Roller Coaster of Insulin Therapy Rationale for insulin therapy in type 2 diabetes

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Problems and challenges Problems and challenges in patients with type 1 in patients with type 1 diabetes. diabetes. Larry A Distiller Centre for Diabetes and Endocrinology Johannesburg

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The South African Journal of Diabetes & Vascular Disease presents: Problems and challenges in patients with type 1 diabetes. Larry A Distiller Centre for Diabetes and Endocrinology Johannesburg http://www.diabetesjournal.co.za

Transcript of Roller Coaster of Insulin Therapy Rationale for insulin therapy in type 2 diabetes

Page 1: Roller Coaster of Insulin Therapy Rationale for insulin therapy  in type 2 diabetes

Problems and challenges Problems and challenges in patients with type 1 in patients with type 1

diabetes.diabetes.

Larry A Distiller

Centre for Diabetes and Endocrinology

Johannesburg

Page 2: Roller Coaster of Insulin Therapy Rationale for insulin therapy  in type 2 diabetes

Type 1 Diabetes

Type 1 DM is, in essence, a simple hormone deficiency state……

Beta cell destruction results in Insulinopenia.

Exogenous Insulin is freely available. Replace this missing hormone

In concept, no different from hypothyroidism, HRT etc.!

So what’s the problem?

Page 3: Roller Coaster of Insulin Therapy Rationale for insulin therapy  in type 2 diabetes

Redefining the “problem” of diabetes

Diabetes the “Illness”:Patient has symptoms of hyperglycemia

Symptoms treated

Patient no longer ill!

Able to continue “normal” lifestyle with minimum disruptions.

Achieved with blood glucose <15mmol/l

Page 4: Roller Coaster of Insulin Therapy Rationale for insulin therapy  in type 2 diabetes

Redefining the “problem” of diabetes

Diabetes the “Risk Factor”:

The need to achieve as good glycaemic control as possible (HbA1c <7%) to avoid microvascular (and possibly macrovascular) complications.

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Targets for glycaemic control are set.

HbA1c <7%

FPG 4.4-6.7 mmol/l

PPG <10mmol/l But are seldom achieved

WHY?

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THEORETICAL BARRIERS TO CONTROL

Patient BarriersAgeGenderEducational levelPast experience with diabetesRace EthnicitySocioeconomic statusAttitudesPersonalityEnergy LevelPhysical HealthMental HealthReligionEmotional StatePast Experience with diabetes educationStress

Education BarriersVisionProfessionValuesKnowledgeSkillsAttitudePersonalityGenderEnergy LevelExperienceFlexibilityEthnicityReligion

Environmental BarriersStressEducational MethodReimbursement Physical SettingPart of countryWeatherFamilyFriendsWorkCultureProblems re:•Nutrition•Exercise•Medication•Foot Care•Emergencies

Page 7: Roller Coaster of Insulin Therapy Rationale for insulin therapy  in type 2 diabetes

The Treatment of the Patient with type 1 diabetes changed forever following the DCCT.

This change was preceded by and made possible by

the advent of three things:

Page 8: Roller Coaster of Insulin Therapy Rationale for insulin therapy  in type 2 diabetes

The foundation of modern diabetes management

SHGMPen

Devices/CSII

Diabetes Nurse

Educator

Intensive management of type 1 diabetes

Page 9: Roller Coaster of Insulin Therapy Rationale for insulin therapy  in type 2 diabetes

Allows for

Patient self-empowerment

Better acceptance of diabetes & its treatment through better patient counseling, education and understanding

Self-adjustment of insulin doses

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Goals of Insulin Therapy

• To achieve blood glucose profiles as close to the euglycaemic range as possible.

Target : HbA1c <7%

• To provide as much flexibility as possible.

• To ensure the best quality of life.

And at the same time to minimize hypoglycaemia

This is best done by mimicking normal insulin secretion as closely as possible

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Know & Understand your Insulins

• Types

• Onset of Action

• Onset & Duration of

Peak Action

• Total Duration of

Action

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Know Your Patient !

Each person is as unique as a fingerprint

• Age / self care ability

• Coexisting conditions

• Type & duration of diabetes

• Exercise

• Meal plan

• Medications / alcohol

• Complications etc…

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Your Client Must Also Understand the Insulin

• First: Listen

• Counsel – it is not a normal human activity to stab oneself repeatedly

• Educate

• Regular review & follow-up

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Decide

Which Insulin Regimen?Which Insulins?What expectations?

The patient cannot be dictated to, but must be a partner in the decision process.

The more frequently one injects, the more flexibility in life-style.

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Helping Your Patient Choose a Regimen

You get what you pay for!

• “Pay” 4 -5 injections “Buy” flexibility, quality of life, improved

control

• “Pay” 2 injections “Buy” control only with regimented

lifestyle and strict dietary habits

But in the end the PATIENT must make the choice. It is he/she, not you, who

has to live with it!

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And how low to go?

• The lower the HbA1c, the tighter the control, the higher the risk of hypoglycaemia.

• In most patients, the fear of hypoglycaemia in the short term exceeds the fear of long-term complications

So how low should we go?

Is a target HbA1c of <7% acceptable for everyone?

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Should the Risk of Hypoglycaemia modify our

Treatment?Yes

Age (<8yrs: >60yrs

CVD

Advanced Complications

Hypo Unawareness

Job-Risk

Sleeping alone

Etc.

No

Young

Healthy

Aware

Fit

Compliant

Most patients in the middle !

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And what about SHGM

FAQ

• How often?• When?• What does it mean?

“The answer, my friends, is blowing in the wind”

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There are four kinds of ‘testers”

1. Those who won’t

2. Those who don’t

3. Those who do – by “rote”.

4. Those who do with purpose.

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Those who won’t

• These patients refuse to test

or• Test 2-3 times a month – a pointless exercise

or• Prefabricate test results

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Those who don’t

• Test only when they “feel bad”, to confirm low or high blood glucose levels.

• Seldom test when they “feel alright”.

Not a cost-effective exercise and largely a waste of time

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Those who do – by “rote”

• These patients test 4 times a day, often obsessively, but do nothing whatsoever about the results.

• They seem to believe that either:

• Testing regularly makes them “good diabetics”

• Regular home glucose monitoring is therapeutic

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Page 24: Roller Coaster of Insulin Therapy Rationale for insulin therapy  in type 2 diabetes

Those who do with purpose

Two groups:

• Fixed dose insulin therapy

• Functional Insulin therapy

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Fixed dose insulin therapy

• May be on twice daily or multiple injection regimen

• Insulin dose is fixed – no attempt to anticipate, no adjustment with meals.

In these patients “pattern testing” is recommended.Test 2-3 times a day at different times.Adjust insulin every 2-3 days.

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Functional Insulin therapy

• Carbohydrate-counting

• Regular before meal adjustments

• Corrective doses

The ideal situationTest 4+ times a day meaningfully

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Rules of Testing

No amount of sophistication is going to allay the fact that all your knowledge is about the past and all your decisions are about the future.

-Ian E Wilson

• Set Targets: the patient must know what glucose levels are satisfactory, which are too high and which are too low.

• Avoid hypoglycaemia. Lowest level recommended should be ≥4 mmol/l.

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Rules of Testing

And above all:

Always ask “why?”

• Why am I too high

• Why am I low?

• Why is my blood glucose normal?

And learn from past mistakes

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Don’t Try to Change History !

• Do not adjust insulin retrospectively

• History cannot be changed

• Pre meal / pre-bed results help to indicate adequacy of previous dose