Case Study Hands On Experience Patient case study
- Slides: 45
Case Study Hands On Experience
Patient case study: Patient A Patient information Age, gender • 55 years old, male Duration • Type 2 diabetes for 10 years Current treatment • • Metformin (1000 mg BID) Gliclazide (80 mg before breakfast and dinner) Rosuvastatin (10 mg daily) ASA (80 mg/d. L) Current Lab. • • Hb. A 1 c: 9. 2% FPG: 205 mg/d. L PPG: 216 mg/d. L Cr: 0. 8 mg/d. L BP - BMI • 135/85 mm. Hg - 26 kg/m 2 Additional background • No diabetic complications • Employee; dinner is the main meal • • TG: 200 mg/d. L LDL: 87 mg/d. L ALT: 24 IU/L U/A: +1 Glucose
Mr A: 7 -points curve Fasting 205 Post breakfast Pre Lunch Post lunch Pre dinner After dinner 3 am Hb. A 1 c 216 125 187 142 312 242 9. 2%
Options & Comments: 1) Metformin/Gliclazide? 2) Adding / replace Repaglinide? 3) Adding Acarbose? 4) Adding Pioglitazone? 5) Adding basal Insulin? 6) Adding prandial Insulin? 7) Starting pre-mixed Insulin? 8) Starting basal/prandial Insulin Analogues?
Presentation title Date 6
Presentation title add? • Injection treatment • Basal insulin or premix • victosa • Oral drugs Date 8
Treatment of Mr A Started with Novomix® Before Dinner
After taking Novomix® for one week, SMBG of A • Fasting 180 mg/dl Titrated the dose during 3 months 12 units 14 units 16 units
Lab. Results: • Hb. A 1 c Reduction (3 m. later) 9. 2% -1. 9 % 7. 3%
Lab. Results: (2 m. later) • Fasting plasma glucose Reduction 205 mg/d. L -85 mg/d. L 120 mg/d. L
Mr A: 7 -points curve Fasting 120 Post breakfast Pre Lunch Post lunch Pre dinner 122 After dinner Hb. A 1 c 7. 3%
14 Glycemic targets American Diabetes Association. Diabetes Care 2016.
Clinical challenge: Hb. A 1 c reduction (%) Selecting the appropriate treatment for your patient 0. 0 0. 5 1. 0 1. 5 2. 0 2. 5 3. 0 Sulfonylureas Metformi n Glinides DPP-IV inhibitors 0. 5 -0. 7 1. 5 Efficacy as mono therapy 1. 5 1. 01. 5 GLP-1 RAs TZDs 1. 0 -1. 5 0. 5 - 0. 8 Insulin ≥ 2. 5 Insulin is the most effective glucose-lowering agent Nathan DM. N Engl J Med. 2007; 356: 437 -40 Nathan et al. Diabetes Care. 2009; 32: 193 -203 Anti diabetic agents
IDF treatment algorithm (2013 update) Lifestyle measures Usual approach Alternative approach Then, at each step, if not to target (generally Hb. A 1 C<7. 0%) Consider first line Sulfonylurea or α-glucosidase Metformin Consider second line Sulfonylurea Metformin (if not first line) or α-gluc or DPP-4 or TZD or GLP-1 agonist Consider third line Basal insulin or pre-mix insulin or Consider fourth line Basal + mealtime insulin Basal or pre-mix (later basal+mealtime) IDF 2012 Global Guidelines for Type 2 diabetes
Presentation title Date 18
Patient case study: Patient B Patient information Age, gender • 48 years old, female Duration • Type 2 diabetes for 8 years Current treatment • • Metformin (1000 mg BID) Gliclazide (160 mg before breakfast and dinner) Atorvastatin (20 mg daily) Losartan (25 mg daily) Current Lab. • • Hb. A 1 c: 9. 6% FPG: 195 mg/d. L PPG: 255 mg/d. L Cr: 1 mg/d. L BP - BMI • 140/80 mm. Hg - 25. 8 kg/m 2 Risk factors & complications • Hypertension • Non- proliferative Retinopathy Additional background • Doesn’t exercise • Bank employee; 2 main meals (8 am, 8 pm) and snacks • • TG: 250 mg/d. L LDL: 77 mg/d. L ALT: 12 IU/L U/A: +2 glucose
Mrs B: 7 -point curve Fasting Post breakfast Pre Lunch Post lunch Pre dinner After dinner Hb. A 1 c 195 255 220 245 196 296 9. 4%
Options & Comments: 1) Metformin/Gliclazide? 2) Adding/replace Repaglinide? 3) Adding Acarbose? 4) Adding Pioglitazone? 5) Adding Sitagliptin? 6) Adding basal Insulin? 7) Adding prandial Insulin? 8) Starting pre-mixed Insulin? 9) Starting basal/prandial Insulin?
Benefits of long-term insulin use : risk of CV maladies • Insulin reduces cardiovascular risk from diabetes 1 50% of patients with T 2 DM with complications already have them at diagnosis 2 -14% risk Each Hb. A 1 c percentage point reduction counts 3 -37% Micro-vascular complications -21% risk Death related to diabetes risk Hb. A 1 c -1% 1. 2. 3. Non-fatal Myocardial infarction Holman, et al. NEJM 2008; 359: 1577– 89 UKPDS 6. Diabetes Res 1990; 13(1): 1 -11 Stratton, et al. BMJ 2000; 321(7258): 405 -12
Improved PPG after switching to BIAsp 30 from BHI Efficacy PRESENT subgroup analysis Hb. A 1 c 1. 58% FPG PPG 53 mg/d. L Shestakova et al. CMRO 2007; 23(12): 3209 -3214 85. 5 mg/d. L
Improved PPG reduction on BIAsp 30 vs. human premix IMPROVE subgroup analysis PPG (mg/d. L) -99* -93* -58* Baseline Final * p<0. 001 Cohort includes patients switching from BHI 30 to BIAsp 30 for 24 weeks Shah et al. Int J Clin Pract 2009; 63(4): 574 -582
Premix insulin titration strategy INITIATE study titration algorithm Titration based on the lowest SMPG value on any 3 days prior to titration Pre-prandial blood glucose value Premix insulin dose adjustment mmol/L mg/d. L Units < 4. 4 < 80 -2 4. 4 -6. 1 80 -110 No adjustment 6. 2 -7. 8 111 -140 +2 >7. 8 >140 +4 Any episodes of hypoglycaemia should be taken into account prior to titration Unnikrishnan et al. IJCP 2009: 63(11): 1571 -7
Patient case study: Patient C Patient information Age, gender • 65 years old, female Duration • Type 2 diabetes for 10 years Current treatment • • • Metformin (1500 mg /day) Gliclazide (80 mg before breakfast and dinner) Sitagliptin (100 mg/day) Atorvastatin (10 mg daily) Losartan (12. 5 mg daily) Current Lab. • • Hb. A 1 c: 10% FPG: 220 mg/d. L PPG: 300 mg/d. L Cr: 0. 9 mg/d. L BP - BMI • 130/80 mm. Hg - 24 kg/m 2 Risk factors & complications • Hypertension • Non- proliferative Retinopathy Additional background • Doesn’t exercise • 3 meals and 2 snacks • • TG: 265 mg/d. L LDL: 80 mg/d. L ALT: 30 IU/L U/A: +3 glucose
Mrs C: 7 -point curve Fasting Post breakfast Pre Lunch Post lunch Pre dinner After dinner Hb. A 1 c 220 300 250 220 320 10%
Options & Comments: 1) Metformin/Gliclazide? 2) Adding/replace Repaglinide? 3) Adding Acarbose? 4) Adding Pioglitazone? 5) Adding basal Insulin? 6) Adding prandial Insulin? 7) Starting pre-mixed Insulin? 8) Starting basal/prandial Insulin?
Presentation title Start: • Basal and bolus insulin • Basal insulin alone • Premixe insulin Date 37
Mean Hb. A 1 c at last visit (%) Insulin use is often delayed, despite poor glycaemic control 10 9. 4% 8. 8% 9 8 n i l u s n I Diet 2. 9 years OAD, oral antidiabetic drug Roper Starch US Study, 2000. 9. 1% a i t r ne 3 OADs I n tio 2 OADs a i t i I 1 n. OAD 4. 7 years 2. 5 years 2. 7 years
The 1 -2 -3 Study Safety Efficacy Hb. A 1 c <7% (ADA goal) Once Daily 41% Twice Daily 70% Three Times Daily 77% Phase 1 OD Phase 2 BID Phase 3 TID 3 3 1 Rate of minor hypoglycaemic episodes 15 22 12 Major nocturnal hypoglycaemia episodes 0 0 0 Number of patients with major hypoglycaemic events Garber A, et al. Diabetes, Obesity and Metabolism 2006; 8(1): 58 -66
Presentation title • Thank you Date 48
Intensification of insulin regimens Diabetes Care 2017; 40(Suppl. 1): S 64–S 74 | DOI: 10. 2337/dc 16 -S 010
Basal Insulin Overtreatment Anthony L. Mc. Call. Endocrinol Metab Clin N Am 2012; 41: 57– 87.
Intensification of insulin regimens Diabetes Care 2017; 40(Suppl. 1): S 64–S 74 | DOI: 10. 2337/dc 16 -S 010
Intensification of insulin regimens Diabetes Care 2017; 40(Suppl. 1): S 64–S 74 | DOI: 10. 2337/dc 16 -S 010
Intensifying With Novo. Mix® 30 BIAsp, biphasic insulin aspart; BID, twice daily; OD, once daily; TID, three-times daily; TZDs, thiazolidinediones Unnikrishnan et al. Int J Clin Pract 2009; 63: 1571– 7
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
Titration Guide Unnikrishnan et al. Int J Clin Pract 2009; 63: 1571– 7
Patient case study: Patient information Age, gender • 61 years old, male Duration • Type 2 diabetes for 20 years Current treatment • Lansulin 70/30 (25 -20 -15) • Cell sept ( 1 g Bid) • Atorvastatin (20 mg daily) Current Lab. • Hb. A 1 c: 9. 7% • FPG: 223 mg/d. L • PPG: 300 mg/d BP – Wt - BMI • 140/80 mm. Hg - 72 kg - 25. 8 kg/m 2 Additional background • 20 yrs HTN/ PCI: 10 yrs ago/ PDR: laser+ • Renal transplant: 4 yrs ago living donor • Prednisolon (2. 5 mg daily) • ASA (80 mg/day) • Atenolol (100 mg daily) • Cr: 1. 1 mg/d. L • TG: 220 mg/d. L • LDL: 82 mg/d. L
Options & Comments: 1) Adding Metformin? 2) Adding Gliclazide/Repaglinide? 3) Adding Acarbose? 30 : 22 Pioglitazone? IU breakfast – 22 IU lunch – 22 IU dinner 4)Novomix Adding Lansulin D/C
Intensification of insulin regimens Diabetes Care 2017; 40(Suppl. 1): S 64–S 74 | DOI: 10. 2337/dc 16 -S 010
Patient case study: 29/6/89 Patient information ( ﻓﺎﻃﻤی. . . )ﻗﺪﺭﺕ ﺍ Age, gender • 69 years old, male Duration • Type 2 diabetes for 10 years Current treatment • Metformin (1000 mg/day) • Glibencalmide (20 mg/day) Current Lab. SMBG • FPG: 250 – 400 • BS: 400 - 500 BP • 160/70 mm. Hg He admitted for insulin therapy
Mr G. F – 29/7/1389 BP: 120/70 mm. Hg/ Eye Exam: mild NPDR • Metformin 1500 mg/day • Insulin NPH 18 IU (am) – 4 IU (pm) • Insulin Regular 10 IU (am) – 4 IU (pm)
Recent Follow Ups
Presentation title Date 63
Mr G. F – 11/12/1394 BP: 130/80 mm. Hg/ Wt: 71 kg/ Variable BS with frequent hypos • Metformin 1000 mg Bid • Insulin NPH 16 IU (am) – 10 IU (pm) • Insulin Regular 18 IU (am) – 10 IU (pm) • Atorvastatin 20 mg Qd • Losartan 50 mg Bid • Hydrochlorothiazide 50 mg Qd • ASA 80 mg Qd • Gabapentin 300 mg Qhs
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