How to initiate insulin in Primary Care

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Type 2 diabetes is a progressive disease characterized by incessant deterioration of pancreatic cell function. With the increasing incidence of type 2 diabetes, especially among younger individuals who will live longer with their disease more patients will develop severe insulin deficiency and require insulin replacement. Because primary care providers see the vast majority of patients with type 2 diabetes, they may soon find themselves overwhelmed with insulin-requiring patients.

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Unfortunately , insulin therapy too often is used as a “punishment” for above-target hyperglycemia. A better approach would be to explain to patients early in the course of their disease, instead of at the end, the natural history of insulin deficiency in type 2 diabetes.

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The majority of patients are and continue to be treated in a primary care setting, i.e., by their general practitioner. These primary care providers, however, are often reluctant and apprehensive about using insulin in patients with T2DM.

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Physicians concerns/fears of insulin initiation are related to the following: 1- Lack of confidence in patient’s ability to manage insulin therapy. 2- Fear of hypoglycemia. 3- Complexity of insulin therapy is considered too difficult to be managed in a busy primary care practice. 4 - Difficult logistics of communicating with the patient during/after insulin initiation and titration.

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Patients also have several barriers to insulin initiation. These include: 1- Lack of self-confidence to manage insulin therapy. 2- Fear of hypoglycemia. 3- Weight gain. 4 - Need for frequent blood glucose monitoring 5- Pain associated with needle use. 6-Negative self-perceptions regarding insulin use

These factors could lead to an undue delay in making the necessary transition from oral agents to insulin. :

These factors could lead to an undue delay in making the necessary transition from oral agents to insulin . These factors could lead to an undue delay in making the necessary transition from oral agents to insulin.

What Type of Insulin to start with ?:

What Type of Insulin to start with ?

Physiology of insulin secretion :

Physiology of insulin secretion Insulin is produced by the β-cells of the pancreas to clear glucose from the blood and allow uptake of glucose by the muscle, fat, and liver. The pancreas makes a small amount of insulin, termed “ basal insulin ,”even in the fasting state to suppress catabolism of muscle, fat, and other body tissues and regulate hepatic glucose production.

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The β-cells must also respond to the glucose challenge of carbohydrate consumption and secrete insulin in appropriate amounts after a meal in an regulated manner to maintain normal glucose levels. These are the physiological mechanisms that physicians attempt to replicate with exogenous insulin therapy.

Physiologic Insulin Secretion: Basal/Bolus Concept :

Physiologic Insulin Secretion: Basal/Bolus Concept Breakfast Lunch Supper Insulin (µU/mL) Glucose (mg/dL) Basal Glucose 150 100 50 0 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 A.M. P.M. Time of Day Basal Insulin 50 25 0 Nutritional Glucose Nutritional (Prandial) Insulin Suppresses Glucose Production Between Meals & Overnight The 50/50 Rule

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Mansour is a 51-year-old male construction worker with a 9-year history of type 2 diabetes. For the first 3½ years, he was treated with metformin up to 2000 mg daily. Subsequently, he was treated with metformin plus a Glimepiride tab for 4½ years. His HbA 1c  increased progressively over those 8 years. Pioglitazone 30 mg daily was then added to the metformin plus sulfonylurea combination. Now, 14 months later, he presents with a fasting plasma glucose of 162 mg/dL and an HbA 1c  of 9.2% . Case Study

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He reports polyuria, nocturia (2 to 3 times nightly), and dryness of the mouth. He has lost 4 kg during this period. He notes progressive fatigability for the past several months. He is physically active on his job. He is not following any particular diet but claims to be "careful" with what he eats. He has no history of cardiovascular disease

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On physical examination, his blood pressure is 130/82 mm Hg, pulse is 95 beats per minute, (BMI, 29). His HbA 1c  is 9.2% . There are no abnormalities in thyroid, liver, or renal function test results. Trace microalbuminuria is present. A lipid panel reveals the following: total cholesterol 180 mg/dL , HDL cholesterol 42 mg/dL, triglycerides 158 mg/dL, and LDL cholesterol 107 mg/dL .

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What is the most likely cause of the patient's progressive severity of hyperglycemia? 1-Excessive food intake with excess carbohydrates. 2-Inadequate exercise. 3-Progressive beta-cell failure. 4 -Increasing insulin resistance. 5-Progressive beta-cell failure and increasing insulin resistance.  

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what is the preferred next therapeutic step that should be taken to treat Mansour 's poorly controlled diabetes? 1- Add a GLP-1 receptor agonist or a DPP-4 inhibitor to his existing 3 medications ( ie , use quadruple therapy) 2- Discontinue the sulfonylurea and add a GLP-1 receptor agonist or a DPP-4 inhibitor to metformin and the thiazolidinedione . 3- Initiate basal insulin therapy, with or without continuation of metformin . 4- Initiate basal-bolus insulin therapy, with or without continuation of metformin . 5- Seek an endocrine consultation.

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what is the A1c target for this patient ? 1 - < 6.5% 2 - < 7 % 3 - 7.5 - 8 %

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The ADA Recommendations on the Use of Insulin in Type 2 Diabetes

Step One: Initiating Insulin:

Step One: Initiating Insulin 1- At Initial stages of insulin use in Type 2 diabetes doctors may use single dose long acting basal insulin , because still patient Beta cell function did not fail completely. 2- Added basel insulin is given without disturbing OHA regimen . 3- The usual option is to start 10 units of Levemir (insulin detemir ) or Lantus (insulin glargine ) or or NPH (N)Post dinner.  

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If HbA 1c is <7%... Continue regimen and check HbA 1c every 3 months If HbA 1c is ≥7%... Move to Step Two… After 2-3 Months … Nathan DM et al. Diabetes Care 2006;29(8):1963-72.

Step Two: Intensifying Insulin :

Step Two: Intensifying Insulin If fasting blood glucose levels are in target range but HbA 1c ≥7% check blood glucose before lunch,dinner,bedtime and add a second injection : When number of insulin Injections increase from 1-2…..Stop of insulin secretagogues ( sulfonylureas ).

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If HbA 1c is <7% ... Continue regimen and check HbA 1c every 3 months If HbA 1c is ≥7%... Move to Step Three… After 2-3 Months… Nathan DM et al. Diabetes Care 2006;29(8):1963-72.

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Step Three: Further Intensifying Insulin Recheck pre-meal blood glucose and if out of range, may need to add another injection . If HbA 1c < 7% continue Regimen. If HbA 1c still out of range full basal-bolus insulin . . After 2-3 month

After 2-3 month :

After 2-3 month If HbA 1c < 7% continue Regimen. If HbA 1c continues to be out of range. Check 2-hr postprandial levels. 2- houre post prandial Glucose Target < 180 mg/ dL Adjust preprandial rapid-acting insulin

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Follow-up Mansour was treated with basal insulin ( Levemir) with continuation of metformin and the sulfonylurea, but the thiazolidinedione was discontinued. Despite improvements in his fasting plasma glucose and a reduction of his HbA 1c  from 9.2% to 8.4%, he remained far from his HbA 1c  goal (< 7 mmol/L ). After several months, the sulfonylurea was discontinued. and basal-bolus insulin was introduced, together with more intensive self-monitoring of blood glucose while continuing metformin. His current regimen is basal-bolus insulin combined with metformin 850 mg twice daily. His most recent HbA 1c  is 6.8% . .

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Thank You

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