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INTENSIVE INSULIN
THERAPY
J. Robin Conway M.D.
Diabetes Clinic, Smiths Falls, ON
1-800-717-0145
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Objectives
•
Optimize diabetes management
•
Assist you in initiating insulin in your office
–
When to start insulin therapy?
–
Insulins, doses, delivery options
–
Patient training
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Challenges in Initiating Insulin?
1.
Patient attitudes
Patient attitudes
–
Fear of needles

–
Insulin viewed as a threat by patient & physician
–
Hypoglycemia
2.
Physician Attitudes
Physician Attitudes
–
Discomfort with insulin
•
Lack of knowledge and experience
–
Fear of needles
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Type 1 Diabetes:
•
Impaired or absent ß cell function:

↓ insulin secretion
•
Normal insulin action:

↑ insulin sensitivity
•
The insulin deficiency results in
unacceptable blood glucose control
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Type 2 Diabetes: Double Impairment
•
Impaired ß cell function:

↓ insulin secretion
•
Impaired insulin action:

↑ insulin resistance
•
Results in unacceptable blood glucose
control
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Type 1 & 2 Diabetes: Key Concepts
•
Minimizing the complications of diabetes
requires:
–
Early diagnosis and treatment of diabetes
–
Maintaining HbA
1C
level < 7%
•
Achieving HbA
1C
< 7% requires control of

post-prandial and fasting hyperglycemia
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CDA Guidelines (for glycemic control)
Normal Optimal

A
1C
level
(0.04-0.06)

(< 0.07)
Preprandial
glycemia
(mmol/L)
3.5-6.1 4-7
Postprandial
glycemia
(mmol/L)
4.4-7.8 7-11
Haars s et al., CMAJ 2003; 159 (Suppl.): S1-29. Gerstein, H.C. et al. CDA views on the UKPDS and revision of the
guidelines affected by the results of this study.
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Steps to Glycemic Control
•
Establish glycemic objectives
–

Target fasting and post-prandial glycemia
•
Diet counseling with exercise component
•
Diabetes education for every patient
•
Pharmacological treatment; oral and insulin
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Patient Counselling Topics
A.Review symptoms and treatment of
hypoglycemia
B.Proper training and correct use of glucose
monitor
C.Target desired glycemic levels for each
patient
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A. Hypoglycemia
•
Definition: Glycemia < 3.8 mmol
•
Patients may experience hypoglycemia at
different glycemic levels
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Symptoms of Hypoglycemia

Mild
•
< 3.3 mmol/L
•
Neurovegetative
symptoms
–
Sweating
–
Trembling
–
Palpitations
–
Anxiety
–
Tingling
–
Pallor
–
Hunger
Moderate to Severe
•
< 2.8 mmol/L
•
Symptoms of glucopenia
–
Confusion
–
Visual disturbances
–

Weakness
–
Speech disorder
–
Behavioural disorder
–
Drowsiness
–
Coma
–
Convulsions
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Preventing Hypoglycemia
•
Check BG 4-6 times per day
•
Carry glucose tablets
•
Have Glucagon Kit available
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Preventing Hypoglycemia
•
Test before driving and ideally 1 hour later
(target: over 5.5 mmol/L)
•
Perform two SMBG 30 minutes apart prior to

bedtime (confirming rising or falling BG)
•
When drinking alcohol, perform SMBG hourly
•
With exercise, perform SMBG pre- and post-
exercise
•
If hypoglycemia episodes persist, raise target
glucose levels
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Hypoglycemia Treatment
Guidelines
The Rule of 15
The Rule of 15
•
If BG is 4 mmol/L or below
–
Treat with 15 grams of carbohydrates (glucose
tabs)
–
Check BG in 15 minutes, and if not above 4
mmol/L, repeat treatment
Glucagon
•
Current emergency kit readily available and
knowledgeable person trained to administer
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Preventing
Hyperglycemia and DKA
•
Monitor BG 4-6 times per day
•
Use Correction Boluses when appropriate
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Hyperglycemia Treatment Guidelines
The Key to Preventing DKA
1st BG over 14 mmol/L:
1st BG over 14 mmol/L:
•
Take a correction bolus, check again
in 1 hour
•
Call physician immediately or go to ER if
nausea and vomiting are present
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B. Patient Training
•
Training by a multidisciplinary team at DEC is
IDEAL for:
–
Diet counseling
–

Education on the injection sites
–
Education on the various injection devices
–
Evaluation of the patient’s support network
•
Other resources may exist for training, i.e. retail
pharmacy
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C. Blood Glucose Monitoring
•
To adjust the insulin treatment
•
To detect or confirm hypoglycemia or severe
hyperglycemia
•
To adjust treatment to the circumstances of daily
life using an insulin scale prescribed by the
attending physician
•
To improve patient safety and increase motivation
to comply with treatment
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Ideal Testing Frequency
•
Stable type 2

–
1-2 readings/day
•
Type 1 or Unstable type 2
–
3-8 readings/day
•
Important to stress the need to vary testing
times
–
AC, PC, h.s. and prn during the night

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Injection Tools and Options
•
Durable delivery devices
–
Novolin-Pen
®
3
–
Novolin-Pen
®
Junior
–
InDuo
®
–

Innovo
®
–
HumaPen
®
•
Insulin pumps
•
Syringes
•
Disposable: multidose,
prefilled (3.0 mL)
–
NovolinSet
®
(NPH,
Toronto, 30/70 )
–
Humulin
®
N
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Advancing Insulin Therapy Through
Device Innovation
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We are trying to duplicate

how the pancreas works in
releasing insulin for
someone who doesn’t
have diabetes
Goal of Insulin Therapy
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Non-diabetic Insulin and Glucose
Profiles
9.0
6.0
3.0
0
7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
Insulin
Glucose
a.m. p.m.
Breakfast Lunch Supper
75
50
25
0
Basal insulin
Basal glucose
Insulin
(µU/mL)
Glucose
(mmo/L)
Time of Day

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Insulin Preparations
Start 3-4
hrs. Peakless
Humulin
®
U vial only
Lantus (Glargine) vial only
Levemir (Detemir) cartridge
Prolonged
action
Start 1.5
hrs
Peak 7 hr
Novolin
®
ge NPH
Humulin
®
N
Intermediate
Vial and cartridge
Start 30-60
min.
Peak 4 hr
Novolin
®
ge Toronto

Humulin
®
R
Short-acting
(regular)
Vial and cartridge
Start < 15
min.
Aspart (NovoRapid
®
)
Lispro (Humalog
®
)
Rapid-acting
Vial and cartridge
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Insulin PreMixes
•
Regular + intermediate
–
Novolin
®
10/90, 20/80, 30/70, 40/60, 50/50
–
Humulin
®
30/70, 20/80

•
Analogue Pre-Mix
–
Humalog
®
25/75 (insulin lispro protamine
suspension)
–
NovoMix 30* (protaminated insulin aspart)
* Not available