Insulin in Primary Insulin in Primary CareCare

Dr Saqib Mahmud, MRCP(UK), Dr Saqib Mahmud, MRCP(UK), MRCGPMRCGP

IntroductionIntroduction

• Prevalence of DM in UK-2.2 million. Prevalence of DM in UK-2.2 million. • 90%-T2DM90%-T2DM• Diabetic epidemic predicted to Diabetic epidemic predicted to

reach 300million by 2025reach 300million by 2025• Increased incidence of T2DM due Increased incidence of T2DM due

to ageing population, sedentary to ageing population, sedentary life style & obesitylife style & obesity

• T2DM results from insulin T2DM results from insulin resistance & abnormal insulin resistance & abnormal insulin secretionsecretion

Insulin resistanceInsulin resistance

Failure of peripheral tissues to Failure of peripheral tissues to respond or use respond or use

insulininsulinprevents insulin prevents insulin signalling to the liver to signalling to the liver to

reduce glucose productionreduce glucose production hyperglycaemiahyperglycaemia

Abnormal insulin Abnormal insulin secretionsecretion

•Early phase Early phase loss of rapid loss of rapid release of stored insulin in release of stored insulin in

response to foodresponse to food

•Late phase Late phase newly newly manufactured insulin manufactured insulin

becomes impaired becomes impaired hyperglycaemiahyperglycaemia

New approach to T2DM New approach to T2DM MxMx• Our approach has dramatically Our approach has dramatically

changed during the past few yearschanged during the past few years

• Historically insulin was owned by Historically insulin was owned by health care professionals & self health care professionals & self management of insulin was management of insulin was discourageddiscouraged

• Now, self management is actively Now, self management is actively encouraged with patient education & encouraged with patient education & self adjustment on the start of self adjustment on the start of therapytherapy

• Patients make the informed choicePatients make the informed choice

UKPDSUKPDS

• Demonstrated beyond doubtDemonstrated beyond doubt improved glycaemic control reduces improved glycaemic control reduces microvascular complicationsmicrovascular complications

• T2DM runs a progressive course – T2DM runs a progressive course – 4% decline in beta cell function 4% decline in beta cell function

• Most patients will eventually need Most patients will eventually need insulin to counteract beta cell insulin to counteract beta cell failurefailure

• Insulin is widely under used & Insulin is widely under used & frequently delayed particularly in frequently delayed particularly in primary careprimary care

Reluctance to insulin RxReluctance to insulin Rx

• Stems from lack of confidenceStems from lack of confidence• Practice factorsPractice factors• Patient factorsPatient factors• Insulin initiation interpreted as Rx Insulin initiation interpreted as Rx

failure rather than natural failure rather than natural progression of diseaseprogression of disease

• Current NHS developments are Current NHS developments are likely to expect insulin initiation likely to expect insulin initiation largely in the primary care in largely in the primary care in futurefuture

Glycaemic controlGlycaemic control

•Various guidelines including Various guidelines including UKPDS recommend HbA1c UKPDS recommend HbA1c <7.5%<7.5%

•NICE - HbA1c b/w 6.5 to 7%NICE - HbA1c b/w 6.5 to 7%

•NSF Diabetes – HbA1c <7.5%NSF Diabetes – HbA1c <7.5%

•QoF target – HbA1c < or = QoF target – HbA1c < or = 7.4%7.4%

Indications for Insulin Indications for Insulin initiationinitiation• To maintain glucose control as To maintain glucose control as

beta cell failure progressesbeta cell failure progresses• Progressive rise in HbA1c >7.5% Progressive rise in HbA1c >7.5%

despite max OHAsdespite max OHAs• Osmotic symptomsOsmotic symptoms• Sudden weight loss & intense Sudden weight loss & intense

tirednesstiredness• Painful peripheral neuropathy & Painful peripheral neuropathy &

diabetic Amytrophydiabetic Amytrophy• Episode of DKAEpisode of DKA

Indications - continuedIndications - continued

• MI (DIGAMI study)MI (DIGAMI study)

• PregnancyPregnancy

• Development of complications – Development of complications – most urgent need for insulinmost urgent need for insulin

Barriers to initiate Barriers to initiate insulininsulin

Practice factorsPractice factors

• Reluctance to use insulin in T2DMReluctance to use insulin in T2DM

• Reluctance by GPs to become Reluctance by GPs to become involved in insulin initiationinvolved in insulin initiation

• Traditionally insulin introduction Traditionally insulin introduction was seen as a last resortwas seen as a last resort

• Need for referral to secondary Need for referral to secondary carecare

Patient factors Patient factors – – reluctance toreluctance to insulininsulin• Major barrier – widespread fear of Major barrier – widespread fear of

self injecting / fear of needlesself injecting / fear of needles• Fear of hypoglycaemia- Fear of hypoglycaemia- overestimate overestimate

ofof riskrisk

• Inability to deal with insulin-Inability to deal with insulin-handle handle equipment, adjust doseequipment, adjust dose

•Feeling of loss of health-Feeling of loss of health-insulin is insulin is seen as ‘beginning of the end’seen as ‘beginning of the end’

•Weight gain-Weight gain-levels off with time in levels off with time in most, counteracted by combining metformin, most, counteracted by combining metformin, may not occur in somemay not occur in some

Patient factors - Patient factors - misconceptionsmisconceptions

• Becoming ‘addicted to insulin’- Becoming ‘addicted to insulin’- once they once they start will be unable to stop it even if it does not suit start will be unable to stop it even if it does not suit themthem

• Punishment for those who fail on other Punishment for those who fail on other RxRx

• Insulin causes ‘ill health’– Insulin causes ‘ill health’– usually fromusually from observations of othersobservations of others (particularly when insulin was (particularly when insulin was

introduced too late) introduced too late) leading to death or complications to leading to death or complications to followfollow

• ‘‘Live for today’- Live for today’- some prefer to live with some prefer to live with increased risk of complicationsincreased risk of complications

• Physical barriers – vision & Physical barriers – vision & dexteritydexterity

Assessing if insulin is Assessing if insulin is appropriateappropriate• Is the patient on max doses of Is the patient on max doses of

OHAs with HbA1c>7%OHAs with HbA1c>7%• Can the patient cope with daily Can the patient cope with daily

injections or hypoglycaemiainjections or hypoglycaemia• Are the long term complications Are the long term complications

likely to occur in the patients life likely to occur in the patients life timetime

• Does the patient need an LGV or Does the patient need an LGV or PCV license to workPCV license to work

• Is the patient clinically obeseIs the patient clinically obese

Common insulin regimesCommon insulin regimes

• Once daily – basal with OHAs, eg; Once daily – basal with OHAs, eg; glargine or levemirglargine or levemir

• Twice daily pre-mixed insulins, Twice daily pre-mixed insulins, eg; Novomix 30eg; Novomix 30

• Multiple injections ( basal / bolus Multiple injections ( basal / bolus ) eg; glargine or levemir / ) eg; glargine or levemir / novorapid – basal, once a day. novorapid – basal, once a day. Bolus, at meal times-tdsBolus, at meal times-tds

Once daily- Basal with OHAs Once daily- Basal with OHAs (glargine/ levemir) suitable for;(glargine/ levemir) suitable for;

• Over weight& insulin resistantOver weight& insulin resistant

• Reluctant to start insulinReluctant to start insulin

• Unable to inject themselvesUnable to inject themselves

• Optimizing control is not vital but Optimizing control is not vital but hypoglycaemia is unacceptablehypoglycaemia is unacceptable

• Initiate at 10u or 0.2u/kg – Initiate at 10u or 0.2u/kg – dinner/bedtime, titrate dose 3-7 days dinner/bedtime, titrate dose 3-7 days

• Pre-breakfast BG levels are good Pre-breakfast BG levels are good indicators of their effectivenessindicators of their effectiveness

Twice daily pre-mixed Twice daily pre-mixed insulins – insulins – good choice for;good choice for;

• Fairly regular lifestyles, eat similar Fairly regular lifestyles, eat similar amounts at similar times each dayamounts at similar times each day

• When OHAs are no longer sufficient When OHAs are no longer sufficient to control BG levels after meals to control BG levels after meals (becoming insulin depleted)(becoming insulin depleted)

• Eg;0.4x70kg=28u, start with 60% of Eg;0.4x70kg=28u, start with 60% of this dose=16u, split 50/50 this dose=16u, split 50/50

• 8 units am/pm titrate dose8 units am/pm titrate dose

Multiple injections Multiple injections (basal/bolus)(basal/bolus)suitable for;suitable for;

• Who need flexibility because of erratic Who need flexibility because of erratic life style, shift work, regular travelling life style, shift work, regular travelling across time zones, regular sportacross time zones, regular sport

• Who need to optimize BG control b/c Who need to optimize BG control b/c of complications, illness or woundof complications, illness or wound

• Median daily dose s 0.4-0.5u/kg body Median daily dose s 0.4-0.5u/kg body wtwt

• Eg;0.4x70kg=28uEg;0.4x70kg=28u• 1/31/3rdrd of total daily dose basal of total daily dose basal• 2/32/3rdrd remaining bolus divide b/w 3 remaining bolus divide b/w 3

main mealsmain meals

ConclusionConclusion

• Most individuals with T2DM will Most individuals with T2DM will require insulin eventually due to require insulin eventually due to disease progression and beta cell disease progression and beta cell failurefailure

• Patients should be informed of this at Patients should be informed of this at initial diagnosis and not allowed to initial diagnosis and not allowed to believe that need for insulin is a believe that need for insulin is a result of failure on their part to result of failure on their part to controlcontrol the diseasethe disease