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Lecture:
Insulin Initiation and Monitoring
30 minutes
Slide 2
Slide 3
START TREATMENT
OAD TREATMENT
START INSULIN
INSULIN INTENSIFICATION
Lifestyle + Metformin
Basal
Basal Insulin Premix Insulin
HbA1c 7.0%
Slide 4
HbA1c %
Nathan et al., Diabetes Care 2009;32:193-203.
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What is Insulin
After a meal carbohydrates are digested and enter the blood system, which transports them to the cells
Some cells (those of muscles and fat tissue) need assistance to have blood sugar enter into them and to be used for energy production
The liver needs assistance to start the process of storage of glucose in the form of glycogen
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Meal
Meal
Meal
600
Type 2 diabetes
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Insulin binds to the insulin receptors on the cell membranes of the target cells in the liver, muscles and adipose tissue
Liver
Muscles
Adipose Tissue
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Maintain blood glucose levels between 80-140 mg/dl: 1. By promoting uptake of glucose by target cells 2. subsequent breakdown into energy (glycolysis) storage as glycogen (glycogenesis)
By inhibiting new glucose formation from non carbohydrate source (gluconeogenesis) or production of glucose by liver
3.
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Most people with type 2 diabetes will, in time, need insulin therapy because
60
50 40 30 20 10 0 1 2 3 4 5 6
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UKPDS
9 8.5
Median HbA1c (%) 8
ADOPT
8
7.5
7.5 7 Recommended treatment target <7.0% 6.2% upper limit of normal range 0 2 4 6 8 Years from randomisation 10
6.5 6
6.5
6 0 1 2 3 Time (years) 4 5
*Diet initially then sulphonylureas, insulin and/or metformin if FPG>15 mmol/L; ADA clinical practice recommendations. UKPDS 34, n=1704
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Insulin can be initiated at any time Traditionally, insulin has been reserved as the last line of therapy However, considering the benefits of normal glycemic status, Insulin can be initiated earlier and as soon as possible
Inadequate Lifestyle + 1 OAD + 2 OAD + 3 OAD
INITIATE INSULIN
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but Insulin usage is currently very low in Indonesia compared to its neighbouring countries
Population Indonesia Bangladesh Philippines Vietnam Thailand Malaysia 104 161 982 417 3,258 2,029 Mega Units Insulin Units / Capita 248 Total Insulin Used 694 3,097 Insulin Usage per Capita
3 19 9 5 49 70
92 67 29
Million People
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Insulin Indications
Absolut Indication Type 1 Diabetes Relative Indication
Besides the above, there are a number of conditions where insulin is required, e.g. chronic liver, kidney function interruption and high dosage steroid therapy
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FAST-ACTING INSULIN
12
Time (h)
16
20
24
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PRE-MIX
GIR (mg/kg/min)
FAST-ACTING
0 4
8 12 16 20 24
Time (h)
0 4
8 12 16 20 24
Time (h)
0 4
8 12 16 20 24
Time (h)
Basal Insulin provides a steady concentration of insulin in the bloodstream over 24 hours. Initially, basal insulin should be given at 10 units per day at night time or in the morning1
Premixed insulins contain a mixture of rapid-acting and intermediate-acting insulin in a fixed combination to provide coverage of prandial and basal insulin requirements2
Fast-acting insulins include single amino acid replacement that reduce their ability to selfassociate into dimers and hexamers. This means that they are quickly absorbed into the bloodstream, following subcutaneous injection.3
1. Hompesch M. Diabetes Obes Metab 2006; 8:568; 2. Weyer et al. Diabetes Care 1997;10:16121614.; 3. 1. Heinemann et al. Diabetes Care. 1998;21:19104
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0.2 0.5
0.5 1 0.5 1 1.5 4 1.5 4 1-3 1-3 0.2 0.5 0.2 0.5 0.5 1 0.5 1
0.5 - 2
0.5 - 1 0.5 - 1 4 - 10 4 - 10
1-4 1-4 3 - 12 3 - 12
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Start with Premix Insulin OR add Basal Insulin to OAD OR Start Basal/Bolus Therapy
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BASAL INSULIN
FASTACTING INSULIN
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Start with Basal Insulin 10u / daily with meal or before bedtime. Same injection time every day
If glycemic target is not reached within 2-3 months, intensify Insulin treatment
Premix Insulin Usually keep OAD Basal with Prandial Usually keep OAD Basal Bolus Usually keep OAD
Switch to Premix twice-daily. Add Prandial starting Start with equal basal dose, with 4u / day either but give 50% per injection once or twice-daily and and titrate accordingly titrate accordingly
Source: PERKENI Insulin Guidelines 2011
Switch to Basal Bolus (3 daily prandial) start with 4u / day and titrate accordingly)
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Prefilled devices
Disposable disposed of once empty Less teaching time required Primarily plastic Easy and Convenient for Patients
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WE WILL COVER HOW TO START A PATIENT ON INSULIN AND INJECTION TECHNIQUES IN A SEPARATE WORKSHOP