California Association of Nurse Practitioners March 18, 2016

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1 California Association of Nurse Practitioners March 18, 2016 INSULIN THERAPY AND YOUR PRACTICE BY ZARMINE NACCASHIAN PHD, GNP, RN, CDE

2 BARRIERS TO INSULIN INITIATION Clinician "Clinical inertia High: slow to treat, low: fast to treat Patient training/educational requirements Risk for hypoglycemia Risk for weight gain Questions of atherogenicity Questions of mitogenicity Patient Stigma Fear of needles Need for more intensive monitoring Need for greater regimentation of lifestyle Fear of hypoglycemia Fear of weight gain Therapy of "last resort"

3 TYPES OF INSULIN Insulin Preparation Onset Peak Duration Lispro Aspart Glulisine 5-15 min 1-2 hrs 4-6 hrs Human Regular min 2-4 hrs 6-10 hrs Human NPH (neutral protamine Hagedorn) 1-2 hrs 4-10 hrs hrs Glargine Detemir toujeo 1-2 hrs Flat 24 hrs

4 OVERVIEW BASAL-BOLUS INSULIN THERAPY Basal Insulin (eg, glargine, detemir, NPH) Suppresses hepatic glu production between meals and during overnight hours Nearly constant levels throughout the day and night Bolus Insulin (Meal-time/Prandial) (eg, lispro, aspart, glulisine) Limits postprandial hyperglycemia Immediate rise and sharp peak at ~1 hour ~ 50% of daily needs ~ 15%-20% of total daily insulin requirement per meal Start at U/kg/day (or U, usually at bedtime) Titrate by 10%-15% once or twice weekly to achieve fasting blood glucose targets Start at 0.05 U/kg/meal (or 3-6 U AC meal), Dosed based on planned CHO intake (1 U/15 g) Titrate by 1-2 U once or twice weekly to achieve postprandial blood glucose targets (< mg/dl) (ideally, < mg/dl 2 hours after start of meal; can use preprandial BG before next meal as guide). Can add "correction insulin" to adjust for preprandial hyperglycemia (eg, 1-2 U for every 50 mg/dl over target)

5 QUESTION FOR DISCUSSION Which of the following is important to reduce the risk of hypoglycemia in patients with type 2 DM on pre-mixed insulin regimen Answers: A) Administer at least 2 injections pre-mixed doses/day B) Administer rapid acting insulin before largest meal C) Ensure a meal is timed to coincide peak of intermediate acting insulin D) Maintain oral anti-diabetic agents to target post prandial BG

6 QUESTION FOR DISCUSSION Rule of 15 is appropriate to address which of the following patient reported barriers to insulin initiation? Answers: A) Fear of weight gain B) Fear of hypoglycemia C) Lack of time for BG monitoring D) Preconception that insulin initiation is linked to progression of disease

7 CASE #1 A 45-year-old overweight man with an 8-year history of type 2 DM presents for a checkup. Three months ago, his A1C was 9.6%, despite treatment with metformin 1000 mg bid and glipizide 15 mg qd. You initiated insulin glargine 10 units at bedtime, titrated to 20 units over 3 weeks. Today, his A1C is 7.9%, and his blood glucose log shows fasting levels ~ mg/dl and post-prandial levels ~ mg/dl. He reports no symptoms of hypoglycemia. What might be an appropriate action at this time? Answers: A) Switch to pre-mixed insulin bid B) Add 1 injection of rapid-acting insulin at breakfast C) Switch to basal-bolus regimen, with rapid-acting insulin titrated for each meal D) Increase dose of basal insulin to target fasting blood glucose levels mg/dl

8 CASE #2 A 52-year-old obese woman with a 10-year history of type 2 diabetes and 8-year history of hypertension presents for a checkup. Her A1C today is 7.8%, and her blood glucose log shows fasting levels mg/dl and post-prandial levels mg/dl. Other findings are WNL. Current medications include metformin 1000 mg bid, pioglitazone 30 mg qd, glimepiride 8 mg qd, lisinopril 20 mg qd, and basal insulin 38 units at bedtime. She says she feels fine, but is worried about hypoglycemia, especially at school, where she teaches 6 th grade. What might be an appropriate action at this time? Answers: A) Increase dose of basal insulin to target A1C <7% B) Do nothing; patient at fasting blood glucose targets C) Add 1 dose of rapid-acting insulin before largest meal D) Split basal insulin into 2 doses and titrate to target A1C <7% E) Switch to basal-bolus insulin regimen with carbohydrate counting and correction factor

9 CASE #3 A 57-year-old woman presents to your office for a checkup. She has a 9-year history of type 2 diabetes and 5-year history of hypertension. Workup identifies A1C 8.6%, albumin:creatinine ratio 18 mcg/mg, creatinine 1.1 mg/dl, and egfr 56 ml/min/1.73m 2. Other findings are WNL. Her self-monitored blood glucose log identifies fasting blood glucose levels mg/dl and post-prandial levels mg/dl. Current medications include metformin 1000 mg bid, glipizide 15 mg qd, linagliptin 5 mg qd, and hydrochlorothiazide/lisinopril 25/20 mg qd. She walks most days for exercise and uses the "plate method" to limit caloric intake, when she can. However, she travels during the day for work and often misses meals and exercise. When asked about use of insulin, she expresses concern and notes that she believes insulin is not effective based on her mother's experience with insulin at the end of her life.

10 ANSWERS FOR CASE #3 A) Identify A1C target <8% based on kidney function B) Insulin is required since she is not fully engaged in exercise & diet interventions C) Initiate no change D) Identify glycemic targets <7% FBS mg/dl and post prandial <180 mg/dl E) Suggest trial of insulin with frequent self monitoring of BG levels to demonstrate effectiveness of insulin F) Recommend initiating basal insulin at 10 units QHS and titrate to FBS to goal mg/dl G) If basal insulin is initiated & titrated to goal, consider mealtime insulin, if post prandial BG levels remain 180 mg/dl H) Discuss her mother s experience with insulin and your clinical experience with patients taking insulin

11 CASE #4 A 68-year-old white woman presents for the evaluation of type 2 DM. She was diagnosed with the dz. 15 years ago & was initially treated with glyburide. Metformin was added to her treatment regimen approximately 10 years ago, and pioglitazone was added 4 years ago. A1C levels have been relatively well controlled, fluctuating in the low-mid 7% range over the past several years. During the past 6 months, she has noted a progressive in her BG readings, especially in the fasting state ( mg/dl+). She is now experiencing polyuria, nocturia, blurred vision, and progressive fatigue. Her medical Hx. is notable for HTN, hyperlipidemia, & CAD. She received drug-eluting stents to the right coronary artery and left anterior descending artery 2 years ago. Ventricular function is normal. Steatohepatitis has been suspected, based on a mild in hepatic transaminases. She has battled depression for most of the past decade. What would you advise as the next step in the management of this case?

12 CASE #4 Medications now include glimepiride 4 mg once daily (QD), metformin 1000 mg twice daily, pioglitazone 30 mg QD, fosinopril 20 mg QD, metoprolol SR 100 mg QD, simvastatin 40 mg QD, sertraline 20 mg QD, and aspirin 81 mg QD. She weighs 216 pounds, and her BMI is 37 kg/m 2. Blood pressure is 152/86 mm HG; pulse rate is 76 BPM and regular. The lungs are clear; heart sounds are normal. The abdomen is obese without organomegaly or tenderness. Extremities show decreased distal pulses, 1+ edema, & mild loss of vibratory sensation but intact monofilament sensation in the feet. Other relevant data include: FBS: 278 mg/dl; A1C: 10.7%; TC: 165 mg/dl; HDL: 42 mg/dl; LDL: 89 mg/dl Trig: 172 mg/dl; Cr: 1.3 mg/dl (egfr 49 ml/min); AST: 64 IU/L; ALT: 51 IU/L; Bilirubin: 0.8 mg/dl; Alkaline phosphatase: 84 IU/L

13 DISCUSSION OF CASE #4 T2DM for 15 years (long time) Likely expressing significant deterioration in beta-cell function, as a result, insulin secretory capacity. A1C despite therapy with 3 oral agents metformin, a sulfonylurea, and a TZD Best solution is to begin insulin therapy: A basal insulin would appear to be the simplest initial intervention, Degree of A1C elevation suggests that a more intensive program, Premixed insulin twice daily or Basal-bolus strategy Metformin requires reconsideration due to her renal dysfunction. TZD use cautiously with insulin, combination risk for edema.

14 INSULIN AND CARDIOVASCULAR EFFECTS One concern that has re-emerged is whether insulin use affects the risk for cardiovascular events. In 2009, the results of a series of 3 large, long-term, randomized diabetes/cardiovascular trials -- ACCORD (Action to Control Cardiovascular Risk in Diabetes), ADVANCE (Action in Diabetes and Vascular Disease: PreterAx and DiamicroN MR Controlled Evaluation), VADT (Veterans Affairs Diabetes Trial) -- were released. These studies sought to determine if more stringent glucose control (target A1C < 6%-6.5%) would result in a reduction of cardiovascular events compared with the use of "standard care," that is, A1C levels in the mid-to-high 7% range.

15 INSULIN AND CARDIOVASCULAR EFFECTS Each trial proved negative: Near normalization of bld glu levels with more complex pharmacologic regimens was not associated with a reduction in rates CV complications. In the ACCORD study, all-cause mortality actually 22% in intervention group, D/T CV deaths. Hypoglycemia was more common among intensive-therapy groups in these studies, concern about the detrimental effects of hypoglycemia. Additional investigation has failed to find a direct connection between hypoglycemia and mortality in these patients. In one post-hoc analysis from ACCORD, patients randomized to intensive therapy but whose A1C was not reduced to goal actually experienced the highest rates of mortality. These preliminary data suggest that it may be risky to continue to aggressively advance insulin treatment in certain individuals who do not respond to more conventional approaches. 15

Diabetes Mellitus 1. Chapter 43. Diabetes Mellitus, Self-Assessment Questions

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