Insulin work shop RUCHIREK THAMCHAROEN ENDOCRINOLOGIST Noninsulin injection

Insulin work shop RUCHIREK THAMCHAROEN ENDOCRINOLOGIST

Non-insulin injection GLP-1 receptor agonist

Non-insulin injection GLP-1 receptor agonist + Ultra long insulin

ADA 2020 4 unit ac before large meal or 10% of Total daily dose

Biphasic insulin analog Novo. Mix® 70/30 better than human premix insulin Higher maximum concentration vs BHI More effective PPG control vs BHI Serum Insulin Shorter acting vs BHI Reduces risk of hypoglycaemia Faster start action vs BHI Flexible mealtime injection – no need to wait 30 minutes before eating Novo. Mix® 30 Physiological insulin profile Physiological fasting insulin rate Human premix insulin 30/70 Time 15

Biphasic insulin analog Novo. Mix® 70/30 targets both PPG and FPG Physiological insulin profile Basal component Meal-related peaks Novo. Mix® 70/30 ■ ■ Basal component Meal-related peaks Plasma insulin level ■ ■ Novo. Mix 70/30 closely mimics the physiological insulin response Physiological insulin profile Novo. Mix® 30 Protamine crystallised insulin aspart (basal component) Time 16

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) mechanism

GLP-1: Beyond glucose metabolism Brain Liver Glycogen storage Heart Neuroprotection Myocardial contractility Heart rate Myocardial glucose uptake Ischaemia-induced myocardial damage Neurogenesis Memory DPP-4 GI tract Motility Fat cells Glucose uptake Lipolysis His Ala Glu Gly Thr Phe Thr Ser Asp GLP-1 Glu Lys Ala Gln Gly Glu Leu Tyr Ser Phe Ile Kidney Natriuresis Val Ser Pancreas New β-cell formation β-cell apoptosis Insulin biosynthesis Ala Trp Leu Val Lys Gly Arg Gly Blood vessel Endothelium-dependent vasodilation DPP-4, dipeptidyl peptidase-4; GLP-1, glucagon-like peptide-1 Adapted from Meier JJ et al. Nat Rev Endocrinol 2012; 8: 728– 42 Skeletal muscle Glucose uptake

GLP-1 receptor agonist 4กลไลทำใหนาตาลลดและนำหนกลง ลง 1. Increase insulin 2. Decrease glucagon 3. Slow gastric emptying time 4. Increase satiey ทำใหอมเรวขน Cardiovascular benefit in T 2 DM with established CAD

T 2 DM 0. 1 -0. 2 units/ka/day T 1 DM 0. 4 -0. 6 units/kg/day

ADA Standards of Medical Care in Diabetes 2020 Established ASCVD = CAD, PAD, MI, stroke Liraglutide Semaglutide Dulaglutide Canagliflozin Empagliflozin Dapagliflozin 23

SGLT 2 inhibitor

GLP-1 receptor agonist Liraglutide Dulaglutide Semaglutide

Combination Injectable Therapy ถาเพม basal insulin ฉดวนละครงจน FBS ดแลว แต A 1 C ยงลงไมไดตามเปาหมาย หรอตองใช dose basal insulin > 0. 5 units/kg/day พจารณาให ควรให metformin ตอ แตพจารณาหยด ผปวยทตองได อาจชวยใหลด combination injectable therapy sulfonylureas, DPP-4 inhibitors insulin ขนาดสง การให thiazolidinedione , SGLT 2 inhibitor dose insulin ลงได

Combination Injectable Therapy ถาเพม basal insulin ฉดวนละครงจน FBS ดแลว แต A 1 C ยงลงไมไดตามเปาหมาย หรอตองใช dose basal insulin > 0. 5 units/kg/day พจารณาให combination injectable therapy premixed Basal insulin + glucagon-like peptide-1 receptor agonists (GLP-1 RAs) Basal insulin + bolus insulin 1 -3 ครงตอวน - Decrease post prandial glucose - less weight gain and hypoglycemia Humalin(70/30) Mixtard(70/30) Novomix(70/30)

Insulin glargine 100 unit/ml + lixisenatide 3 ug/ml (prefilled pen 3 ml) การออกฤทธ Dose basal insulin < 30 unit/day basal insulin 30 -60 unit/day Max dose ออกฤทธยาว Insulin degludec 100 unit/ml + liraglutide 3. 6 µg/ml (prefilled pen 3 ml) ออกฤทธยาวพเศษ starting - insulin glargine 15 unit + lixisenatide 5 insulin degludec 16 unit + liraglutide µg 0. 58 µg SC OD - insulin glargine 30 unit + lixisenatide 10 µg - insulin glargine 60 unit + lixisenatide - insulin degludec/liraglutide 50 unit + 20 µg liraglutide 1. 8 µg

Gestational diabetes mellitus

T 1 DM with insulin pump

Care map insulin intravenous drip

Care map insulin intravenous drip -ม การให rate insulin drip ตาม requirement smbg -มการใหสารนำทม 5%D เพอปองกน hypoglycemia และ NSS + KCL คเพอปองกน hypokalemia

Care map insulin intravenous drip -มการตดตาม smbg อยาง ใกลชด และมการปรบ rate insulin ทเหมาะสม มการ overlap insulin iv drip และ subcutaneos เพอปองกน rebound hyperglycemia

Care map insulin subcutaneus

Care map insulin subcutaneous injection Sliding scale for Humalin R แยกเปน 3 level เพอปองกน hypoglycemia

Care map insulin subcutaneous injection plan home med ตามระดบ Hb. A 1 c