SALÓN CONSTRUCTORES / FASE
DIFERENCIAS Hay una nube blanca en uno y una nube negra en otro
The numerous insulin preparations and combinations can make insulin therapy complicated and confusing for the primary care practitioner. The following recommendations can be made to simplify decision-making (based on the discussion above):
1. Consider the addition of insulin to an existing 2-drug regimen when glycaemic targets are no longer met. Other options will include adding a 3rd oral anti-diabetic agent or a GLP-1 receptor agonist. Refer to Chapter 11 for guidance on choosing the most appropriate 3rd anti-diabetic agent.
2. When adding insulin as a 3rd anti-diabetic agent, the choice of insulin regimen should be a once daily basal insulin regimen to minimise hypoglycaemia and weight gain.
3. Choose insulins with a low acquisition cost. There are no substantial differences within a particular class of insulins to justify large differences in cost. Biosimilar insulins and clones are acceptable. If costs are similar, a basal insulin analogue is preferred to human insulin. When the cost-differential is high, start with a human basal insulin.
4. If nocturnal hypoglycaemia is a limiting factor to achieving glycaemic control with a human basal insulin, switch to a long- acting basal insulin analogue (if not already in use).
5. When glycaemic control deteriorates with a 3-drug regimen that includes an adequately titrated basal insulin, treatment should be escalated to either a premix insulin regimen, or a “basal plus” regimen (where the basal insulin is maintained and prandial doses of short acting insulin is added). A third alternative would be the addition of a GLP-1 receptor agonist to the basal insulin regimen. Refer to Chapter 11 for further guidance.
6. When glycaemic control deteriorates with a triple oral regimen (e.g. metformin + SU + TZD/DPP-4 inhibitor/SGLT2 inhibitor), continue metformin treatment and initiate insulin treatment with a twice-daily premix insulin, or refer the patient for basal- bolus insulin therapy.
7. Use only insulin pen delivery devices (disposable pens or pen refills); vials and syringes should not be used.
Prior to initiating insulin treatment, it is important to ensure that there are adequate resources avaiable to support the patient in initiating and adjusting insulin treatment. Note that in the 4T study discussed above, 28% and 63% of patients achieved an HbA1C <7% at 1 year and 3 years respectively.32,33 To achieve this result, patients had to be willing to perform self-blood glucose monitoring, they had access to dietitians
pre-supper SBGM for 3 consecutive days. In addition they performed an 8-point glucose profile (including 3am) at week 0, 12, 24, 38 and 52, and also tested blood glucose whenever they felt unwell. Glucose test-strip supply was unlimited and uninterrupted. A computer system guided insulin dose titration and also monitored investigator and patient compliance with the monitoring and titration protocol. The target fasting glucose was 4.0 to 5.5 mmol/L and the post-prandial glucose target was 5.0 to 7.0 mmol/L.
This type of protocol for insulin therapy is commonplace, and some trials have used even more rigorous SBGM and titration algorithms. An inability to offer similar support services and “forced” titration protocols to patients when initiating insulin therapy is unlikely to achieve similar results to that seen in clinical trials, and is likely to result in treatment failure.
10.5.1 Initiating and titrating basal insulin as a 3
rdanti-diabetic agent (refer to chapter 11, figure 2)
1. Ensure that there are adequate resources avaiable to support the patient in initiating and adjusting insulin treatment: protocols for monitoring and titration, regular access to a diabetes nurse educator to be instructed on injection technique, SBGM, management of hypoglycaemia, hyperglycaemia and sick-days, access to frequent doctor and clinic visits (6 per year), telephonic support between visits, uninterrupted supply of insulin and glucose test strips. 2. Continue all oral agents.
3. Initiate 10 units of basal insulin (or 0.2u/kg) using an intermediate or long-acting insulin (use insulins with a low acquisition cost; clones and biosimilar insulins are acceptable). 4. Titrate dose as described in Chapter 11, Figure IV
5. If unexplained nocturnal hypoglycaemia occurs, instruct the patient to reduce the basal insulin dose by 10% or 2-4 units, to stop titration, and to inform the doctor if it occurs again. If there are persistent episodes of nocturnal hypoglycaemia then switch to a long-acting insulin analogue (if not already in use).
6. Consider using a long-acting insulin analogue (glargine, detemir) in the following situations:
• If nocturnal hypoglycaemia is problematic with NPH insulin • In those who require assistance from a carer or healthcare
professional to administer their insulin injections
• In those whose lifestyle is significantly restricted by recurrent symptomatic hypoglycaemic episodes
• When circumstances exist where the risk of severe hypoglycaemia and/or its potential consequences can be significant and/or catastrophic (Refer to Chapters 11 and 12)
10.5.2 Escalating to pre-mixed insulin
(refer to chapter 11, figure 3)
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clinic visits (6 per year), telephonic support between visits, uninterrupted supply of insulin and glucose test strips. 2. Continue with metformin only and stop all other anti-diabetic
drugs. 3. Insulin dose:
a. Split the existing basal insulin dose to give 2/3 as a premix in the morning before breakfast and 1/3 as a premix in the evening before supper
b. If the patient is not already on a basal insulin (e.g. a patient on 3 oral drugs, or 2 oral drugs and a GLP-1RA), then initiate premix insulin at a total dose of 0.3 u/kg given as 2/3 in the morning before breakfast and 1/3 in the evening before supper. Use premixes with a low acquisition cost.
4. The patient must monitor his or her fingerprick glucose before breakfast and before supper. The target glucose will vary depending on the individualised target HbA1C (Refer to Chapter 8)
5. Titrate the pre-breakfast insulin dose to achieve the pre- supper target glucose level, and vice versa.
6. Titration increments can be calculated using Figure IV in Chapter 11. Titration frequency varies, depending on circumstances. For example, titration may take place daily if the patient is under direct supervision in hospital, weekly if the patient needs to see the healthcare provider to supervise titration as an out-patient, or every three days if the patient has good numeracy skills and is able to self-titrate without supervision.
7. If unexplained hypoglycaemia occurs, instruct the patient to reduce the last injected insulin dose (preceding the hypoglycaemic event) by 10% and to stop titration. If the patient experiences recurrent episodes of hypoglycaemia then they should contact their doctor, who could then consider an analogue insulin pre-mix (if not already in use) or refer to a specialist.
10.5.3 Escalating from basal insulin to a “basal-plus”
insulin regimen (refer to chapter 11, figures 2 and 3)
Patients suboptimally controlled with an existing basal insulin regimen may improve their glycaemic control by targeting post- prandial hyperglycaemia. A short or rapid-acting insulin can be added befor the largest meal of the day, or before the meal that has the greatest post-prandial glucose excursion. This short/ rapid acting insulin can then be titrated based on the SBGM level before the next meal (refer to Chapter 11, Figures IV and V). Further doses of short or rapid acting insulin can be progressively added for the other meals that are associated with post-prandial hyperglycaemia, until a complete basal-bolus regimen is used. Oral agents other than metformin should be progressively discontinued to reduce the complexity of the regimen.
Authors: Aslam Amod, Joel Dave and Zane Stevens
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