Download Management type 2 DM with Insulin and when to use or not to use

Management type 2 DM
with Insulin
Workshop 1
and when to use or not to
use
Resources
needed to do it
properly
The minimum
 Staff
support who are trained
 Access to dietician and podiatrist
 Access to Nurse specialist team if needed
 Basic supplies to start and maintain insulin
 Knowledge of the equipment
 Know about glucagon
 Computer and relevant software
 Patient brochures
Knowledge to do it properly
 Know
your insulins and know the oral agents
 Know the delivery systems for insulin
 Work out patient (patho) physiology
 Get a correct classification of DM if possible
 Understand benefit and risk
 Recognise futility
Big room… lots of people
Participation essential
Share experiences please
Work stations set up for hands on
Introduction Case: Mrs RS
 54 years old
 School assistant; clerical; low responsibility
 Married; says one of the few positives in her
life
 3 children, all adult and overseas or elsewhere
 Diabetes 14 years
 Overweight all adult life now 112 kg, BMI: 39
 General job/life dissatisfaction and hates being
so fat
 Little exercise but tries and loses momentum
 Financially OK, no house mortgage
Diabetes history
Medication
 Metformin 1g bd
 Gliclazide 160 mg BD
 Pioglitazone 30 mg (3 years)
 Insulin 120 units glargine at 9pm (>1U/kg) for last year
Blood glucose
 Glycaemia poorly controlled: A1c 9-10 % (75-85 mmol/mol)
Recent evening preprandial BGLs average 11 mmol/L
 Recent evening postprandial BGLs average 15 mmol/L

Significant other health factors;
no other issues if not detailed
Medications
 ACE plus CCB
 Statin
Blood pressure usually <130 sBP
LDL 2.1 mmol/l, HDL 1.0 mmol/l, Trigs 2.5 mmol/l
with a glucose profile like this
20
INSULIN glargine 120 U
15
Plasma glucose (mmol/L)
Plasma glucose (mmol/L)
20
15
10
10
5
5
Meal
Meal
Meal
0
0
06:00
10:00
14:00
18:00
22:00
02:00
06:00
What would you do and how?
What resources would you need?
Back to the case
Mrs RS
 Using
 Very
Metformin, Pio, SU, Insulin at high dose
high HbA1c
Mrs RS: what really happened


Tried basal bolus finally after other insulin regimens failed
No change in glucose parameters despite getting up to 200
U per day
 Piogliazone stopped; no benefit seen




Roux-en Y
Insulin fell to 40 Units per day single dose
Felt much better, mood better.. More energy.. I feel alive
Moved job, now CEO large firm

‘’should have done it years ago’ and maybe would not have
needed insulin.
What if…?
She was 74
kg using 42
units
And this is the Insulin profile
And not 112 kg
using 120 units
With glucose profile like this
20
15
15
10
10
5
Plasma glucose (mmol/L)
Plasma glucose (mmol/L)
20
5
Meal
Meal
Meal
0
0
06:00
10:00
14:00
18:00
22:00
02:00
06:00
What would you do and how?
Basal bolus best
20
15
15
10
10
5
Plasma glucose (mmol/L)
Plasma glucose (mmol/L)
20
5
Meal
Meal
Meal
0
0
06:00
10:00
14:00
18:00
22:00
02:00
06:00
More cases
Case 1: 25 yr male with type 1 DM for 10
years going on o/s experience

Using basal bolus insulin of Glargine (18 Units) and Humalog 4-6
Units pre meal usually, with corrections as needed. Generally holds
A1c about 55-60 mmol/mol and no hypo issues.

Seeks help as about to go overseas to Europe by self; wants to
know how to manage insulin on flight

Plane goes at 7pm to Auckland from CHCH then leaves to Los
Angeles at 2130pm arriving 1500hrs on the same day in Los
Angeles after 12 hour flight. 2 meals served, one at departure and 1
just prior to landing

Transit in a closed room for 1 hour then boards again for another 11
hour evening flight to Heathrow. Departs at 1700 hrs and arrives
11am in London. Two meals again.
Case 2; 67 year old women with
Type 2 DM on metformin
 HbA1c
usually 6.6% or 50
 You diagnose PMR and start on Prednisone
40 mg am
 Glucose
levels take off and go into double
figures during the day
Case 3: 40 years diabetes and using
insulin for 20 years
currently Humalog Mix 25 BD
 Doses
are 28 U am and 40 U pm
Case 4: 50 year old male, weight 71 kg
 On
Humalog Mix 25 30 U am and 20 Units pm
pre meals of breakfast and dinner for 1 year.
 Insulin resulted in much improved glucose levels
and better energy.
 Using metformin as well
 Glycaemic regulation: Hb A1c 50 mmol/mol
 Evening insulin reduced over last few months
because prone to hypos around 3 am; needed
ambo only once in last year.
 Not keen on more injections
Case 5: Called to see male patient
aged 42 who has D and V’s
 Others in same situation in house.
 Can’t hold solids down but is having
some oral
fluid.
 Diarrhoea about 6 times per day
 Usual Insulin is Humalog mix 25: 30 U am and 30
Units pm
 Body weight is 63 kg
 On
insulin since aged 36 yrs, and usually well
regulated
Case 6: spot diagnosis
Case 7: female aged 62 and 94 kg
 Taxi
driver doing shift work
 On Metformin and SU at max doses
 12 years DM
 Glucose levels often double figures when
tested.
 Has refused Insulin to date