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Insulin Elixir of life Dr. Sergio Diez Alvarez Staff Specialist Physician The Challenge Mr XL has type 2 diabetes and has been on Oral Hypoglycemic Agents (metformin + glibenclamide) for 8 months, his HbA1c is 8.3% and you have decided to offer him the option of going on to insulin. In theory, there is no difference between theory and practice. In practice, there is a big difference. -Unknown Understand the Stakeholders The Willing Patient The Willing Clinician The Insulin type and Regimen The Delivery Device Safety Accessories Other factors The Patient Insulinopaenia – beta cell reserve Insulin Resistance – mainly hepatic, muscle, and adipose tissues Type 1 – complete insulin deficiency Type 2 – Insulin dependent (LADA) vs. insulin requiring DAWN Study Resistance to Insulin Therapy Among Patients and Providers Results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study Diabetes Care November 2005 vol. 28 no. 11 2673-2679 Patients Patients rate the clinical efficacy of insulin as low and would blame themselves if they had to start insulin therapy. Self-blame is significantly lower among those who have better diet and exercise adherence and less diabetes-related distress. Patients who are not managing their diabetes well (poor perceived control, more complications, and diabetes-related distress) are significantly more likely to see insulin therapy as potentially beneficial. The Clinician Most nurses and general practitioners (50–55%) delay insulin therapy until absolutely necessary, but specialists and opinion leaders are less likely to do so. Delay of insulin therapy is significantly less likely when physicians and nurses see their patients as more adherent to medication or appointment regimens, view insulin as more efficacious, and when they are less likely to delay oral diabetes medications. Resources were considered barely adequate currently and there were concerns about worsening problems with increasing numbers of patients with diabetes, and increased use of insulin Clinicians Shifting 1980s - clinicians tended to be more pessimistic than patients and overestimate the barriers complying with treatment. Insulin was seen as efficacious but there was resistance because of a lack of support, a skills deficit, and a lack of confidence and experience in starting insulin. Psychological Resistance Remember – at time of Diagnosis 50% of -cell function is already lost. Insulin must be regarded as “expected therapy”. Not “Failure” Not “Last Resort” Not “End-stage therapy” AND SHOULD BE STARTED MUCH EARLIER Innovators vs. Conservative Clinicians History of Insulin Insulin first isolated 1921 by Banting and Best Insulin first used as a treatment for diabetes in 1922 Had short duration period and required several daily injections Had to be given through reusable glass syringes with large often blunted needles The Insulin Types Human vs. Analogs Long Acting Insulin (Basal) Short Acting Insulin (Bolus) Pre-mixed Insulins 24-hour plasma glucose and insulin profiles in healthy individuals The Lancet, 2001, Vol 358, pages 739–746. Owens DR et al. Lancet 2001;358:739–746 Insulin Regimens There is NO best Insulin – there is only the Right Insulin for the Right Patient Daily Bolus (in combination with OHA's) Twice daily Basal bolus Basal plus 1,2,3 CIIS These can all be used in combination with OHAs ( especially insulin sensitizing agents) Delivery Devices Syringes Pen-sets – disposable or Refill Continuous Insulin Infusion Pump Glucose Monitoring Standard (simplified) Glucometer Blood Ketone measuring (for Insulin dependent patients) Continuous Glucose Monitoring Device Other (important ) Factors Family Friends (peers or colleagues) Co-morbidities Diabetic Complications e.g. retinopathy Media (including internet) After Sales Strategy Match the regime to the patient What is the target HbA1c? How avidly should hypos be avoided? How many injections is the patient willing to give? Fasting or postprandial the greater problem? What device can the patient use? Relative contribution of FPG & PPG to hyperglycaemia. (12 hour profile) FPG contribution. PPG contribution. p=0.048 p=0.001 83 69 65 35 31 17 HbA1c tertiles : <7.3% 7.3%-8.0% >8.0% Peter R, Owens DR et al- Diab Med- 2004 Complications Lipodystrophy Lipoatrophy & lipohypertrophy