Starting insulin in general practice JoAnne ManskiNankervis Louise Ginnivan What we are going to cover tonight Evidence and rationale for use of insulin in T2D and current clinical guidelines Self monitoring goal setting and common patient concerns ID: 538558
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Slide1
Enhanced General Practice Management of Diabetes
Starting insulin in general practice
Jo-Anne Manski-Nankervis
Louise GinnivanSlide2
What we are going to cover tonight
Evidence and rationale for use of insulin in T2D and current clinical guidelinesSelf monitoring, goal setting and common patient concernsFamiliarisation with insulin and dose adjustmentCase studies and questionsSlide3
Evidence and rationale for use of insulin in type 2 diabetes and current guidelinesSlide4
Type 2 diabetes: The scope of the problem
Prevalence~1 million Australians have T2D~280 Australians develop T2D every dayUp to 60% of cases can be preventedComplicationsMicrovascular and macrovascular
65-80% of people with diabetes will die of coronary heart disease
Financial costs
T2D costs Australia $3 billion/yearSlide5Slide6Slide7
Rationale for Treating to Target
UKPDS:
Tight glycaemic control reduces micro (and macro) vascular complications
1
1% reduction in HbA1c→ 21% ↓ diabetes endpoint, 21% ↓ diabetes related death, 14% ↓ AMI, 37% ↓ microvascular complications
Metabolic memory
2
Tight control early in diabetes results in continued reduction microvascular risks, AMI and death even if glycaemic control deteriorates later
1
Stratton et al (2000), BMJ 321:405-412
2
Holman et al (2008),
N
Engl
J Med 359:1577-89Slide8
ADS recommended targets.
General Target
≤ 7
% (53mmol/mol)
Specific Situations
DM:
short duration
no CV Disease
Managed with lifestyle +/- metformin
≤ 6%
(42mmol/mol)
(risk of hypos permitting)
Managed with any other OHA (not metformin or insulin)
≤ 6.5% (48mmol/mol)Managed with insulin≤ 7%(53mmol/mol)Pregnancy or planning a pregnancy≤ 6%(42mmol/mol)DM of longer duration (> 10-20 years) or has CV diseaseAny form of therapy≤ 7%(53mmol/mol)Recurrent severe hypo or hypo unawarenessAny form of therapy≤ 8%(64mmol/mol)Patients with major co-morbidities likely to limit life expectancyAny form of therapySymptomatic therapy
Wah
Cheung et al (2009) MJA 191(6):339-344Slide9
Depiction of the elements of decision making used to determine appropriate efforts to achieve
glycemic
targets.
Inzucchi
S E et al.
Dia
Care 2012;35:1364-1379
Copyright © 2011 American Diabetes Association, Inc.Slide10Slide11
Lots of potential targets for new therapiesSlide12
Insulin
“We have obtained from the pancreas of animals a mysterious something which injected into totally diabetic dogs completely removes all the cardinal symptoms of the disease...If the substance works on the human it will be a great boon to medicine”JB Collip
, 8 January, 1922Slide13
Relationship between insulin resistance, insulin deficiency and glycaemia
Relative insulin deficiency starts
Eventual absolute insulin deficiency
IR not increasing
PP BGL is the first abnormalitySlide14
Antihyperglycemic
therapy in type 2 diabetes: general recommendations
. (ADA/EASD)
Inzucchi
S E et al.
Dia
Care 2012;35:1364-1379
Copyright © 2011 American Diabetes Association, Inc.Slide15
RACGP Guidelines Slide16
RACGP Guidelines 2014Slide17
Reproduced with permission from The Royal Australian College of General Practitioners from: General practice management of type 2 diabetes. Melbourne: RACGP, 2014.Slide18
Treating to target and starting insulin
Good glycaemic control reduces micro (and macro) vascular complications BUT about half our patients are not well
controlled
Lifestyle + OHA + insulin most validated pathway
“Therapeutic inertia” and barriers to insulin initiation
Mean HbA1c prior to insulin initiation: 9.4% (
Fremantle
Study, Davis et al 2006)
Patient, doctor and system level
Clinical inertia in response to inadequate glycaemic control: Do specialists differ from primary care physicians? Slide19
Should we be commencing insulin in general practice?
There is a relative lack of access to specialistsBenefits of continuity of care and accessibilityInsulin initiation in general practice is safe1,2
Practice nurses and CDEs can take the lead for this with adequate training and support (UK, Netherlands)
Endocrinologist 1:2000
Practice nurse
1:125
CDE-RN
1:630
GP 1:47
1
Davies et al (2007) Diabetes Obesity & Metabolism 9(5):706-13.
2
Samann
et al. (2013) Family Practice 30(3):290-3.Slide20
Who might benefit from initiation of insulin?
Strong indications for insulin therapy include:HbA1c for ≥ 7.5% (58mmol/mol) for more than 3 months
Maximum oral therapy yet control not ideal
Oral hypoglycaemic treatments not tolerated or contraindicatedSlide21
Goal setting and common patient concernsSlide22
Case study
Brian: 61 year old electrician
PMH:
Hypertension (controlled),
Hypercholesterolaemia
Type 2 diabetes diagnosed 8 years ago
Medications
ACE inhibitor and low-dose
thiazide
Atorvastatin
(40 mg daily)
Metformin
(1000mg
bd
) and Glibenclamide (10mg bd)LifestyleStopped smoking 10 years ago; gave up alcohol 12 months agoPhysically unfit and inactive. Pathology and anthropometric measuresSlowly gaining weight, despite diet and exercise advice, BMI 34 kg/m2, WC 104 cmA1C now stable, ~ 8.5% (69mmol/mol). Does not self-monitor blood glucose levelsWhat would you do in this case: Lifestyle? Other oral agents? Insulin? Other medications?What if: HbA1c 7.5% (58mmol/mol)? He was aged 45? Or 80? HbA1c 11.6% (103mmol/mol)?Slide23
Barriers to insulin initiation
Patient factors
Physician factors -
These are likely to apply to nurses too!
Belief that diabetes is not a serious illness
Fear of addiction
Belief that insulin makes patient fat
Fear of hypoglycaemia
Belief that insulin would not help
Pain associated with insulin injection
Other fears regarding injection of insulin
Pain associated with blood tests
Lack of faith in doctor
Anxiety
Concern that can never stop insulin
Life will be restricted as a result of starting insulinBelief that insulin causes problems like blindnessNon-compliance with medical appointmentsNon-compliance with medicationsBelief that patient wouldn’t comply with treatmentFear of hypoglycaemia in a specific patientBelief that patient couldn’t cope with pain involved in insulin injectionPatient too old or inadequate level of educationNo experience with treatmentNot wanting to give to obese patients because insulin would result in further weight gainBelief that a specific patients diabetes is so severe that even insulin wouldn’t helpLack of resources in office based practice – drug cost, staff availability, skills of staff, timeBelief that insulin initiation is complexLack of motivation to improve clinical practiceBelief that insulin would impair patient quality of lifePatient co-morbiditiesSlide24
Talking about insulin
Brian presents with his wife, who is very keen for him to improve his health. She has a little knowledge of diabetes. They are aware you have recommended starting insulin. Brian’s wife asks what they have done wrong in trying to control his blood glucose level, and what the future holds for him. “Is it our fault?” she asks
How do you respond?
Brian isn’t sure that he wants to go on insulin
“Are we Dancing or Wrestling?”
Ambivalence
Wanting
and not wanting to
change,
being ‘stuck.’
Normal, common, powerful
Making assumptions about change
This person ought to change, wants to
change
This
person is primarily motivated by their healthPeople are either motivated to change or notA tough approach is always best, I’m the expert. They ought to follow my adviceSlide25
Importance-confidence-readinessSlide26
Express Empathy
Ambivalence is normal. Understand the patients perspective
Develop Discrepancy
Importance/confidence ruler
Change talk
Roll with resistance
Reframe patient concerns positively,
Avoid confrontation
Emphasize personal choice and control
Support Self-Efficacy
Belief in the ability to change is an important motivator
Principles
of motivational interviewing
Change talk
Problem Recognition“What things may happen if your diabetes remains as poorly controlled as this?”Intention to change and optimism about change:“What might be some of the advantages in going on to insulin?”“Who are the people in your life that would support you in making the change to insulin?”“If we were to bump into each other on the street in six months time, what do you think you would you like to tell me about your diabetes and how you are managing it? …how would you like things to turn out?”Slide27
Familiarisation with insulin, dose adjustment and blood glucose monitoringSlide28
What are the types of insulin?
Brian decides to give insulin a try.
What options are available?Slide29
Insulin
time-action profiles
12
24
2
4
6
8
10
14
16
18
20
22
hours 12242468101416182022hoursPhillips LK & Phillips PJ, 2006; Profiles adapted from Clinical Practice Guidelines: Type 1 Diabetes in Children and Adolescents by Australian Paediatric Endocrine Group. p58#20/80 and 30/70 short/intermediate-acting also available *25/75 rapid/intermediate-acting also available. Accessed at http://www.nhmrc.gov.au/publications/synopses/_files/cp102.pdf on November 19, 2007 12242468101416182022hours
Rapid acting analogue
Basal analogue (insulin glargine)
30% rapid-acting & 70% intermediate-acting analogue insulinSlide30
Insulin Regimens
BD pre-Mix:
Basal:
Basal+1:
Basal BolusSlide31
Patient
benefits of analogue insulin
Rapid
acting analogues:
insulin
lispro
(
Humalog
); insulin
aspart
(
Novorapid
); insulin
glulisine
(Rapid acting insulin analogue)
Major advantages:Inject and eat (no need to inject 30 minutes prior to meal)Lowered hypoglycaemic risk compared to insulins with ‘longer tails’Basal analogues:insulin glargine (Lantus); insulin detemir (Levemir)Major advantage is reproducible profileless “hypos”Less impact on weight gainSignificant improvements in health related Quality of Life measuresOnce-daily dosing possible in most people, especially with glarginePhillips LK & Phillips PJ, 2006; Hirsch I, 2005; Fischer JS, 2004; Rosenstock J,2005; Janka HU, 2005; Phillips PJ, 2006; Phillips PJ, 2007.Slide32
What is required to start insulin in general practice?
Equipment EducationGP and PN/CDE willing to work with each otherIn practice protocolExpert back up and local referral networks
eg
. CDE, endocrinologist
Confidence!Slide33
What’s involved?: Getting started on Glargine (Lantus)
addressing fasting glucose levels
GP and PN baseline visit
PN Baseline visit 2 (next day)
Titration calls or F-F with PN
PN Reminder call
GP and PN Week 4 visit and monthly thereafter
Timeline
Tasks: GP assesses need for insulin and documents plan to use protocol. PN gives first Lantus dose
Tasks: PN watches patient give their own dose, check technique etc
BASAL TITRATION TOOL
0
0+1 day
Weeks 1-3
34, 8, ...FBGLs 4 - 7.0 consistentlyDecision made to consider Rapid acting insulin analogueTasks: PN and GP liaise, review and decision to start Rapid acting insulin analogueTasks: PN works with patient to up-titrate, liaison with GP and DNE/Endo as neededTasks: PN reminds patient re next weeks visitTasks: GP and PN clinical reviewXTarget Fasting glucose levels: 4-7mmol/LSlide34
Case study
Brian: 61 year old electrician
Visit 1: GP
GP reviews glycaemic control and confirms the need to start
insulin
Provide script for insulin glargine
Record in notes directions for practice nurse/CDE to utilise
practice protocol for initiation of insulin
Notify
VicRoads
of commencement of insulin
Update NDSS registrationSlide35
Lantus Initiation
The patient is NOT to be started on glargine unless they have demonstrated that they are able to monitor their blood glucose levels reliably.
The starting dose of glargine is to be 10 units once daily preferably in the evening.
The Solostar disposable pen or cartridge can to be used.
Both timing of and dose of Lantus can be modified at the discretion of the general practitioner.
The patient is to return the next day so that self-administration of the second injection can be observed.Slide36
Case study
Brian: 61 year old electrician
Visit 1: PN/CDE
Demonstration of insulin pen
How to prevent, treat and
recognise
hypos
Sick day management
Healthy diet and lifestyle
Give sharps container/refer to Diabetes Australia for sites
Ensure patient monitors with BGL machine twice per day
How to give insulin and importance of site rotation
GIVE/INSTRUCT PATIENT TO ADMINISTER 10 UNITS
INSULIN
Storage of insulin
Sharps disposal Insulin dose and administration timeArrange next day visit: pt to give insulin under supervisionSlide37
What’s involved?: Getting started on Glargine (Lantus)
addressing fasting glucose levels
GP and PN baseline visit
PN Baseline visit 2 (next day)
Titration calls or F-F with PN
PN Reminder call
GP and PN Week 4 visit and monthly thereafter
Timeline
Tasks: GP assesses need for insulin and documents plan to use protocol. PN gives first Lantus dose
Tasks: PN watches patient give their own dose, check technique etc
BASAL TITRATION TOOL
0
0+1 day
Weeks 1-3
34, 8, ...FBGLs 4 - 7.0 consistentlyDecision made to consider Rapid acting insulin analogueTasks: PN and GP liaise, review and decision to start Rapid acting insulin analogueTasks: PN works with patient to up-titrate, liaison with GP and DNE/Endo as neededTasks: PN reminds patient re next weeks visitTasks: GP and PN clinical reviewXTarget Fasting glucose levels: 4-7mmol/LSlide38
Case study
Brian commences the 10 units of glargine and demonstrates
good injection technique.
His dose now needs to be titrated.
Tools for insulin titration:
Accu-Chek
360 basal insulin titration tool
RACGP Guidelines now contain algorithms for
titration of basal, mixed and
prandial
insulins.
Options:
Health professional led titration OR
Patient self titration Slide39
Guidelines provide HbA
1c, FBG and PPBG targets
Normal
Targets for diabetes patients
ADS/EASD
AACE
IDF
Stepping
Up study
HbA1c
<6.0
<7.0
<
6.5
<6.5
<7.0FBGL<5.53.9-7.2<6.0<6.04.0 - 7.0PPBGL2 hours postprandial<7.8<10<7.8<8.04.5 - 10.0Slide40
Stepping Up protocol for adjustment of glargineSlide41Slide42
Case study
Brian: 61 year old electrician
Brian has been stabilised on a dose of 44 units of
glargine and his
fasting blood glucose levels are
consistently in the target range of 4-7mmol/L.
His HbA1c has improved from 8.5% (69mmol/mol)
to 7.5% (58mmol/mol).
What is the next step?Slide43
GP and PN insulin visit (with Study DNE prn)
Titration calls or F-F with PN
PN Reminder call
Tasks: GP review, discussion with patient, PN review and education in use of
RAPID ACTING TITRATION TOOL
X
X+1
Weeks X + 1-3
X+3
FBGLs 4 -7 .0 consistently
Decision made to consider rapid insulin
Tasks: PN and GP liaise, review and make decision to start Rapid acting insulin analogue
See patient and do
3 DAY PROFILE
GP and PN Week 4 visit and monthly thereafterPPBGLs 4.5 - 10.0 consistentlyTasks: Ongoing clinical monitoringX+4, 8, ...Target Post-Prandial Glucose levels: 4.5-10mmol/LTasks: PN works with patient to up-titrate, liaison with GP and DNE/Endo as neededTasks: PN reminds patient re next weeks visitTasks: GP and PN clinical review TimelineWhat’s involved?: Starting Rapid acting insulin analogue (Rapid acting insulin analogue: Apidra/Novorapid/Humalog) addressing 2hr post-prandial glucose levelsSlide44
Rapid acting insulin analogue Initiation
Rapid acting insulin analogue can be initiated at any time
after
the patient has been on Lantus for
4 weeks
.
Fasting
blood glucose levels should be in
target
range prior to Rapid acting insulin analogue initiation.
Identify the
meal
with the highest post-prandial glucose readings. If
above target
(>10.0mmol/L) a pre-meal injection of Rapid acting insulin analogue should be initiated.The Solostar injecting device for Rapid acting insulin analogue is identical to that used for Lantus, except for pen colour . Starting dose 4 Units immediately prior to designated mealSlide45
Determining which meal to target: 3 day 7 point profileSlide46Slide47
Stepping Up protocol for titration of rapid acting insulin analogueSlide48
Some notes on blood glucose monitoringSlide49
Why test?
SMBG allows patients to evaluate their individual response to therapy and assess whether glycaemic targets are being achieved.
Results of SMBG can be useful in preventing hypoglycaemia and adjusting medications (particularly
insulin
doses).
SMBG allows clinicians to compare HbA1c derived average glucose estimation with actual BGLs from patients and make decisions on therapy changes and interventions. Slide50
Top 10 reasons patients give for not testing.1
The meter makes me feel bad about myself
Monitoring seems pointless (because there is nothing I can really do about my blood glucose results anyway).
Checking blood glucose reminds me that I have diabetes – 24/7
The meter seems to control my life, telling me what I can and cannot do.
Monitoring serves as an opportunity for friends and family to bother me
None of the health care providers ever do anything with the results anyway.
Checking blood glucose sometimes hurts.
Monitoring can be inconvenient.
Monitoring can be expensive.
Life is too busy and demanding to take the time for regular monitoring.
1. William
Polonsky
, "Diabetes
Burnout”Slide51
The conclusion about SMBG
In well controlled T2D not on insulin achieving target HbA1c less than 7%
(53mmol/mol) without
glycaemic symptoms there does not appear to be evidence for SMBG
In
T2D not currently achieving glycaemic targets, symptomatic, risk of hypoglycaemia, sick day management, insulin
and those in whom a therapy change is being considered SMBG has a role as long as patients are instructed in the interpretationSlide52
Glucose monitoring and diaries
Ideally all patients on insulin are to monitor blood glucose levels at least twice daily - before breakfast [required] and at another time [preferably about 2 hours after a meal].
Fingerprick
glucose ideally with
times & readings
are to be recorded in glucose monitoring diary.
Any symptomatic hypoglycaemic episodes are to be recorded in the diary.
Patients are to be advised to bring the diary and meter in with them at every visit (option to upload data in clinic)
Structured monitoring with feedback from the GP/PN/CDE is likely to be more effectiveSlide53
Case studies and questionsSlide54
Tim
49 years oldT2D diagnosed at age 46HbA1c 7.6% (60mmol/mol)No complications on screeningCurrent diabetes medications:Sitagliptin metformin combination (
Janumet
) 50mg/1000mg
bd
Commenced on glargine – 10 units
Reached target fasting BSLs: 5-6mmol/L, some post-
prandial
elevationsSlide55
Tim continued
Started exercise at lunch, getting hypo symptoms when getting back to the officeVery hungry – adding chocolate milk to lunchConcerned about weight gainHow could you assist Tim to better manage this?Slide56
Karen
42 year old single
woman with three young
children
HbA1c 12%
(108mmol/mol) on
maximal oral therapy
Commenced on
Lantus
, achieved fasting levels but high glucose excursions after evening meal
Inconsistent blood glucose monitoring
Commenced on
ApidraSlide57
Karen continued
Two episodes of hypoglycaemia following rapid acting insulin analogue Fell asleepHypo whilst drivingWhat advice would you give Karen about hypoglycaemia management?
What are the options for the management of Karen’s diabetes?
What would you advise her about driving?Slide58
Hypoglycaemia management
https://www.diabetesaustralia.com.au/Understanding-Diabetes/What-is-Diabetes/Hypoglycaemia/#Treating HypoglycaemiaSlide59
AustRoads
, Assessing Fitness to Drive for Commercial and Private Drivers, amended March 2013Slide60
AustRoads advice re Hypoglycaemia
AustRoads
, Assessing Fitness to Drive for Commercial and Private Drivers, amended March 2013
5 to driveSlide61
Alberto
75 years oldHbA1c consistently >10% (86mmol/mol)Maximal oral therapy, refused insulin for three years, now agrees to tryBSLs 15 – 22+ mmol/L
Lantus
increased from 10 to 22 units over the following weekSlide62
Alberto continued
One week later Alberto gets ‘hypo’ symptoms after a walkBSL is 8mmol/LDoes not want to titrate insulin furtherWhat goals would you set for Alberto?He was happy with the high blood glucose levels. Is insulin really necessary?Slide63
Contact Details
Ms Louise Ginnivan - Diabetes Educator 0499 599 084Dr Jo-Anne Manski-Nankervis:
8344 3373
jomn@unimelb.edu.auSlide64
© Copyright The University of Melbourne 2011