New Insulins and Insulin Delivery Systems Bruce W

New Insulins and Insulin Delivery Systems Bruce W. Bode, MD, FACE Atlanta Diabetes Associates Part 3

Insulin Therapy in Type 2 Diabetes Indications l Significant hyperglycemia at presentation l Hyperglycemia on maximal doses of oral agents l Decompensation – Acute injury, stress, infection, myocardial ischemia – Severe hyperglycemia with ketonemia and/or ketonuria – Uncontrolled weight loss – Use of diabetogenic medications (eg, corticosteroids) l Surgery l Pregnancy

Starting With Basal Insulin in DM 2 Advantages l 1 injection with no mixing l Insulin pens for increased acceptance l Slow, safe, and simple titration l Low dosage l Effective improvement in glycemic control l Limited weight gain 6 -37

Treatment to Target Study: NPH vs Glargine in DM 2 patients on OHA l Add 10 units Basal insulin at bedtime (NPH or Glargine) l Continue current oral agents l Titrate insulin weekly to fasting BG < 100 mg/d. L - if 100 -120 mg/d. L, increase 2 units - if 120 -140 mg/d. L, increase 4 units - if 140 -180 mg/d. L, increase 6 units - if >180 mg/d. L, increase 8 units

Treatment to Target Study; A 1 C Decrease

Treatment to Target Study: % at Goal Results l 57% of patients in both groups reached A 1 C 7% l At wk 24, mean insulin glargine dose was higher than mean NPH insulin dose: Insulin glargine NPH insulin 48. 8 IU/day 42. 4 IU/day , P<0. 001 Rosenstock J, Riddle M, HOE 901/4002 Study Group. Diabetes 2002; 51(suppl 2): A 482. Abstract 1982 -PO

Treat to Target Study: Glargine vs NPH Added to Oral Therapy of Type 2 Diabetes l Nocturnal Hypoglycemia reduced by 40% in the Glargine group (532 events) vs NPH group (886 events) Riddle et al, Diabetes June 2002, Abstract 457 -p

Morning vs Bedtime Insulin Baseline: 9. 1 1. 0 A 1 C Change From Baseline (%) 0 Morning Glargine Bedtime Glargine -1 – 0. 96 Bedtime NPH – 0. 84 – 1. 24 -2 P=0. 008 P<0. 001 Adapted from Fritsche A et al, and the 4001 Study Group. Ann Intern Med. 2003: 138: 952

Starting with Bolus Insulin l 16 obese Type 2 patients on NPH or Human 70/30 insulin twice daily randomized to: Insulin aspart premeal with metformin and rosiglitazone NPH or Human 70/30 twice daily l Insulin titrated to 90 to 126 mg/dl at 1. 5 hr post meal in the aspart group and premeal in the conventional group with goal A 1 C <7% Diabetes Care 2003

Insulin Aspart Premeal with Metformin and Rosiglitazone vs Conventional Insulin N =16 P = 0. 03 A 1 C% 0. 42 units/kg 3 kg weight gain 0. 67 units/kg 1 kg weight gain

Advancing Basal/Bolus Insulin l Indicated when FBG acceptable but – A 1 C > 7% or > 6. 5% and/or – SMBG before dinner > 140 mg/d. L Insulin options – To glargine or NPH, add mealtime aspart / lispro – To suppertime 70/30, add morning 70/30 – Consider insulin pump therapy l Oral agent options – Usually stop sulfonylurea – Continue metformin for weight control – Continue glitazone for glycemic stability? l