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Insulin initiation intensification inoutpatient

Ketut SuastikaUniversitas Udayana Den


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OutlinesPresentation structure

Diabetes is a progressive disease and is increasing

in prevalence

The mapping of insulin treatment based recent guidelines

Insulin Initiaton and Intensification from latest update study (A1

Conclusion


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212000171 million1

2030

552 millio

2011

366 million2

Diabetes is a global diseaseEstimated global prevalence of diabetes

1! "ild! Diabetes Care. 2#! 2$%1#$&1'!2! International Diabetes ederation!IDF Diabetes Atlas! ifth *dition! 211


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1! Adapted from% +amlo&,alsted -A. *delman /0! Clincial Diabetes 20001(2)% http%334ournal!diabetes!org3clinicaldiabetes3v1n2

2D!" Progressive loss of insulinsecretion #it$ increasing insulin resistance1

Impaired

glucose tolerance

%ndiagnosed

diabetes

Insulin

&no#n

diabetes

Insulin Postpra

'asting

!icrovascular complications

!acrovascular complications


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Diabetes is a progressive disease

Type 2 diabetes (T2D5) progression is characterised by decline in beta&c

and 6orsening insulin resistance1

7etting to. or maintaining. target ,bA1clevels in T2D5 re8uires intensifie

over time2

1! onseca 0A! Br J Diab Vasc Dis2%/2! 9athan D5. et al! Diabetes Care2:2%1:&2


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Diabetes being a progressive disease t$at is incin prevalence

T2D5 results in a progressive loss of insulin secretion 6ith incre

resistance1

-y 2. ID predicts ''2 million people 6orld6ide 6ill have dia

Diabetes is the fourth most common diagnosed chronic condition

5any people 6ith diabetes do not have good glycaemic control(

1! +amlo&,alsted -A. *delman /0! Clincial Diabetes 20001(2)% http%334ournal!diabetes!org3clinicaldiabetes3v1n223pg!htm

2! International Diabetes ederation!IDF Diabetes Atlas! ifth *dition! 211! -runton! Curr Med Res Opin2112$;'&$2


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in prevalence



Conclusion


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(e# position statement of t$e )D) and E)*D onmanagement of $+pergl+cemia in t+pe 2 diabete

Inzucci SE, et al. Diabetologia. 2012


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(e# )D),E)*D Position on *e-uential Insulin*trateg+ in +pe 2 Diabetes

(on.Insulin/egimes

asal Insulin Onl+ess 'leible!ore 'leible

Conv!ore 8onvenientess 8onvenient

Inzucci SE et al. Diabet!l!"ia. 20#2. $ %u&prec't et al. Intensi(icati!n t! t! bip'asic insulinaspart )0*+0. Int J Clin ,ract 200-


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@atient Centered Approach


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9$at is t$e optimal target b)1clevel:

7oals of optimum ,bA1clevels%

7ood glycaemic control

5inimise development and progression of microvascularand macrovascular complications

b)1c

;70


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Insulin can be initiated at an+ time

Traditionally. insulin has been reserved as the last line of ther

H,o6ever. considering the benefits of normal glycemic status

can be initiated earlier and as soon as possible

Inade-uateifest+le

1 O)D 2 O)D

I(II)E I(*%I(


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in prevalence



Conclusion


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o# to start asal Insulin /tart 6ith basal insulin (Insulin Detemir) 1 < or .1&.2 < per Gg

=nce daily in4ection. anytime in4ection but in same time per each d


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*imple Dose titration #it$ evemir

@atients 6ho e>perienced hypoglycemia reduced their daily dose by unit

'P= target range70.?0 mg,d

'P= ;70 mg,d @3A mmol,B

'P=C?0 mg,dl @50 mm,B

!ean 3.da+ 'P= @mg,dB

!aintaindose

units

'P= target rangeA0.110 mg,d

'P= ;A0 mg,d @ mmol,B

'P=C110 mg,d @61 mmol,B

londe et al Diabetes Obes Metab 200? 11@6B"623.631

Increase

3 units

Decrease3 units

evemirF Dose itration =uidelines"3.0.3 )lgorit$m

/tart 6ith evemir 1 < or .1&.2 < per Gg --


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evemirF,=largine ead.to.ead"*imilar Profiles in +pe 2 Diabetes

Time (h)

GleinGlein = et al! Diab Obes Metab 2$ :%2:&2::

7luco

seinfusionrate

(mg3Dg3min)

0 2 4 6 8 10 12 14 16 18 20 22

0

0.5

1.0

1.5

2.0

2.5

3.0

!#


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evemir reduces nocturnal $+pogl+caemia b+ up65< compared to (P

,'illis1si&i3as. Clin 'er 2004/256#07#84-95#/ Riddle et al 200). Diabetes Care/ 24 6##7 )05014/ Asa3ura et al 2005. E:pert Opin ,'ar&ac!t'er/ #0 6-7 #18/ ;anel ; et al 2005. J Diabetes1

In

In

In

+elative+isD

+iddleet al. 2 @hillis&Tsimias et al. 2;

-29% -44% -53% -65%

9@, vs! glargine 9@, vs! detemir


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o# to Intensif+


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reatment t$erapies for +pe 2 diabetes

Adapted (r!& Racca' et al. Diabetes Metab Res Re= 200+/2)28+.

ifest+le !etformin

.ot$erO)D or=P.1

agonists

asalInsulin

(Once-dailytreat-to-target)

PremiedInsulin

(!ice dailyreat totarget)

asal

Insulin("asal # 1 or2 $randial)

asalInsulin

("asal # $randial

b)1c470< b)1c470


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o normalise blood glucose bot$ 'P= and PP=must be reducedH

Adapted (r!& M!nnier > et al. Diabetes Care 200)/2455#98

PP'P

50< 55

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