1. 24 May 20061 How I Introduce Insulin in Type 2 Diabetes Mellitus Sheena Duffus Diabetes Specialist Nurse Norma Alexander Sister Diabetes Clinic

2. 24 May 20062 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

3. 24 May 20063 Patients perspective Patients resistance to insulin ‘v’ insulin resistance Fear factor Loss of employment / driving categories Weight gain Hypo’s (fear of) ? Feel better

4. 24 May 20064 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

5. 24 May 20065 Grampian Step 1 Review the patient HbA1c, ? Symptomatic, ? Weight loss, Inter-recurrent illness or complication present Height / Weight BMI Waist circumference

6. 24 May 20066 Step 1 Review the medication Compliant ? Dose increase possible Additional OHA Weight control clinic Metabolic insulin resistant drug

7. 24 May 20067 Step 1 Knowledge of diabetes Start again ? – Have they had any formal diabetes education ?

8. 24 May 20068 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 ?

9. 24 May 20069 Step 2 Commence home blood glucose monitoring – An essential tool ! Refer patient to diabetes dietitian Discuss with Consultant, DSN or GP

10. 24 May 200610 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.

11. 24 May 200611 Next step Be positive but address their fear factor Seeing the needle! Dry run – Sticking the needle in! Relief factor

12. 24 May 200612 Preparation Consent Discuss and agree change of treatment Employment Driving Hypo’s Lifestyle Exercise Sick day rules

13. 24 May 200613 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

14. 24 May 200614 Step 4 Discuss insulin regime options Action of insulin - How insulin works Choosing their pen device – dexterity – pen needle length

15. 24 May 200615 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

16. 24 May 200616 Step 4 Injection sites and rotation Storage of insulin – expiry date Sharps disposal Repeat prescriptions

17. 24 May 200617 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

18. 24 May 200618 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