and safety
• Injection technique, sites and rotation.
• Hypoglycaemia
• Driving safety and legal Implications
• Sick day Rules
• Dose Adjustment and exercise ( if suitable)
• After education full assessment carried out to
  ensure patient competence and safety.

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POOR CONTROL -Troubleshooting!

• Compliance - Rx, lifestyle, acceptance
• Unable to use Pen - check technique
• Withdrawing needle too soon - count to 10
• Site problems -random rotation/hypertrophy
• Wrong timing of injections
• Eating to avoid hypos
• Rebound hyperglycaemia- check Sx of hypo