Case Presentation SWITCH Case Study Case 1 Demographic

Case Presentation SWITCH

Case Study: Case 1

Demographic characterestic of Case 1 • Age: 61 years old ♂ • Diabetes Duration: 20 years • HTN: 20 years/ PCI: 10 years ago/ PDR: Laser+/ • Renal transplant: 4 years ago living donor • Weight: 72 kg BMI: 25. 8 • P/E: BP 140/80 mm. Hg

Lab. Results - 1393/2/16 • FBS: 223 mg/d. L, • BS (SMBG): 200 to 300 mg/d. L, • Hb. A 1 c : 9. 7% • Cr: 1. 1 mg/d. L, • TG: 220 mg/d. L, LDL: 82 mg/d. L, HDL: 35 mg/d. L, • U/A: +3 glucose, many WBC

Current Treatment - 1393/2/16 • Lansulin: 70/30: 25 – 20 - 15 • Furosemide 40 mg Bid • Cellcept 1000 mg Bid • ASA 80 mg Bid • Prednisolon 2. 5 mg Qd • Atorvastatin 20 mg Qd • Atenolol 50 mg Qd

• What do you recommend?

Biphasic vs Basal Bolus insulin regimen in T 2 DM: systematic review and meta-analysis of randomized controlled trials All Patients Insulin Naïve Patients CONCLUSIONS: Biphasic and basal bolus regimens were equally effective in reducing Hb. A 1 c in insulin naïve patients with Type 2 diabetes and both regimens are equally effective for initiating insulin in Type 2 diabetes. Wang C et al. , Diabet Med. 2015; 32(5): 585 -94. doi: 10. 1111/dme. 12694. Epub 2015 Feb 13.

Which patient should be offered a premix versus basal-plus/basal bolus regimen? Premix insulin analogs Basal plus/basal bolus Patient preference Type 1 diabetes (any age) Older age Younger age Need assistance with injections Highly motivated and compliant Organized lifestyle Active lifestyle Two meals a day or evening main meal High variability in eating habits Mosenzon O, et al. Diabetes Care 2013; 36(2): S 212 -S 218.

How to Switch from Mixed Human Insulin to Novo. Mix® 30

Switch to Novo. Mix® 30 from self-mix Human Insulin Patients treated with regular and NPH insulin with 20/80, 30/70 and 40/60 proportions Poor glycemic control History of Hypoglycemia Good glycemic control and no history of hypoglycemia Switch to NM 30 with 10% increasing dose (the summation of both Regular and NPH doses) Switch to NM 30 with 10% decreasing dose (the summation of both Regular and NPH doses) Switch to NM 30 with equivalent dose (the summation of both Regular and NPH doses) Khamseh et al, Novin Pezeshki medical journal , 2015; Vol. 589

Switch to Novo. Mix® 30 from self-mix Human Insulin Patients treated with regular and NPH insulin with 20/80, 30/70 and 40/60 proportions Poor glycemic control History of Hypoglycemia Good glycemic control and no history of hypoglycemia Switch to NM 30 with 10% increasing dose (the summation of both Regular and NPH doses) Switch to NM 30 with 10% decreasing dose (the summation of both Regular and NPH doses) Switch to NM 30 with equivalent dose (the summation of both Regular and NPH doses) Khamseh et al, Novin Pezeshki medical journal , 2015; Vol. 589

BIAsp 30: Titration Algorithm FBG or pre-dinner SMBG BIAsp 30 dose adjustment (mg/d. L) <80 – 2 U 80– 110 – 111– 140 +2 U 141– 180 +4 U >180 +6 U BIAsp, biphasic insulin aspart; FBG, fasting blood glucose; SMBG, self-measured blood glucose Adapted from Raskin et al. Diabetes Care 2005; 28: 2811

BIAsp 30: Dosage Regimen Timing of blood glucose measurements used for dose titration Dose to titrate BIAsp 30 OD BIAsp 30 BID BIAsp 30 TID Breakfast – Pre-dinner Pre-lunch Lunch – – Pre-dinner Dinner Pre-breakfast BIAsp, biphasic insulin aspart; BID, twice daily; OD, once daily; TID, three-times daily Garber et al. Diabetes Obes Metab 2006; 8: 58– 66; Raskin et al. Diabetes Care 2005; 28: 260– 5

ACTION • Novomix 30 : 22 IU breakfast – 22 IU lunch – 22 IU dinner • Lansulin D/C

SMBG – 1393/2/31 Novomix 30 : 22 IU breakfast – 22 IU lunch - 22 IU dinner Date FBS 93/2/28 2 h PPG after breakfast 2 h PPG after lunch Before dinner 2 h PPG after dinner 210 267 172 230 Before lunch 93/2/29 105 180 288 296 320 93/2/30 93 180 320 190 255 Novomix 30 : 22 IU breakfast – 26 IU lunch - 22 IU dinner 3 AM

Two Weeks Later Novomix 30 : 22 IU breakfast – 26 IU lunch – 22 IU dinner No hypoglycemia

Case Presentation Intensification

Case Study: Case 2

Demographic characterestic of Case 2 • Age: 58 years old • Diabetes Duration: 15 years • Weight: 82 kg BMI: 27. 1 • P/E: BP 145/85 mm. Hg, +1 lower extremity pitting edema • DM Complications: Microalbuminuria • FBS: 130 mg/d. L, BS: 250 mg/d. L, Hb. A 1 c: 9% • Cr: 1. 2 mg/d. L, K: 4. 4 meq/L, ALT: 19 IU/L,

Current Treatment • Glibenclamide: 15 mg/day • Metformin: 1500 mg/day • Atorvastatin: 20 mg Qd • ASA: 80 mg Qd • Pioglitazone 30 mg daily for 5 years; because of edema D/C • Then after, 30 unit Glargine bedtime

SMBG FPG 1 h PPG after breakfast 145 265 Before lunch 1 h PPG after lunch 220 Before dinner 1 h PPG after dinner Bed time 280

Inter-active question Options: 1. Increasing the dose of OADs / which one? / how much? 2. Adding other OADs / which? 3. Adding Insulin / which type? / why? 4. Other opinions?

Insulin start • What kind of insulin would you start? • Starting dose? • How do you titrate? • Who titrates?

Approach to initiation and intensification of insulin in Type 2 diabetes American Diabetes Association 2016; 39(Suppl. 1): S 52–S 57

Basal Insulin Overtreatment Anthony L. Mc. Call. Endocrinol Metab Clin N Am 2012; 41: 57– 87.

Intensification of insulin regimens Diabetes Care 2016; 39(Suppl. 1): S 52–S 59 | DOI: 10. 2337/dc 16 -S 010

Intensification of insulin regimens Diabetes Care 2016; 39(Suppl. 1): S 52–S 59 | DOI: 10. 2337/dc 16 -S 010