1. Insulin Delivery Systems Atlanta Diabetes Associates
New Insulins
and
Insulin Delivery Systems
Bruce W. Bode, MD, FACE
Atlanta Diabetes Associates
Part 3

2. Insulin Therapy in Type 2 Diabetes Indications
Title
Subtitle
Insulin Therapy in Type 2 Diabetes Indications
Significant hyperglycemia at presentation
Hyperglycemia on maximal doses of oral agents
Decompensation
Acute injury, stress, infection, myocardial ischemia
Severe hyperglycemia with ketonemia and/or ketonuria
Uncontrolled weight loss
Use of diabetogenic medications (eg, corticosteroids)
Surgery
Pregnancy

3. Starting With Basal Insulin in DM 2 Advantages
Title
Subtitle
Starting With Basal Insulin in DM 2 Advantages
1 injection with no mixing
Insulin pens for increased acceptance
Slow, safe, and simple titration
Low dosage
Effective improvement in glycemic control
Limited weight gain
INSULIN TACTICS
Starting With Basal Insulin
Advantages
Patients who no longer respond adequately to oral agents will benefit from combination therapy that consists of maintaining the use of oral antidiabetic agents together with insulin therapy. The advantages of adding basal insulin to prior treatment with oral agents include the following: (1) only one insulin injection may be required each day, with no need for mixing different types of insulin; (2) the use of insulin pens can enhance patient acceptance of the treatment; (3) titration can be accomplished in a slow, safe, simple fashion; and (4) eventually combination therapy requires a lower total dose of insulin. The result is effective improvement in glycemic control while causing only limited weight gain.
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4. Treatment to Target Study: NPH vs Glargine in DM2 patients on OHA
Add 10 units Basal insulin at bedtime (NPH or Glargine)
Continue current oral agents
Titrate insulin weekly to fasting BG < 100 mg/dL
- if mg/dL, increase 2 units
- if mg/dL, increase 4 units
- if mg/dL, increase 6 units
- if >180 mg/dL, increase 8 units

5. Treatment to Target Study; A1C Decrease

6. Treatment to Target Study: % at Goal
Title
Subtitle
Treatment to Target Study: % at Goal
Results
57% of patients in both groups reached A1C 7%
At wk 24, mean insulin glargine dose was higher than mean NPH insulin dose:
Insulin glargine NPH insulin
48.8 IU/day IU/day , P<0.001
Treatment to Target Study: Timing and
Frequency of Nocturnal Hypoglycemia
This slide shows the results of a 24-week, multicenter, randomized, parallel study that evaluated the efficacy of bedtime NPH insulin vs. insulin glargine in restoring glycemic control to target A1C < 7.0% while continuing oral therapy and the timing and frequency of nocturnal hypoglycemia
Rosenstock J, Riddle MC, and the HOE901/4002 Study Group.
Diabetes 2002;51(suppl 2):A482. Abstract 1982-PO
In 4002 at Endpoint- Basal Insulin dose (IU)
Lantus N= mean 46.95, SD 26, Median 42, Min 1 , Max 144
NPH N= mean 41.72, SD 23.9, Median 38, Min 3, Max 138
Rosenstock J, Riddle M, HOE901/4002 Study Group. Diabetes 2002;51(suppl 2):A482. Abstract 1982-PO

7. Riddle et al, Diabetes June 2002, Abstract 457-p
Treat to Target Study: Glargine vs NPH Added to Oral Therapy of Type 2 Diabetes
Nocturnal Hypoglycemia reduced by 40% in the Glargine group (532 events) vs NPH group (886 events)
Riddle et al, Diabetes June 2002, Abstract 457-p

8. A1C Change From Baseline (%)
Title
Subtitle
Morning vs Bedtime Insulin
Baseline: 9.11.0
Morning Glargine
Bedtime Glargine
Bedtime NPH -2 -1
A1C Change From Baseline (%)
–1.24
–0.96
–0.84
P<0.001
P=0.008
A1C Change From Baseline
A1C levels were reduced by –1.24% with morning insulin glargine, –0.96% with bedtime insulin glargine, and –0.84% with bedtime NPH insulin
Improvement in A1C was more pronounced with morning insulin glargine than with bedtime insulin glargine (0.28%, P=0.008) or with bedtime NPH insulin (0.40%, P<0.001)
Adapted from Fritsche A et al, and the 4001 Study Group. Ann Intern Med. 2003:138:952
Fritsche A et al, and the 4001 Study Group. Ann Intern Med. 2003:138:952

9. Starting with Bolus Insulin
16 obese Type 2 patients on NPH or Human 70/30 insulin twice daily randomized to:
Insulin aspart premeal with metformin and rosiglitazone
NPH or Human 70/30 twice daily
Insulin titrated to 90 to 126 mg/dl at 1.5 hr post meal in the aspart group and premeal in the conventional group with goal A1C <7%
Diabetes Care 2003

10. Insulin Aspart Premeal with Metformin and Rosiglitazone vs Conventional Insulin
A1C%
0.42 units/kg
3 kg weight gain
0.67 units/kg
1 kg weight gain

11. Advancing Basal/Bolus Insulin
Title
Subtitle
Advancing Basal/Bolus Insulin
Indicated when FBG acceptable but
A1C > 7% or > 6.5%
and/or
SMBG before dinner > 140 mg/dL
Insulin options
To glargine or NPH, add mealtime aspart / lispro
To suppertime 70/30, add morning 70/30
Consider insulin pump therapy
Oral agent options
Usually stop sulfonylurea
Continue metformin for weight control
Continue glitazone for glycemic stability?