Insulin Conundrums

Veronica Green

*p < 0.0001 **p = 0.021

Epidemiological extrapolation showing benefit of a 1% reduction in mean HbA1c with a mean duration of diabetes of 10 years

Ris

k re

du

ctio

n (

%) as

soci

ated

with

a

1%

low

er

Hb

A1c

43%

Amputation or death due to

peripheral vascular disease

*

*

21%

Any diabetes- related endpoint

*

37%

Microvascular complications

*

14%

Myocardial infarction

*

19%

Cataract extraction

16%

**

Heart failure

5. Stratton IM et al. BMJ 2000; 321: 405–412.

-40

-30

-20

-10

0

Risk reductionRisk reduction for each 1% reduction in HbA1c in type 2

diabetes

Standard approach to the management of Type 2 diabetes

Lifestyle Changes

Diet and Exercise

Oral Monotherapy

Oral Combination+glipins +

Oral + exenatide / +

Insulin

Treatment intensification

V Green Byetta workshop 2

When to start insulin?

NICE

• Hba1c >7.5%• Use NPH od/bd• Or long acting

analogue if– Hypoglycaemia– Can’t do it themselves– Otherwise would need

BD basal+orals

• Hba1c >9%• Use BD biphasic• Use analogue mix if

– Marked post prandial raise

– Need to inject immediately pre-meals

– hypos

NICE 2009

Or Not

• NPH ½ price of analogue long acting insulin but

• 20% variability in absorption with each injection

• iFriedburg SJ, Lam YWF, Blum JJ, Gregerman RI.

2006. Insulin absorption: a major factor in apparent insulin resistance and the control of type 2 diabetes. Metabolism. 55(5) 614-619

Who is Afraid of What?

Taking the Fear out of Taking the Fear out of Insulin Injections Insulin Injections

Doctor’s FearsWill I do my patient any good?

Will they put on more weight?

Will their complications worsen?

Will it make a difference to the blood glucose levels?

Nurse’s FearsCan this person learn to inject?

Is it going to make a difference?

Am I able and competent to do this?

What if something goes wrong?

What insulin to use?

Patient’s FearsWill this make me a drug addict?

What about my lifestyle?

My diabetes mild, I don’t need insulin

Needle phobia

Fear of hypos

Needles

Injection sites

Effect on Lifestyle

• Find out about work, social life BEFORE deciding on a regime

• Adapt the regime about the life not the other way round.

Insulins

Rapid Acting Analogues

• Work almost straight away

• Last 3-5 hours

• Used pre/post prandially

• NovoRapid , Humalog, Apidra

Short Acting Insulins

• Act 30 minutes post injection

• Last 6-8 hours

• Given pre prandially

• Actrapid or Humulin S

Intermediate Acting Insulins

• Act after 1-2 hours

• Last 12-14 hours• Given

morning/evening or bedtime

• Insulatard or Humulin I

Pre Mixed Insulins

• Act after 30 minutes, last 12-14 hours

• Given morning and evening pre meal

• Mixtard, Humulin M

• Mixed analogues – NovoMix 30, Humalog Mix 25, 50

Long Acting Analogues

• Act immediately

• Last 18-24 hours

• Given am or pm

• Lantus or Levemir

Classification

• Mild – can be treated by the person themselves without help

• Moderate – Need help in treating, but are conscious

• Severe – Pt unable to help themselves, need of hospital care

Symptoms

Neuro-glycopenic• Confusion• Drowsiness• Speech difficulty• Poor coordination• Atypical behaviour• Diplopia

Autonomic• Sweating / pale• Palpitations• Shaking (tremor)• Hunger

Other signs

• Malaise• Headache• Hemiplegia

(particularly in the elderly)

• Person may have individual signs e.g. numb lips

Nocturnal hypoglycaemia 1

• Effects 30-40% of all diabetics

• Can be slept through

• The person may only be aware the next morning that they have had a hypo

Nocturnal hypos 2

• Nightmares / vivid dreams

• Waking up unrested• Waking up with a

headache• High fasting sugar

(often alternating with OK ones)

Hypo Unawareness

• Loss of bodily warning signs

• Can cause severe hypos

• Caused by– Running very tightly– Frequent hypos– Duration of diabetes

Glucose Sensor ProfileModal Day

-5.0

0.0

5.0

10.0

15.0

20.0

12:00 AM 4:00 AM 8:00 AM 12:00 PM 4:00 PM 8:00 PM 12:00 AM

Time

Glu

cose

Con

cent

ratio

n (m

mol

/L)

10-Sep-02

11-Sep-02

12-Sep-02

13-Sep-02

72 hour continuous glucose monitoring

PhysiologyBG<3

Neuroglycopenic symptoms

Autonomic symptoms

Treat with glucoseRelease of glucagon, + stress

hormones

Glucogenolysis, gluconeogenesis (liver/kidney)

Raise in BG

Treatment

• 20g glucose

• Back up long acting carbohydrate

• Find the cause

• Adjust medication if required

Causes

• Too much insulin / OHA

• Too little food

• Timing of injection in relation to food

• Alcohol

• Exercise

• Injection site problems

• Hot weather

Lipohypertrophy

Case Histories