Case Studies on Insulin Initiation Nicole Mc Grath

  • Slides: 22
Download presentation
Case Studies on Insulin Initiation Nicole Mc. Grath 2013

Case Studies on Insulin Initiation Nicole Mc. Grath 2013

Case 1 • 52 year old woman, type 2 diabetes for 10 yrs, BMI

Case 1 • 52 year old woman, type 2 diabetes for 10 yrs, BMI 32 (87 kg) – On Metformin 850 mg mane, 1700 mg nocte; Gliclazide 80 mg bd • Regularly picks up scripts; assures you she is taking – Not testing BG – Hb. A 1 c 70 mmol/mol • What to do?

Case 1 Discussion • Increase Gliclazide to 160 mg bd • Start home BG

Case 1 Discussion • Increase Gliclazide to 160 mg bd • Start home BG testing • BG elevated: – Fasting around 10 – Before evening meal 12 – 2 hours after evening meal 13 • What next?

Case Study 1 - Mrs J Age 52. BMI 32 (87 kg). Hb. A

Case Study 1 - Mrs J Age 52. BMI 32 (87 kg). Hb. A 1 c: 70 mmol/mol Currently on: Metformin 850 mg mane, 1, 700 mg at dinner, Gliclazide 160 mg BD. Blood glucose (mmol/L) How would you start Mrs J. on insulin?

Case Study 1 - Mrs J. • NZGG: – Start Isophane 8 -10 units

Case Study 1 - Mrs J. • NZGG: – Start Isophane 8 -10 units at bedtime. – Continue orals – consider reduction of Gliclazide to 80 mg BD. – Give the patient instruction to selfadjust insulin dose. • Likely doses to achieve red line: – Isophane 30 -35 units nocte – Gliclazide 160 mg bd – Metformin 850 mg mane, 1700 mg evening meal

Case Study 2 – Mrs T: Age 74. Hb. A 1 c 75 mmol/mol

Case Study 2 – Mrs T: Age 74. Hb. A 1 c 75 mmol/mol (9%) , Currently on: Prednisone 5 mg/day for Rheumatoid Arthritis and maximal OHA therapy. Blood glucose (mmol/L)

Case Study 2 – Mrs T. As you can see… high glucose levels rising

Case Study 2 – Mrs T. As you can see… high glucose levels rising during the day but dropping over night. Consider: • 10 units of isophane at breakfast and adjust the dose as required. – Good fasting achieved with 15 units but…. Red line still suboptimal so change to • 15 units of Pre-mixed insulin breakfast – Penmix 30 / Humulin 30/70 .

Case 3: 66 yr old male with COPD • On Metformin 1 gm bd,

Case 3: 66 yr old male with COPD • On Metformin 1 gm bd, Glipizide 5 mg bd; – Hb. A 1 c 57 mmol/mol • Needs course of Prednisone for exacerbation COPD – Prednisone 40 mg daily 5 days then 20 mg 5 days Fasting Pre-lunch Pre-dinner 6. 8 12. 6 17. 2 7. 1 13. 8 18. 0

PATHWAY FOR MANAGING HYPERGLYCAEMIA SECONDARY TO STEROIDS FOR CLIENTS WITH COPD (on Health. Point)

PATHWAY FOR MANAGING HYPERGLYCAEMIA SECONDARY TO STEROIDS FOR CLIENTS WITH COPD (on Health. Point) • Whilst on 40 mg Prednisone – Test BSLs at least tds – OHAs –increase usual mane dose by 100% e. g. usual mane dose Gliclazide 80 mg –increase to 160 mg • If patient is maximised on OHAs: – transient hyperglycemia can sometimes be tolerated for a short period. – Alternatively, a morning dose of Penmix 30/70 (usually 0. 2 units/kg body weight) can be given during steroid treatment. – Some patients may need to be commenced on ongoing insulin

Case Study 4 - Mr L. Age 62. BMI 27 (78 kg) Hb. A

Case Study 4 - Mr L. Age 62. BMI 27 (78 kg) Hb. A 1 c 68 mmol/mol. Currently on: maximal OHA therapy. Blood glucose (mmol/L)

Case Study 4 – Mr L. High fasting and post-prandial BG: basal insulin with

Case Study 4 – Mr L. High fasting and post-prandial BG: basal insulin with current OHA will treat fasting hyperglycaemia but not post meal BG elevations Suggest Premixed insulin: As lunch not so much of an issue, Novomix 30 or Humalog 25: Start 15 units bd (0. 2 units/kg/dose) Stop sulphonylurea

Case Study 5 - Mr K. Age 64. Hb. A 1 c 75 mmol/mol

Case Study 5 - Mr K. Age 64. Hb. A 1 c 75 mmol/mol (9%). Currently on: maximal OHA therapy. Blood glucose (mmol/L)

Case Study 5 – Mr K’s blood glucose is particularly high after his main

Case Study 5 – Mr K’s blood glucose is particularly high after his main meal (dinner). • Consider 10– 12 units of premixed insulin (Humalog Mix 25 or Novomix 30) at dinner.

Case 6: 55 yr old male, BMI 35 (116 kg), known diabetes 4 yrs,

Case 6: 55 yr old male, BMI 35 (116 kg), known diabetes 4 yrs, Hba 1 c 85 • No home BG testing • Long gaps between prescription requests – Prescribed Metformin 1 gm bd, Gliclazide 160 mg bd • Microalbuminuria, background retinopathy, hypertension

Case 6 • Option 1 – advice on diet, exercise, taking medication – warn

Case 6 • Option 1 – advice on diet, exercise, taking medication – warn of possible adverse consequences; – increase Metformin to 1500 mg bd; – Start BG testing and reporting back to nurse

Case 6 • Option 2: 3 month F/U Hb. A 1 c 76: –

Case 6 • Option 2: 3 month F/U Hb. A 1 c 76: – Has achieved good reduction with compliance but Hb. A 1 c still suboptimal and not testing much • Fasting BG 10, Pre-dinner 13 • Glargine in addition to Metformin and Gliclazide a reasonable option – Starting dose: 0. 2 units / kg / day: – Weight 116 kg: start 24 units daily (morning or night) – Insulin self-adjustment in conjunction with weekly contact with nurse

Case 6 • Option 3: – Accept failure of OHA – Prescribe pre-mixed insulin

Case 6 • Option 3: – Accept failure of OHA – Prescribe pre-mixed insulin bd • He eats 2 meals per day: brunch and dinner – Novo. Mix 30 or Humalog Mix 25: 24 units bd » Could well need to double that – Stop sulphonylurea, continue Metformin • Provide insulin self-adjustment handout or ask pt to increase each dose by 2 units every 3 days until BG 4 -8 – Hopefully practice nurse will be able to contact him weekly to support/supervise

Case 7: 37 year old female, BMI 45 (weight 128 kg); diabetes 3 years

Case 7: 37 year old female, BMI 45 (weight 128 kg); diabetes 3 years • Hb. A 1 c 85 • Prescribed Metformin 1 gm bd; Gliclazide 160 mg bd and appears to be taking them • Not testing BG • Sleep Apnoea

Case 7 • Option 1 – Weight loss essential: • Refer to dietitian for

Case 7 • Option 1 – Weight loss essential: • Refer to dietitian for consideration of Optifast • Refer for consideration Bariatric Surgery – Pioglitazone in addition to Metformin and Gliclazide – Repeat Hb. A 1 c in 3 months

Case 7 • Option 2 – Accept weight loss/exercise not achievable – Consider insulin,

Case 7 • Option 2 – Accept weight loss/exercise not achievable – Consider insulin, although insulin resistance will mean large doses necessary • Eats 3 meals per day and snacks in the evening • Penmix 30 or Humulin 30/70: 26 units bd, stop sulphonylurea – Insulin self-adjustment: may need to increase by > 4 units each time if BG remain very high – Will probably need 60 units bd if she doesn’t change her diet/weight

Case 8: 41 yr old male, BMI 27 • Diabetes 8 yrs, on Metformin

Case 8: 41 yr old male, BMI 27 • Diabetes 8 yrs, on Metformin 1500 mg bd, Gliclazide 160 mg bd, Pioglitazone 45 mg daily • Truck driver • Hb. A 1 c 62 mmol/mol • Microalbuminuria, erectile dysfunction, retinopathy • BG: fasting 9, pre-dinner 10 • Requires heavy traffic licence medical certificate • Patient feels he is doing as much as he can re diet, exercise

Case 8 • Needs insulin but want to minimise effect on driving – Isophane

Case 8 • Needs insulin but want to minimise effect on driving – Isophane at night 10 units • Increase by 2 -4 units every 3 days to achieve fasting BG < 7 – Continue OHA • NB. LTSA do not generally require specialist reports for type 2 patients on insulin