Managing the patient on insulin. A Practical Approach Neum Conference October 24, 2008 John A Geddes MD

Managing the patient on insulin.

A Practical Approach

Neum Conference

October 24, 2008

John A Geddes MD

“Менаџмент “ коg пацијента који је на инсулину

Практични приступ Проф.Џон Геgис Октобра, 2008. у Неуму

Managing the patient on insulin

B.N je 57 godina stara žena kojoj je diagnosticiran diabetes prošle godina kada je bila u bolnici zbog oboljenja koronarnih arterija. Ona koristi Metformin 500mg tri puta dnevno i insulin koristi ujutro. Ona posjećuje endokrinologa svakih 4 mjeseca. Ona dolazi po ramapril (BP je 146/92) i tablete za spavanje. Ona ima problema sa spavanjem, budi se dva puta u toku noći da ide na toalet i onda više ne može zaspati.


Posljednji put kad ste je vidjeli naručili ste neke krvne nalaze da uradi. Njena glukoza na tašte je bila 12,4. Neće vidjeti endokrinologa u sljedećih dva mjeseca.

Last time you saw her you ordered some blood work. Her fasting blood glucose was 10.8. She doesn’t see the endocrinologist for

another two months.


Šta vi trebate da znate o ovom pacijentu u cilju postizanja zadovoljavajuće

kontrole glukoze?

What do you need to know about this patient in order to manage her insulin to achieve satisfactory glycemic

control?


Diet/Nutrition

Exercise

Insulin


Diet/Nutrition

Kinds of food consumedFrequency of meals

Ability to count calories/carbohydrates?Availability of nutritional counselling?


Exercise

TypeFrequency

Impediments to exercising


Insulin


Insulin

Type

Mode of administration

Dose

Frequency of administration


Insulin

Type Regular, NPH, Lente, Ultra Lente

Insulin AnaloguesLispro/aspart (Rapid Acting)

Glargine (Lantis)Detemir

Action Profiles of Various Insulin TypesP

las

ma

Insu

lin le

ve

ls

HoursNote: action curves are approximations for illustrative purposes. Actual patient response will vary.

regular 6-10 hours

NPH 12–20 hours

lispro/aspart 4–6 hours

BASAL INSULINS

glargine ~ 20-26 hours

Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

BOLUS INSULINS

Action Profiles of Mixed Insulin TypesP

las

ma

Insu

lin le

ve

ls


regular 6-10 hours

NPH 12–20 hours



las

ma

Insu

lin le

ve

ls


NPH 12–20 hours


BASAL INSULINS


BOLUS INSULINS


las

ma

Insu

lin le

ve

ls



BASAL INSULINS

glargine ~ 20-26 hoursdetemir – 20-24 hrs


BOLUS INSULINS


Mode of Administration

Syringe

Pen

CSII – Continuous Subcutaneous Insulin Infusion - INSULIN PUMP

Inhaled

Morate razmotriti i tip inzulina koji se

koristi. broj jedinica koje koristi I vrijeme administracije u svezi sa

vrijednostima glukoze u toku dana,

dijete i navike vježbanja pacijenta.

You will need to consider the type of insulin used, the number of units taken and the time of administration in conjunction with the glucose readings over the day, the diet and exercise habits of the patient.

ADA. Clinical Practice Recommendations. 2001.

What are the goals of intensive glycemic management?

Near-Normal Glycemia

Avoid short term crisis

Hypoglycemia

Hyperglycemia

Diabetic Ketoacidosis

Avoid long term complications

Improve quality of life

Targets for Glycemic Control

Canadian Diabetes Guidelines - 2008

Hgb A1c < 7%

Preprandial glucose – 4.0-7.0 mmol/l

Postpradial glucose – 5.0 – 10.0 mmol/l

(5.0 – 8.0 if HgbA1c target not met)

Canadian Diabetes Association Guidelines 22008



Hgb A1c < 7%







Hgb A1c < 7%







Hgb A1c < 7%





ADA. Clinical Practice Recommendations. 2001.

What are the goals of intensive glycemic management?

Near-Normal Glycemia

Avoid short term crisis

Hypoglycemia

Hyperglycemia

Diabetic Ketoacidosis

Avoid long term complications

Improve quality of life

Return to the patient:

Otkrivate da B.N. koristi 32 jedinice M3 inzulina ujutro. Njen Hgb A 1C je 9,6 %. Njena glukoza na tašte je 12,2.

You discover that B.N. is taking 32 units of M3 insulin in the morning. Her Hgb A1C is 9.6%. Her fasting blood sugar is 12.2.

Vi znate da ona treba više inzulina (ili više vježbanja ili manje hrane). Ona vam govori da joj je jedanput ranije doktor povećao insulin za 4 jedinice I da se osjećala užasno poslijepodne I da je morala uzeti meda. Ona se plaši da poveća njen insulin ponovo.

Šta joj savjetujete?You know that she needs more insulin (or more exercise or less food). She tells you that

once before a doctor had increased her insulin by 4 units and she ended up feeling terrible in the afternoon and had to eat honey. She is afraid to increase her insulin

again.

What will you advise?

Tokom sljedeće sedmice pacijent je koristio glukometar da provjerava vrijednosti njene glukoze u različito vrijeme u toku dana I dobila je sljedeće rezultate: ujutro- 14,1 podne-11,1 4 pm-5.3 veče- 13.8

Takođe ste shvatili da ona uzima kafu, sir I pecivo za doručak, supu I voće za ručak I da je njen glavni obrok u 5 I 30 kada joj muz dođe s posla.

Pla

sm

a In

sulin

lev

els



Blood Glucose HGBA1c - 9.6

AM 14,1 noon 11,1 4pm 5,3 hs 13,8

Teoretski… ova pacijentica treba više inzulina I treba bolju distribuciju inzulina tokom dana. Ovo se najbolje može postići time da se podijeli doza inzulina I das a upotrebom multiplih injekcija NPH ili upotrebom nekog od novijih dugodjelujućih insulin analoga kao bazalnog inzulina, I ako je potrebno dodaju se bolus ili pred obrok brzodjelujući insulin uz obrok.In theory....this patient needs MORE insulin and needs it better distributed over the day. This is best accomplished by dividing the insulin doses and by either using multiple injections of NPH or by using one of thenewer long acting insulin analogues as a basal insulin and, if necessary, adding bolus or prandial rapid acting insulin with meals.

Možete pokušati povećati njen

UKUPNI insulin za 10% (3-4

jedinice) I podijeliti ih tako da

dobije 2/3 ujutro 2/3 prije njene

večere.

(M3 inzulin -22 jedinice ujutro, 14 jedinica prije večere)

(Self monitoring with a glucometer will

help to adjust the insulin requirements.)


las

ma

Insu

lin le

ve

ls




las

ma

Insu

lin le

ve

ls



glargine ~ 20-26 hoursdetemir – 20-24 hrs



Patient concerns

Hypoglycemic episodesCost

Use of needlesAbility to comply (vision, Understanding)

Availability of Diabetes Education.

Educate the patient. (AND YOURSELF)

Glucose monitoringDiet and insulin needsHypoglycemia

Adjust the insulin (dose, type, time)according to the response to therapy.

Try for good glycemic control – all day

Consider other factors (vision, exercise, age, intellect)

Basal/bolus therapy is now considered to be the management of choice.

h

Edukovati pacijenta. (I sami sebe) Glukoza nadzor. Dijeta i potrebe inzulina. Hipoglikemija.

Prilagodite inzulin (doza, vrsta, vrijeme)prema odgovoru na terapiju.

Pokušajte dobre kontrole glikemije - cijeli dan Razmislite o drugim faktorima (vid, vježbe, dobi, intelekt)

Bazalna terapija je sada smatrana kao izbor za upravljanje dijabetesom.

Documents

Managing the patient on insulin. A Practical Approach Neum Conference October 24, 2008 John A Geddes MD