Association Clinical Practice Guidelines Pharmacotherapy in Type 1 Diabetes Chapter 12 Updated July 2015 Angela McGibbon Cindy Richardson Cheri Hernandez John Dornan 2015 ID: 208725
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Glycemic Management in Adults with Type 1 Diabetes
Chapter 12Angela McGibbon MD PhD FRCPC FACP, Lenley Adams MD FRCPC FACP, Karen Ingersoll RN CDE, Tina Kader MD FRCPC, Barna Tugwell MD FRCPC
2018 Clinical Practice GuidelinesSlide2
Disclaimer
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Slide3
In memoriam
…Angie completed her MD, residency in Internal Medicine and fellowship in Endocrinology at Dalhousie University before returning to her hometown, Fredericton in 2003. She was a Clinical Associate Professor of Medicine (Endocrinology) at Memorial and Dalhousie Universities and was active in regional and provincial diabetes strategies and all levels of medication education. She was known for her warmth, compassion and dedication to her family, her patients and her community. She passed away from a sudden illness on February 11, 2018. She will be missed.
Dr. Angela
McGibbonSlide4
Key Changes
Formerly titled “Pharmacotherapy in Type 1 diabetes”New title to reflect other treatment modalities for type 1 diabetesNew information on New bolus (prandial) and basal insulin preparationsRole of CSII and CGM
2018
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes
CGM
, continuous glucose monitoring;
CSII
, continuous subcutaneous insulin infusionSlide5
Pharmacotherapy in Type 1 Diabetes Checklist
USE basal-bolus injection therapy or continuous subcutaneous insulin infusionTAILOR insulin regimens to the individual’s treatment goals, lifestyle, diet, age, general health, motivation, hypoglycemia awareness status, and ability for self-managementCOUNSEL about the risk, prevention and treatment of insulin-induced hypoglycemia
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes Slide6
Serum Insulin Level
Time
Analogue Bolus
Human Basal
Analogue Basal
Human Bolus
guidelines.diabetes.ca
|
1-800-BANTING (226-8464)
|
diabetes.ca
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes Slide7
Types of insulin
Insulin type (trade name)
Onset
Peak
Duration
BOLUS (
prandial or mealtime)
insulins
Rapid-acting insulin analogues (clear)
Insulin aspart (
NovoRapid
®)
Insulin glulisine (
Apidra
®)
Insulin lispro (Humalog®) U-100 U-200
Faster-acting insulin aspart (
Fiasp
®)
9
–20min
10–15min
10–15min4min
1–1.5h1–1.5h 1–2h0.5-1.5h
3–5h3.5–5h 3–4.75h3-5h
Short-acting insulins (clear)Insulin regular (Humulin®-R, Novolin®
ge Toronto)Insulin regular U-500 (Entuzity® (U-500)30min15min
2–3h4-8h6.5h
17-24hBASAL insulinsIntermediate-acting (cloudy)Insulin neutral protamine
Hagedorn
(Humulin®
N, Novolin®
ge NPH)
1–3h
5–8hUp to 18h
Long-acting insulin (clear)Insulin detemir (Levemir®)Insulin glargine U-100 (Lantus®)Insulin glargine U-300 (Toujeo®)Insulin glargine biosimilar (
Basaglar®)
Insulin degludec U-100, U-200 (Tresiba®)90min
Not applicableU-100 glargine 24h, detemir 16–24hU-300 glargine >30hdegludec 42h
PREMIXED
insulins
Premixed regular insulin –NPH (cloudy)Humulin® 30/70Novolin® ge 30/70, 40/60, 50/50A single vial or cartridge contains a fixed ratio of insulin(% of rapid-acting or short-acting insulin to % of intermediate-acting insulin)Premixed insulin analogues (cloudy)Biphasic insulin aspart (NovoMix® 30)Insulin lispro/lispro protamine (Humalog® Mix25 and Mix50)Slide8
Insulin Therapy in Type 1 Diabetes
BASAL – BOLUS INJECTION THERAPY
Bolus insulin at meal times + basal insulin once or twice a day
OR
CONTINUOUS SUBCUTANEOUS INSULIN INFUSION
“
insulin pump therapy
”
with continuous subcutaneous infusion of insulin via a catheter
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes Slide9
Must Counsel About Hypoglycemia
Must counsel all patients with type 1 diabetes about hypoglycemia: recognition, treatment, preventionAssess risk factors for severe hypoglycemiaAssess for hypoglycemia unawareness and treat accordingly
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes Slide10
Benefits of Continuous Subcutaneous Insulin Infusion (CSII)
For individuals using basal bolus injections (BBI), changing to CSII providesSmall improvement in A1CImproved treatment satisfaction and diabetes specific related QOLReduction in severe hypoglycemia if there is a high baseline rate of severe hypoglycemia (non-severe and nocturnal hypoglycemia unchanged)
BBI
, basal-bolus insulin
;
C
SII
, continuous subcutaneous insulin infusio
n;
QOL
, quality of life
Yeh HC et al. Ann Intern Med 2012;157:336-47. Pickup JC et al. Diabet Med 2008;25:765-74.
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes Slide11
Benefits of Continuous Glucose Monitoring (CGM)
If using BBI or CSII with SMBG, adding CGM with high sensor adherence providesImprovement in A1C with no increase in hypoglycemiaImprovement in QOL, diabetes distress, fear of hypoglycemiaIf using sensor-augmented pump (SAP) therapy with nocturnal hypoglycemia, using SAP with low glucose suspend providesReduction in nocturnal hypoglycemia with no A1C increase
BBI,
basal-bolus insulin
;
CSII,
continuous subcutaneous insulin infusion
;
CGM
, continuous glucose monitoring
;
SMBG
, self-monitoring of blood glucos
e;
SAP,
sensor augmented pump
;
QOL
, quality of life
Bergenstal RM et al. N Engl J Med 2010;363:311-20. Bergenstal RM et al. N Engl J Med 2013;368:224-32. 2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes Slide12
Adjunctive therapy in type 1 diabetes
Metformin, SGLT2 inhibitors (dapagliflozin, empagliflozin, sotagliflozin), GLP-1 receptor agonist (liraglutide) have been studied Metformin did not provide sustained metabolic or CV benefitsSGLT2 inhibitors demonstrated some metabolic benefits but risk of DKA needs to be better understoodLiraglutide also showed some metabolic benefits but there are no current indications for use in type 1 diabetesNO recommendation for adjunctive therapy
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes
CV
, cardiovascular;
DKA
, diabetic ketoacidosisSlide13
Recommendations 1-2
In adults with type 1 diabetes, basal-bolus injection therapy or CSII as part of an intensive diabetes management regimen should be used to achieve glycemic targets [Grade A, Level 1A]In adults with type 1 diabetes using basal-bolus injection therapy or CSII,
rapid-acting insulin analogues
should be used in place of regular insulin to
improve A1C
and to
minimize the risk of hypoglycemia
[Grade B, Level 2 for basal-bolus injection therapy; Grade B, Level 2 for lispro in CSII; Grade B, Level 2 for aspart in CSII, Grade D, Consensus for glulisine in CSII] and to achieve postprandial BG
targets
[Grade B, Level 2 for basal-bolus injection therapy; Grade B, Level 2 for CSII]
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes
BG;
blood glucose
; CSII,
continuous subcutaneous insulin infusionSlide14
Recommendation 3
In adults with type 1 diabetes on basal-bolus injection therapy, A long-acting insulin analogue may be used in place of NPH to reduce the risk of hypoglycemia [Grade B, Level 2 for detemir; Grade B, Level 2 for glargine U-100; Grade D, Consensus for degludec and glargine U-300], including nocturnal hypoglycemia [Grade B, Level 2 for detemir; Grade B, Level 2 for glargine U-100; Grade D Consensus for degludec, and glargine U-300]
Degludec
may be used instead of detemir or glargine U-100 to reduce nocturnal hypoglycemia
[Grade B, Level 2] compared to detemir; Grade C, Level 3 compared to glargine U-100]
2018
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes Slide15
Recommendation 4
4. All individuals with type 1 diabetes and their support persons should be counselled about the risk and prevention of hypoglycemia, and risk factors for severe hypoglycemia should be identified and addressed [Grade D, Consensus]
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes Slide16
Recommendation 5
In adults with type 1 diabetes and hypoglycemia unawareness, the following nonpharmacological strategies may be used to reduce the risk of hypoglycemia:A standardized education program targeting rigorous avoidance of hypoglycemia while maintaining overall glycemic control [Grade A, Level 1A]Increased frequency of SMBG, including periodic assessment during sleeping hours
[Grade D, Consensus]
CGM
with high sensor adherence
in those using CSII
[Grade C, Level 3]
Less stringent glycemic targets
with avoidance of hypoglycemia for up to 3 months
[Grade C, Level 3]
2018
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes
CGM,
continuous glucose monitoring;
CSII
, continuous subcutaneous insulin infusion;
SMBG
, self-monitoring of blood glucose Slide17
Recommendation 6
6. In adults with type 1 diabetes on basal-bolus injection therapy who are not achieving glycemic targets, CSII with or without CGM may be used to improve A1C [Grade B, Level 2 with CGM; Grade B, Level 2 without CGM]2018
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes
CGM,
continuous glucose monitoring;
CSII
, continuous subcutaneous insulin infusionSlide18
Recommendation 7
In adults with type 1 diabetes,CSII may be used instead of basal-bolus injection therapy to improve treatment satisfaction [Grade C, Level 3]CSII plus CGM may be used instead of basal-bolus injection therapy or CSII with SMBG to improve quality of life, treatment satisfaction and other health-quality-related outcomes [Grade B, Level 2]
2018
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes
CGM,
continuous glucose monitoring;
CSII
, continuous subcutaneous insulin infusion;
SMBG
, self-monitoring of blood glucoseSlide19
Recommendations 8-9
Adults with type 1 diabetes on CSII should undergo periodic evaluation to determine whether continued CSII is appropriate [Grade D, Consensus] 9. In adults with type 1 diabetes and an A1C at or above target regardless of insulin delivery method used, CGM with high sensor adherence may be used to improve or maintain A1C [Grade B, Level 2] without increasing hypoglycemia
[Grade C, Level 3]
2018
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes
CGM,
continuous glucose monitoring;
CSII
, continuous subcutaneous insulin infusionSlide20
Recommendation 10
10. In adults with type 1 diabetes experiencing nocturnal hypoglycemia and using CSII and CGM, SAP with low glucose suspend may be chosen over SAP alone to reduce hypoglycemia [Grade B, Level 2]
2018
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes
CGM,
continuous glucose monitoring;
CSII
, continuous subcutaneous insulin infusion;
SAP
, sensor augmented pumpSlide21
Key Messages
Basal-bolus insulin routines (i.e., multiple daily injections or continuous subcutaneous insulin infusion) are the preferred insulin management regimens for adults with type 1 diabetesInsulin regimens should be tailored to the individual’s treatment goals, lifestyle, diet, age, general health, motivation, hypoglycemia awareness status and ability for self-managementAll individuals with type 1 diabetes should be counselled about the risk, prevention and treatment of hypoglycemia. Avoidance of nocturnal hypoglycemia may include changes in insulin therapy and increased monitoring
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes Slide22
Key Messages
If glycemic targets are not met with optimized multiple daily injections, CSII may be considered. Successful CSII therapy requires appropriate candidate selection, ongoing support and frequent involvement with the health-care teamCGM may be offered to people not meeting their glycemic targets, who will wear the devices the majority of the time, in order to improve glycemic control
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes
CGM,
continuous glucose monitoring;
CSII
, continuous subcutaneous insulin infusionSlide23
Key Messages for People with Diabetes
Insulin therapy is required for the treatment of type 1 diabetesThere are a variety of insulins and methods of giving insulin to help manage type 1 diabetes
Insulin is injected by pen, syringe or insulin pump
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes Slide24
Key Messages for People with Diabetes
Your health-care provider will work with you to determine such things as:The number of insulin injections you need per dayThe timing of your insulin injectionsThe dose of insulin you need with each injectionIf an insulin pump is appropriate for youYour pump settings if you are using a pump
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes Slide25
Key Messages for People with Diabetes
The insulin treatment your health-care provider prescribes will depend on your goals, lifestyle, meal plan, age, and general health. Social and financial factors may also be taken into accountLearning to avoid and treat hypoglycemia (low blood glucose) is an important part of your education. The ideal balance is to achieve blood glucose levels that are as close to target as possible while avoiding hypoglycemia
2018 Diabetes Canada CPG – Chapter 12. Glycemic Management in Adults with Type 1 Diabetes Slide26
Visit guidelines.diabetes.ca Slide27
Or download the AppSlide28
Diabetes Canada Clinical Practice Guidelines
http://guidelines.diabetes.ca – for health-care providers1-800-BANTING (226-8464)http://diabetes.ca – for people with diabetes