1. Insulin Initiation With NovoMix30
Masoud Rahmanian MD

2. Need for treatment intensification
Over 50% of T2D patients require insulin after 6 years
Bergenstal 2001; Wright 2002 2

4. Current diabetes targets and guidelines
Insulin therapy with NovoMix® 30
Current diabetes targets and guidelines
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5. HbA1c targets are converging
Insulin therapy with NovoMix® 30
Good glycaemic
control
ADA/EASD consensus
HbA1c <7%
IDF
HbA1c≤ 7.0%
CDA (Canada)
HbA1c ≤7%
AACE (USA) HbA1c≤ 6.5%
Although the HbA1c targets recommended by international and national diabetes management guidelines are starting to converge, only a third of patients are achieving good glycemic control.
Note the important role of clinical judgement to determine which patients can reasonably and safely achieve their glycemic targets. Consideration should be given to individual risk factors such as the patient’s age, prognosis, the presence of diabetes complications or co-morbidities and the patient’s risk for, and ability to recognize, symptoms of hypoglycemia.
NICE (UK)
HbA1c %
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6. Individualising HbA1c goals
Insulin therapy with NovoMix® 30
Individualising HbA1c goals
Psycho-
Patient-centred care
Bio-
-social
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Inzucchi et al. Diabetes Care 2012;35:1364–79

7. Yet good glycaemic control is not achieved
Insulin therapy with NovoMix® 30
Yet good glycaemic control is not achieved
HbA1c (%)
10.0
12.4% have HbA1c>10.0 %
9.5
20.2% have HbA1c>9.0 %
9.0
8.5
37.2% have HbA1c>8.0 %
8.0
7.5
64.2% of patients with type 2 diabetes have HbA1c≥7.0 %
7.0
6.5
6.0
5.5
Adapted from Unger et al. Am J Med 2008;121:S3–S8.
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8. Current glycaemic targets
Insulin therapy with NovoMix® 30
Current HbA1c goals include:
ADA, EASD, IDF: <7%
AACE, JDS: ≤6.5%
Current pre- and postprandial glucose goals include:
Pre-meal: 90–130 mg/dL
PeakPP: <180 mg/dL
ADA
Pre-meal: <110 mg/dL
1–2-h peak: <160 mg/dL
IDF
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AACE, American Association of Clinical. Endocrinologists; JDS, Japan Diabetes Society

9. Insulin Initiation
Basal
Premixed
Basal- bolus

10. Analogue versus human insulin

11. Formulation of premixes
Insulin therapy with NovoMix® 30
Formulation of premixes
30%
Protamine-crystallised
insulin aspart
Soluble insulin aspart
Premixed suspension of:
Soluble
human insulin
NPH
NovoMix® Premixed human insulin
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12. Increasing complexity of insulin regimens
Insulin therapy with NovoMix® 30
Increasing complexity of insulin regimens:
Basal insulin alone is usually the optimal initial regimen, beginning at U/kg body weight, depending on the degree of hyperglycemia. It is usually prescribed in conjunction with 1-2 non-insulin agents (OGLDs). In patients willing to take >1 injection and who have higher A1c levels (≥9.0%), BID pre-mixed insulin or a more advanced basal plus mealtime insulin regimen could also be considered (curved dashed arrow lines).
When basal insulin has been titrated to an acceptable FPG but A1c remains above target, consider proceeding to basal + meal-time insulin, consisting of 1-3 injections of rapid-acting analogues. A less studied alternative—progression from basal insulin to a twice daily pre-mixed insulin—could be also considered (straight dashed arrow line); if this is unsuccessful, move to basal + mealtime insulin.
The figure describes the number of injections required at each stage, together with the relative complexity and flexibility. Once a strategy is initiated, titration of the insulin dose is important, with dose adjustments made based on the prevailing BG levels as reported by the patient.
Non-insulin agents may be continued, although insulin secretagogues (sulfonylureas, meglitinides) are typically stopped once more complex regimens beyond basal insulin are utilized.
Comprehensive education regarding self-monitoring of BG, diet, exercise, and the avoidance of, and response to, hypoglycemia are critical in any patient on insulin therapy.
ADA/EASD Position Statement. Diabetologia Online; 24 February 2012
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13. NovoMix® 30 is a solution Insulin therapy with NovoMix® 30
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14. Diabetes Care 2013
Insulin therapy with NovoMix® 30
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15. Diabetes Care 2013
Insulin therapy with NovoMix® 30
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16. CONCLUSION: Biphasic and basal bolus regimens were equally effective in reducing HbA1c in insulin naïve patients with T2DM and both regimens are equally effective for initiating insulin in T2DM. Wang C1, Mamza J, Idris I. Diabetic Medicine Jan 16

17. NovoMix®30 or Mixed Human Insulin
Insulin therapy with NovoMix® 30
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18. The dual-release insulin concept: BHI 30
Insulin therapy with NovoMix® 30
The dual-release insulin concept: BHI 30
Physiological insulin profile:
basal component
meal-related peaks
Physiological insulin profile
…together these fail to re-create the physiological insulin profile
BHI 30
Soluble insulin fails to match normal insulin peak
Soluble human insulin
Intermediate-acting insulin provides basal insulin replacement but…
NPH
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19. The dual-release insulin concept
Insulin therapy with NovoMix® 30
The dual-release insulin concept
Physiological insulin profile:
basal component
meal-related peaks
Physiological insulin profile
Premix analogues such as NovoMix® 30 replace both meal-related and basal insulin
NovoMix® 30
Rapid-acting insulin analogues together with a basal insulin provide physiological insulin replacement
Soluble insulin aspart
Protamine crystallised insulin aspart
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20. Benefits of analogue mix insulin
NovoMix® 30 provides significantly greater PPG control than BHI 30 and insulin glargine
50% more people reach recommended HbA1c target with NovoMix® 30 than insulin glargine
NovoMix® 30 is a convenient way to start insulin, with a simple dosing guideline and the easy-to-use FlexPen®
Insulin therapy with NovoMix® 30
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21. Insulin therapy with NovoMix® 30
Overall hypoglycaemia rate following switch from biphasic human insulin to biphasic aspart
n=6323
In addition, overall hypoglycaemia decreased from 6.0 events/patient-year at baseline to 2.1 events/patient-year at Week 24.
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El Naggar et al. Diabetes Res Clin Pract 2012;98:408–13

22. Diabetes Care 2013
Insulin therapy with NovoMix® 30
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23. Insulin therapy with NovoMix® 30
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24. Intensifying from BIAsp 30 BID to TID
BIAsp, biphasic insulin aspart; BID, twice daily; OD, once daily; TID, three-times daily; TZDs, thiazolidinediones
Unnikrishnan et al. Int J Clin Pract 2009;63:1571–7

25. Conclusion NovoMix® 30: Insulin therapy with NovoMix® 30
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26. NovoMix® 30 Improve Glycaemic Control Improve Safety Profile
Insulin therapy with NovoMix® 30
NovoMix® 30
Improve Glycaemic Control
Improve Safety Profile
Improve Convenience
In one Insulin, one Device
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27. “Always aim at complete harmony of thought and word and deed”
Insulin therapy with NovoMix® 30
“Always aim at complete harmony of
thought and word and deed”
Gandhi
Aim at complete harmony
Patient and Physician and Prescription
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28. Any Question?
Insulin therapy with NovoMix® 30
26 April, 2017