2. Insulin Conundrums Veronica Green

3. *p < 0.0001 **p = 0.021 Epidemiological extrapolation showing benefit of a 1% reduction in mean HbA 1c with a mean duration of diabetes of 10 years Risk reduction (%) associated with a 1% lower HbA 1c 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 reduction Risk reduction for each 1% reduction in HbA1c in type 2 diabetes

4. 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

5. When to start insulin?

6. 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

7. 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

8. Who is Afraid of What?

9. Taking the Fear out of Insulin Injections

10. Doctor’s Fears Will 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?

11. Nurse’s Fears Can 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?

12. Patient’s Fears Will this make me a drug addict? What about my lifestyle? My diabetes mild, I don’t need insulin Needle phobia Fear of hypos

13. Needles

14. Injection sites

15. 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.

16. Insulins

17. Rapid Acting Analogues Work almost straight away Last 3-5 hours Used pre/post prandially NovoRapid, Humalog, Apidra

18. Short Acting Insulins Act 30 minutes post injection Last 6-8 hours Given pre prandially Actrapid or Humulin S

19. Intermediate Acting Insulins Act after 1-2 hours Last 12-14 hours Given morning/evening or bedtime Insulatard or Humulin I

20. 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

21. Long Acting Analogues Act immediately Last 18-24 hours Given am or pm Lantus or Levemir

24. 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

25. Symptoms Neuro-glycopenic Confusion Drowsiness Speech difficulty Poor coordination Atypical behaviour Diplopia Autonomic Sweating / pale Palpitations Shaking (tremor) Hunger

26. Other signs Malaise Headache Hemiplegia (particularly in the elderly) Person may have individual signs e.g. numb lips

27. 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

28. Nocturnal hypos 2 Nightmares / vivid dreams Waking up unrested Waking up with a headache High fasting sugar (often alternating with OK ones)

29. Hypo Unawareness Loss of bodily warning signs Can cause severe hypos Caused by –Running very tightly –Frequent hypos –Duration of diabetes

30. 72 hour continuous glucose monitoring

31. Physiology BG<3 Neuroglycopenic symptoms Autonomic symptoms Treat with glucose Release of glucagon, + stress hormones Glucogenolysis, gluconeogenesis (liver/kidney) Raise in BG

32. Treatment 20g glucose Back up long acting carbohydrate Find the cause Adjust medication if required

33. Causes Too much insulin / OHA Too little food Timing of injection in relation to food Alcohol Exercise Injection site problems Hot weather

34. Lipohypertrophy

35. Case Histories