24 May How I Introduce Insulin in Type 2 Diabetes Mellitus Sheena Duffus Diabetes Specialist Nurse Norma Alexander Sister Diabetes Clinic

24 May Points to ponder Time of diagnosis to insulin therapy Oral therapy at maximum combination tolerated by the patient Patient compliance Weight loss clinics? Metabolic syndrome drugs Glitazones not licensed for use with insulin

24 May Patients perspective Patients resistance to insulin ‘v’ insulin resistance Fear factor Loss of employment / driving categories Weight gain Hypo’s (fear of) ? Feel better

24 May Who to target? Persistent hyperglycaemia HbA1c > 7% despite maximum dose OHAs Symptomatic Severe inter-recurrent illness Diabetes complications present Weight loss due to hyperglycaemia Ketosis?! Honk

24 May Grampian Step 1 Review the patient HbA1c, ? Symptomatic, ? Weight loss, Inter-recurrent illness or complication present Height / Weight BMI Waist circumference

24 May Step 1 Review the medication Compliant ? Dose increase possible Additional OHA Weight control clinic Metabolic insulin resistant drug

24 May Step 1 Knowledge of diabetes Start again ? – Have they had any formal diabetes education ?

24 May Revisiting control Step 1 Review lifestyle Exercise – Do they do any ? – What could they do ? Smoking Psychological issues – What else is happening in their life ? stress Motivation – How do they see it ?

24 May Step 2 Commence home blood glucose monitoring – An essential tool ! Refer patient to diabetes dietitian Discuss with Consultant, DSN or GP

24 May Step 3 A. After 2 months if there is an improvement in HbA1c go back to Step 1 B. Negotiate commencement of insulin with the patient.

24 May Next step Be positive but address their fear factor Seeing the needle! Dry run – Sticking the needle in! Relief factor

24 May Preparation Consent Discuss and agree change of treatment Employment Driving Hypo’s Lifestyle Exercise Sick day rules

24 May Insulin regime options Pre – mix and OHAs Novomix 30 via preloaded Flexpen or Novopen 3 Humalog 25 Mix via Humapen Luxura Basal insulin and OHAs Lantus (Glargine) via pre loaded Optiset pen * must use Penfine needles or Autopen 24

24 May Step 4 Discuss insulin regime options Action of insulin - How insulin works Choosing their pen device – dexterity – pen needle length

24 May Step 4 Start doses - titration rates Give clear verbal and written instructions of any OHA to be discontinued! Written instructions of insulin dosage and titration rate

24 May Step 4 Injection sites and rotation Storage of insulin – expiry date Sharps disposal Repeat prescriptions

24 May Start date and time Venue – surgery – ward Time – morning Task – first injection – keep it simple Injection site – where? – rotation Praise – discuss fear & their technique Oral medication – continue or stop – written instructions

24 May Follow up support Injections Daily contact at surgery or phone Who should initiate contact? Dose adjust every few days with patient depending upon their BG results Titrate dose slowly to prevent severe hypo’s Answer questions