Starting and Helping People with Type 2 Diabetes on Insulin

Elaine Cooke, BSc(Pharm), RPh, CDE

Pharmacist and Certified Diabetes Educator

Maple Ridge, BC

After attending this session, participants will be able to:

Objectives

• Understand the unique needs and challenges to consider when

initiating insulin therapy in people with type 2 diabetes

• Recognize hypoglycemia, its causes and the physical and

psychological impact it has on people with diabetes

• Explain how self-monitoring of blood glucose (SMBG) can assist

people using insulin to recognize issues, problem solve and adjust

their insulin when blood glucose (BG) is not at target

• Recognize SMBG “best practices” and counsel people with type 2

diabetes on insulin therapy accordingly

3

4

Diabetes Progression

•50% of ß-cell function is already lost at diagnosis

•ß-cell function will continue to decline despite treatment

Impaired

glucose

tolerance

100

75

50

25

Years from Diagnosis

Bet

a C

ell

Fu

nct

ion

(%

)

-12 -10 -6 -2 0 2 6 10 14

Postprandial

hyperglycemia

Type 2

diabetes

phase I Type 2

diabetes

phase II

Type 2 diabetes

phase III

Lebovitz HE Diabetes Rev 1999:7 139-53.

Stages of Type 2 Diabetes in

Relationship to ß-cell Function

Type 2 Diabetes is a Progressive Disease

6

Issues, Barriers and Patient Needs

Clinician barriers to insulin therapy may be due to:

Barriers to Starting Insulin Therapy

• Perceived complexity of the therapeutic regimen

• Belief that it is not effective in type 2 diabetes

• Fear of hypoglycemic episodes, weight gain and associated

cardiovascular risks

• Fear that insulin therapy will require careful monitoring, more

physician time, and other practice resources

7

Davis SN, Renda SM. Diabetes Educator 2006; 32(4):146S-52S.

Barriers to Starting Insulin Therapy

Insulin therapy may have negative

connotations for some patients:

• Sense of loss of control over

one’s life

• Reduced quality of life

• Sense of personal failure to control

the disease

• Side effects such as weight gain

and hypoglycemia

• Daily, possibly painful, injections

Establish a sense of patient control

by informing patients that:

• Their symptoms will improve with

insulin therapy

• They will be taking a more active

role in managing their diabetes

• Basal insulin regimens are easy to

administer and can be administered

at bedtime

• There are strategies to prevent

hypoglycemia

8

Davis SN, Renda SM. Diabetes Educator 2006; 32(4):146S-52S.

9

Initiating Insulin in Type 2 Diabetes

10

Insulin can be used:

• At diagnosis

• During illness, surgery or

pregnancy

• At any time glycemic targets are

not being met

- Glycemic targets must be individualized.

Target for most individuals with diabetes

is a glycated hemoglobin (A1C) ≤ 7.0%

Insulin in Type 2 Diabetes

CDA Clinical Practice Guidelines. Can J Diabetes 2013;37(Suppl 1):S1-S212;

Harper W, et al. Can J Diabetes 2013;37(Suppl 1):S61-S68, Chapter 13.

Polling Question:

Which of the following is not a barrier to starting insulin? A. Clinician fear it will require more time and practice resources B. Sense of personal failure to control diabetes C. Concerns over cost of therapy D. Concerns that injections will be painful

12

Tailor treatment to the individual. There are many options:

• Start with a basal insulin in addition to oral antihyperglycemic agents

• Start with a premixed insulin in addition to oral antihyperglycemic agents

• Start with intensive insulin therapy (less common and not generally

recommended)

Insulin in Type 2 Diabetes

CDA Clinical Practice Guidelines. Can J Diabetes 2013;37(Suppl 1):S1-S212, Appendix 3.

Resource Slide

Basal Insulin added to Oral Antihyperglycemic

Insulin

• Neutral protamine hagedorn (NPH), glargine U-100, detemir, glargine U-300, degludec

(U-100 and U-200)

Dosing

• Starting dose is generally 10 units daily at bedtime. Can be administered at other times

of day.

Titration

• Several titration regimens are acceptable

• For glargine U-100 or detemir, one regimen is to increase dose by 1 unit every night

until fasting BG has reached their individual target (e.g., 4.0-7.0 mmol/L [ADA 90-130

mg/dL])

• Stop titrating if 2 episodes of hypoglycemia occur in a week or any nocturnal

hypoglycemia

• Insulin glargine U-300 and insulin degludec should not be up-titrated more often than

every 3-4 days due to their longer duration of activity

13

CDA Clinical Practice Guidelines. Can J Diabetes 2013;37(Suppl 1):S1-S212, Appendix 3; CDA Insulin Prescription Tool for Healthcare Providers

[http://guidelines.diabetes.ca/bloodglucoselowering/insulinprescriptiontool]; Toujeo Package Insert; Tresiba Package Insert

Standards of Medical Care in Diabetes—2016 January 2016 Volume 39, Supplement 1-American Diabetes Association Garber, AJ, et al.Endocrine Practice,

2013;19(Suppl 2):1-38.

14

What to discuss with the Patient

Type and starting dose of insulin

• Explain onset, peak, duration, preparation

and storage

Titration schedule

• When to check and what BG targets are being

used for titration

How to use injection device

Injection site and rotation of injections

Hypoglycemia: symptoms, treatment, prevention

• Sick day guidelines

• Driving guidelines

Follow-up date to discuss concerns

Insulin Pen Start Checklist Help Sheet [http://www.diabetes.ca/CDA/media/documents/clinical-practice-

and-education/professional-resources/insulin-pen-checklist-help.pdf]

Resource Slide

Getting Started with Insulin:

Patient Handout

15

Resource Slide

Provide Patient

Insulin Type, Dose and Action

• Type and starting dose of insulin

• Onset, peak, duration and storage

16

Insulin Type Onset Peak Duration

Basal Insulins

Intermediate-acting insulin (cloudy):

• Insulin NPH 1 - 3 h 5 - 8 h Up to 18 h

Long-acting basal insulin analogues (clear)

• Insulin detemir • Insulin glargine U-100 • Insulin glargine U-300 • Insulin degludec

90 min 90 min

Up to 6 h1 60 min

Not applicable

Up to 24 h (detemir 16-24 h)

Up to 24 h (glargine 24 h)

Up to 30 h

Up to 42 h

Harper W, et al. Can J Diabetes 2013;37(Suppl 1):S61-S68, Chapter 13; Toujeo Package Insert; Tresiba Package Insert 1Per Package Insert, onset of action

develops over 6 hours after administration.

Resource Slide

17

• Consult directions with each pen

• New pen needle for each injection

• Re-suspend cloudy insulin (NPH),

tap to send any air bubbles to end

of needle

• Prime with a 2 unit shot each time;

a drop of insulin should appear.

Repeat until a drop appears

Insulin Pens

• Dial dose and perform injection

90⁰ • Count to at least 10, then

remove needle and discard in

sharps container

• Use pen needle length of 4 to 6 mm

Insulin Pen Start Checklist Help Sheet

[http://www.diabetes.ca/CDA/media/documents/clinical-practice-and-

education/professional-resources/insulin-pen-checklist-help.pdf]; Gibney MA, et

al. Curr Med Res Opin 2010;26(6):1519-30.

Resource Slide

Injection Site Rotation

Injection Site

• Abdomen fastest, most consistent absorption, followed by the outer arm, thigh

and buttock

Site Rotation

• Divide injection site into quadrants, use one quadrant weekly separating all

injections by a finger width

Site Preparation • Clean with soap and water

• Alcohol is not required; if used let dry completely

• With 4-6 mm pen needles a skin lift is usually not required unless very lean;

hold skin and lift until injection complete

18

FIT Forum for Injection Technique Canada [https://www.bd.com/resource.aspx?IDX=25063]; FIT Technique Plus Technique for All

[http://www.fit4diabetes.com/files/8713/6544/1790/FIT_Technique_Plus_-_Technique_for_All.pdf]

Resource Slide

19

Hypoglycemia

Lower rates of hypoglycemia have been

observed with rapid acting analogues

than regular insulin

Use of long-acting basal insulin

analogues reduces the risk of nocturnal

hypoglycemia compared to NPH

Causes of hypoglycemia: • Missed meals, smaller or delayed meals

• Too much medication

• Unplanned or extra activity

• Consuming alcohol

CDA Clinical Practice Guidelines. Can J Diabetes 2013;37(Suppl 1):S1-S212; Meece J. Diabetes

Educ 2006;32;9S-18S.

20

Symptoms of Hypoglycemia Symptoms vary from person to person

Early Signs • Trembling, shaking

• Dizzy, light headed

• Palpitations

• Sweating

• Anxiety

• Hunger

• Nausea

• Tingling

• Headache

• Blurred vision

Late Signs • Difficulty concentrating

• Confusion

• Changed behaviour

• Drunk-like behaviour

• Trouble speaking

• Loss of consciousness

Clayton D, et al. Can J Diabetes 2013;37(Suppl 1): Chapter 14.

Hypoglycemia Treatment

Check BG and treat if below 4.0 mmol/L (ADA 70 mg/dL)

Give 15 g fast acting carbohydrate preferably as 3 to 4 dextrose

tablets or: • 15 mL (3 teaspoons) or 3 packets of table sugar

• 175 mL (3/4 cup) juice or regular soft drink

• 6 lifesavers (1=2.5 g of carbohydrate)

• 15 mL (1 tablespoonful) of honey

• 4 x dextrose 4 g tablets

Wait 15 minutes, retest BG and retreat with another 15 g

carbohydrate if BG < 4.0 mmol/L (ADA 70 mg/dL)

If next meal is more than 1 hour away once hypoglycemia has been

reversed, have a snack with 15 g carbohydrate and a protein source

21

Briscoe V, et al. Clinical Diabetes 2006;24;115-21; CDA Clinical Practice Guidelines. Can J Diabetes 2013;37 (Suppl 1):S1-S212

Standards of Medical Care in Diabetes—2016 January 2016 Volume 39, Supplement 1-American Diabetes Association Garber, AJ, et al.Endocrine Practice,

2013;19(Suppl 2):1-38.

.

Prevention of Hypoglycemia for all Insulin-Treated Drivers

22

Measure BG level immediately before and at least every 4 hours

during long drives

Do not drive when BG level is < 4.0 mmol/L (ADA 70 mg/dL) • Do not begin to drive without having some carbohydrate-containing food when

your BG level is 4.0 to 5.0 mmol/L (ADA 70 to 90 mg/dL)

Stop and treat yourself as soon as hypoglycemia and/or impaired

driving is suspected • You should not drive for at least 45 to 60 minutes after effective treatment of

mild to moderate hypoglycemia

Insulin Pen Start Checklist Help Sheet; CDA Getting Started with Insulin 2013

Standards of Medical Care in Diabetes—2016 January 2016 Volume 39, Supplement 1-American Diabetes Association Garber, AJ, et al.Endocrine Practice,

2013;19(Suppl 2):1-38.

.

Polling Question:

Which of the following should be discussed with patients starting insulin? A. Onset, peak, duration, preparation and storage of insulin B. Injection site selection and rotation C. Hypoglycemia recognition, treatment and prevention D. All of the above

24

Patient Education and Tools

Patient should leave from insulin start

session with:

• Insulin, pen or syringes and sharps container

• Dose of insulin, when to inject and titration

protocol

• Knowing injection technique: how, where, site

rotation

• Hypoglycemia sheet for signs, symptoms and

treatment

• Log book, test times and BG targets

• Appointment for follow-up call

25

Intensifying Insulin Therapy

Adding Bolus Insulin

Basal Plus Strategy:

26

Dosing • Starting dose: 2 to 4 units

• Patient can be taught self titration, or dose increase can be done by the health

care practitioner

• The mealtime (bolus) insulin dose may be initiated at one meal daily (generally

the largest meal of the day)

Titration • To safely increase dose, glucose levels should be measured at least prior to

insulin dose, then titrated by 1 unit daily to either of the following targets:

• 2 hour post-meal glucose of ≤ 10.0 mmol/L (ADA 180 md/dL)

(or ≤ 8.0 mmol/L [144 mg/dL] in certain cases)

• Pre-next meal glucose of 4.0 to 7.0 mmol/L (ADA 90 to 130 mg/dL)

CDA Clinical Practice Guidelines. Can J Diabetes 2013;37(Suppl 1):S1-S212, Appendix 3; CDA Insulin Prescription Tool for Healthcare Providers

[http://guidelines.diabetes.ca/bloodglucoselowering/insulinprescriptiontool]; Harper W, et al. Can J Diabetes 2013;37(Suppl 1):S61-S68, Chapter 13

Standards of Medical Care in Diabetes—2016 January 2016 Volume 39, Supplement 1-American Diabetes Association Garber, AJ, et al.Endocrine Practice,

2013;19(Suppl 2):1-38.

.

27

Using SMBG

28

Benefits of SMBG

SMBG identifies glycemic excursions to

allow for day-to-day adjustments of

activity, diet and medication. It can:

• Determine preprandial and postprandial

hyperglycemia

• Confirm hypoglycemia, allowing for appropriate

treatment

• Detect glycemic excursions, providing

immediate feedback to patients about the effect

of food choices, activity and medication on

glycemic control

Awareness of SMBG and A1C provide the best

information to assess glycemic control and help

patients on insulin make changes and regain control CDA Clinical Practice Guidelines. Can J Diabetes

2013;37(Suppl 1):S1-S212; Parkin CG, et al. J Diabetes

Sci Technol. 2009;3:500-8. .

Regular SMBG Frequency

29

Situation SMBG Recommendation

Using multiple daily injections of insulin

(≥ 4 times per day)

Using an insulin pump

SMBG ≥ 4 times per day

Using insulin < 4 times per day SMBG at least as often as insulin is being given

Pregnant (or planning a pregnancy),

whether using insulin or not

Hospitalized or acutely ill

SMBG individualized and may involve

SMBG ≥ 4 times per day

Starting a new medication known to

cause hyperglycemia (e.g. steroids)

Experiencing an illness known to

cause hyperglycemia (e.g. infection)

SMBG individualized and may involve

SMBG ≥ 2 times per day

CDA Clinical Practice Guidelines Expert Committee. Appendix 4. Can J Diabetes 2013;37(Suppl 1):S197-S212.

http://guidelines.diabetes.ca/BloodGlucoseLowering/SMBGRecommendationSheet

Increased SMBG Frequency

30

Situation SMBG Recommendation

Using drugs known to cause hypoglycemia

(e.g. sulfonylureas, meglitinides)

SMBG at times when symptoms of

hypoglycemia occur or at times when

hypoglycemia has previously occurred

Has an occupation that requires strict

avoidance of hypoglycemia

SMBG as often as required by employer

Not meeting glycemic targets SMBG ≥ 2 times per day, to assist in lifestyle

and/or medication changes until such time as

glycemic targets are met

Newly diagnosed with diabetes

(< 6 months)

SMBG ≥ 1 time per day (at different times of

day) to learn the effects of various meals,

exercise and/or medications on BG

Treated with lifestyle and oral agents and

is meeting glycemic targets

Some people with diabetes might benefit from

very infrequent checking (SMBG once or twice

per week) to ensure that glycemic targets are

being met between A1C tests

CDA Clinical Practice Guidelines Expert Committee. Appendix 4. Can J Diabetes 2013;37(Suppl 1):S197-S212.

http://guidelines.diabetes.ca/BloodGlucoseLowering/SMBGRecommendationSheet

31

• Requires a review of all parameters that affect BG

• Involves reviewing a record of glucose values, food, physical activity,

medication administration and other factors that may affect blood sugar

Do not react to one BG value. 3 to 4 days of information are required to determine

a pattern

Organize results so that all BG values occurring at the same time of day can be

seen and reviewed together

Pattern Management

Mensing C, Ed. The Art and Science of Diabetes Self Management Education, 2006 American Association of Diabetes Educators; Chapter 16, pp 357-370.

Resource Slide

If more than one pattern appears, prioritize the work of bringing the

pattern back into target range:

Prioritizing Treatment

32

1. Always fix hypoglycemia (< 4.0 mmol/L [ADA 70 mg/dL]) first

2. Bring fasting BG into target next

3. Work on hyperglycemia patterns, usually looking at pre-meal values followed

by post-meal values

Remember to:

• Adjust only one insulin at a time

• Adjust the insulin dose by no more than 10% at a time

• Reassess BG values after several days before making further changes

Rodbard D. J Diabetes Sci Technol 2007;1:62–71

Standards of Medical Care in Diabetes—2016 January 2016 Volume 39, Supplement 1-American Diabetes Association Garber, AJ, et al.Endocrine Practice,

2013;19(Suppl 2):1-38.

33

Adjusting Insulin When adjusting insulin you need to adjust

the insulin that affects the BG value you are

concerned with

Blood glucose value at: Adjust:

Fasting/pre-breakfast Bedtime basal

Pre-lunch Breakfast bolus

Pre-supper Lunch bolus

Bedtime Supper bolus

CDA Clinical Practice Guidelines Expert Committee. Appendix 4. Can J Diabetes 2013;37

(Suppl 1):S197-S212.

34

Adjusting Insulin If on BID combinations of premixed insulin,

typically pre-breakfast and pre-supper, you

need to be aware of what insulin affects the

BG value

Blood glucose value at: Adjust:

Fasting/pre-breakfast Pre-supper premix

Pre-lunch Pre-breakfast premix

Pre-supper Pre-breakfast premix

Bedtime Pre-supper premix

CDA Clinical Practice Guidelines Expert Committee. Appendix 4. Can J Diabetes 2013;37

(Suppl 1):S197-S212.

Polling Question:

In what order should you address recognized patterns in blood glucose records? A. Fasting blood glucose, hypoglycemia then hyperglycemia B. Hypoglycemia, hyperglycemia then fasting blood glucose C. Hypoglycemia, fasting blood glucose then hyperglycemia

Summary

Due to progressive beta cell loss, insulin will be required in the

majority of individuals with type 2 diabetes

Basal insulin at bedtime is the most common method of starting

insulin in type 2 diabetes and patients can self-titrate

Use Basal Plus strategy to intensify insulin therapy

SMBG is essential in making changes to therapy using pattern

management

It is important to educate patients on the following: • Insulin: action, dose, storage, titration, injection technique and site

• Hypoglycemia

• Driving guidelines

36

Insulin Initiation and Titration

CDA Insulin Initiation and Titration Suggestions/Prescription Form

38

Resource Slide

Getting Started with Insulin:

Patient Handout

39

Resource Slide

Sick Day Guidelines

HealthLink BC Guidelines

40

Resource Slide

Bolus Insulins

41

Insulin Type Onset Peak Duration

Bolus (prandial) Insulins

Rapid-acting insulin analogues (clear):

• Insulin aspart

• Insulin glulisine

• Insulin lispro

10 - 15 min

10 - 15 min

10 - 15 min

1 - 1.5 h

1 - 1.5 h

1 - 2 h

3 - 5 h

3 - 5 h

3.5 - 4.75 h

Short-acting insulins (clear):

• Insulin regular

30 min

2 - 3 h

6.5 h

Resource Slide

Premixed Insulins

HealthLink BC Guidelines

42

Insulin Type Time action profile

Premixed Insulins

Premixed regular insulin – NPH (cloudy):

• Regular 30%/NPH 70%

A single vial or cartridge contains a

fixed ratio of insulin (% of rapid-acting

or short-acting insulin to % of

intermediate-acting insulin) Premixed insulin analogues (cloudy):

• Biphasic insulin aspart

• Insulin lispro/lispro protamine

Resource Slide

Insulin Pen Start Checklist and Help Sheet

Checklist and Help Sheet

43

Resource Slide

Fit Canada Injection Technique

FIT Forum Best Practices FIT Technique for All

44

Resource Slide

Driving Guidelines

Getting Started with Insulin New Driving Guidelines

45

Resource Slide

CDA SMBG Tools

SMBG Recommendation Tool for Healthcare Providers Self-SMBG Frequency & Pattern Tool

46

Resource Slide