Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Insulin Therapy In The Treatment Of T2DM Prof. Ibrahim El-Ebrashy Cairo University Head Of Diabetes & Endocrinology Center T2DM is insulin resistance + insulin deficiency Type 2 diabetes – Characterised by insulin resistance and insulin deficiency – Degrees of resistance and deficiency vary but insulin deficiency is key to developing diabetes Adapted from Bergenstal et al. In: Degroot & Jameson (eds). Endocrinology 2001;821–35 Slide No 3 Natural history: insulin secretion and blood glucose control Glucose level Relative (mg/dL) function (%) Obesity IFG 250 200 150 100 50 Diabetes Uncontrolled hyperglycaemia Insulin resistance Insulin level Beta-cell failure 350 300 250 200 150 100 50 Normal Postprandial glucose Fasting glucose Normal –10 –5 0 5 10 15 20 25 30 Years of diabetes IFG, impaired fasting glucose Adapted from Bergenstal et al. In: Degroot & Jameson (eds). Endocrinology 2001;821–35 Improving control reduces risks of long-term complications • Every 1% drop in HbA1c can reduce long-term diabetes complications 43% 37% 19% 16% 14% 12% Stroke Heart failure Cataract extraction Microvascular disease Lower extremity amputation or fatal peripheral vascular disease UKPDS 35: Stratton et al. BMJ 2000;321:405–12 Myocardial infarction Slide no 4 Slide no 5 Positive legacy effect of early, intensive glucose control Aggregate endpoint 1997 2007 Any diabetes-related endpoint RRR: 12% 9% Microvascular disease RRR: 25% 24% Myocardial infarction RRR: 16% 15% All-cause mortality RRR: 6% 13% At end of post-trial follow up (median 8.5 years) RRR = Relative Risk Reduction Red indicates significant reduction on intensive therapy vs. conventional therapy UKPDS 80. Holman et al. N Engl J Med 2008; 359:1577-89 Slide no 6 Insulin is the most effective anti-diabetic agent Sulfonylureas Biguanides (metformin) 1.5 1.5 Glinides DPP-IV inhibitors TZDs 1.0-1.5 0.5-0.9 0.8-1.0 Insulin HbA1c reduction (%) 0.0 0.5 1.0 ≥2.5 1.5 2.0 2.5 3.0 Efficacy as mono therapy Nathan DM. N Engl J Med. 2007;356:437-40 Anti diabetic agents Slide no 7 Mean HbA1c at last visit (%) Insulin use is often delayed, despite poor glycaemic control 10 9.4% 9.1% 8.8% 9 8 3 OADs 2 OADs 1 OAD Diet 2.9 years 4.7 years 2.5 years OAD, oral antidiabetic drug Novo Nordisk. Type 2 Diabetes Market Research Roper Starch US Study, 2000 2.7 years Slide no 9 T2DM treatment patterns in Egypt 2010-14, thousand patients 2010-12 Change 100% 16% 16% 11% 11% 3% Slide no 10 There is resistance to insulin despite efficacy and guideline recommendations UKPDS • 27% of T2DM patients randomized to insulin initially refused treatment1 DAWN • More than half of insulin-naïve T2DM patients expressed anxiety about starting insulin therapy2 In a survey of insulin-naïve T2DM patients, 28.2% of respondents reported that they would be unwilling to take insulin if it were prescribed3 1UKPDS 33, 1998; 2Peyrot et al. 2005; 3Polonsky et al. 2005 Kunt and Snoek Int J Clin Pract 2009; 63:6-10 Slide no 11 Barriers to starting insulin • • • • Fear of hypoglycaemia Fear of reduced quality of life Reluctance to inject in public Perception that the disease is becoming more severe • Fear of needles/pain from injections • Patients do not feel empowered to take control of their diabetes Korytkowski . Int J Obes Relat Metab Disord 2002;26:S18–S24 Polonsky et al. Diabetes Care 2005;28(10):2543-2545 Rubin and Peyrot. J Clin Psychol 2001;57:457– 478 Slide no 13 Clinical inertia: delay in treatment initiation and optimisation Diabetes duration (years) HbA1c (%) Mean (SD) Mean (SD) No therapy (9%) 2.1 (8.6) 10.0 (2.2) OGLD only (58%) 8.3 (6.3) 9.5 (1.7) Insulin +/- OGLD (33%) 12.0 (7.7) 9.4 (1.8) Therapy N=66726 Home et al. Diabetes Res Clin Pract 2011; 94: 352-63 Slide no 14 Often there is a failure to advance therapy even when required 100 Percentage Patients (%) 90 Time to insulin initiation in patients on >1 OAD is 7.7 yrs† 80 70 60 50 40 30 20 10 †95% CI = 7.4 to 8.5 years 0 0 1 2 3 4 5 6 7 8 9 10 Delay in insulin initiation (years) Calvert et al. Br J Gen Pract 2007;57:455-460 Slide no 15 Common reasons for clinical inertia Insulin naïve patients Insulin makes one fat Fear of hypos Pain from injection Pain from blood tests Primary care physicians Insulin makes one fat Fear of hypos Pain from injection * Percentage of patients/physicians interviewed who provided this as a reason for not starting insulin Nakar et al. J Diabetes Complications 2007;21:220–6 Pain from blood tests Patient concerns still exist after insulin initiation Slide no 16 Percentage of subjects who agree or strongly agree Insulin naïve Insulin-treated 80 p<0.001 for all 70 60 50 40 30 20 10 0 Diabetes has progressed Less flexibility Injection fear Weight gain Seen as sick Snoek et al. Health and Quality of Life Outcomes 2007;5:69 Increased risk of hypoglycaemia Sequential Insulin Strategies in T2DM Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print] Algorithm for initiating insulin therapy. Patient-Based Insulin Regimens Starting Dosages Start Low and Titrate Steadily Dosage Titration for Once-Daily or Twice-Daily Insulin Regimens Transition From One Regimen to Another Data about Premixed Insulin Aspart in treatment of Diabetes Nazia Raja-Khan, Sarah S Warehime, and Robert A Gabbay Vasc Health Risk Manag. 2007 December; 3(6): 919–935. Percentage of subjects achieving HbA1c target values at the end of the study. Raskin P et al. Dia Care 2005;28:260-265 Copyright © 2011 American Diabetes Association, Inc. Eight-point SMPG readings before breakfast, lunch, and supper [BB, BL, and BD] and 90 min after breakfast, lunch, and supper [B90, L90, and D90]; at bedtime [Bed]; and at 3:00 a.m.). Raskin P et al. Dia Care 2005;28:260-265 Copyright © 2011 American Diabetes Association, Inc. Case 1 q A 49-years-old male patient with T2DM 8 years ago, being treated with Insulin Glargine 20 unites at 11 pm and glimpride 3mg before breakfast and metformin 2g/day since 2 years BMI 30 qLifestyle: High-carbohydrate meals is fond of rice or bread and potatoes. Does not exercise. • HbA1c = 7.5% • On antihypertensive for several years. • Recently, a statin has been added to his medications He wants to fast in ramadan? Yes No • What due think you should first ask before deciding the his treatment regimen in ramadan ? 1. His blood glucose analysis during the day • Blood glucose levels over the day: FBG 145mg/dl PPG (Post-breakfast) 165 mg/dl Pre Lunch 133 mg/dl PPG (Post-Lunch) 167 mg/dl Pre Dinner 166 mg/dl After Dinner ( main meal ) 261 mg/dl What are the option to control his blood glucose ? • • • • Increase the dose of glargine? Add a mealtime bolus? Shift to basal-bolus insulin regimen? Switched to premixed analogue insulin before eftar and SU at a lower dose before sohoor and the same metformin doses? • What dietary advice you have to give him in Ramadan ? 1. Eftar starting with a lot of fluids and no sugar 2. Snack after praying taraweeh 3. Lot of fluid during the time allowed to eat 4. Late sohoor Thank You