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Enhanced General Practice Management of Diabetes Enhanced General Practice Management of Diabetes

Enhanced General Practice Management of Diabetes - PowerPoint Presentation

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Enhanced General Practice Management of Diabetes - PPT Presentation

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/yearSlide5
Slide6
Slide7

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.Slide10
Slide11

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 glargineSlide41
Slide42

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 profileSlide46
Slide47

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