Case Studies on Insulin Initiation

Nicole McGrath 2013

Case 1

• 52 year old woman, type 2 diabetes for 10 yrs, BMI 32 (87kg)– On Metformin 850mg mane, 1700mg nocte;

Gliclazide 80mg bd• Regularly picks up scripts; assures you she is taking

– Not testing BG– HbA1c 70 mmol/mol

• What to do?

Case 1 Discussion

• Increase Gliclazide to 160mg bd• Start home BG testing• BG elevated:

– Fasting around 10– Before evening meal 12– 2 hours after evening meal 13

• What next?

Case Study 1 - Mrs JAge 52. BMI 32 (87kg). HbA1c: 70mmol/mol

Currently on: Metformin 850mg mane, 1,700mg at dinner, Gliclazide 160mg BD.

How would you start Mrs J. on insulin?

Blood glucose (mmol/L)

Case Study 1 - Mrs J.

• NZGG:– Start Isophane 8-10 units at

bedtime.– Continue orals – consider reduction

of Gliclazide to 80mg BD.– Give the patient instruction to self-

adjust insulin dose.• Likely doses to achieve red line:

– Isophane 30-35 units nocte – Gliclazide 160mg bd – Metformin 850mg mane, 1700mg

evening meal

Case Study 2 – Mrs T:Age 74. HbA1c 75mmol/mol (9%)

, Currently on: Prednisone 5mg/day for Rheumatoid Arthritis and maximal

OHA therapy.

Blood glucose (mmol/L)

Case Study 2 – Mrs T.

As you can see… high glucose levels rising during the day but dropping over night.

Consider:• 10 units of isophane at breakfast and

adjust the dose as required. – Good fasting achieved with 15 units but….

Red line still suboptimal so change to• 15 units of Pre-mixed insulin breakfast

– Penmix 30 / Humulin 30/70

.

Case 3: 66 yr old male with COPD

• On Metformin 1gm bd, Glipizide 5mg bd;– HbA1c 57 mmol/mol

• Needs course of Prednisone for exacerbation COPD– Prednisone 40mg daily 5

days then 20mg 5 days

Fasting Pre-lunch Pre-dinner

6.8 12.6 17.2

7.1 13.8 18.0

PATHWAY FOR MANAGING HYPERGLYCAEMIA SECONDARY TO STEROIDS FOR CLIENTS WITH COPD

(on HealthPoint)

• Whilst on 40 mg Prednisone– Test BSLs at least tds– OHAs –increase usual mane dose by 100% e.g. usual mane dose

Gliclazide 80mg –increase to 160mg• If patient is maximised on OHAs:

– transient hyperglycemia can sometimes be tolerated for a short period.

– Alternatively, a morning dose of Penmix 30/70 (usually 0.2 units/kg body weight) can be given during steroid treatment.

– Some patients may need to be commenced on ongoing insulin

Case Study 4 - Mr L.

Age 62. BMI 27 (78kg) HbA1c 68mmol/mol. Currently on: maximal OHA therapy.

Blood glucose (mmol/L)

Case Study 4 – Mr L.

High fasting and post-prandial BG:basal insulin with current OHA will treat fasting hyperglycaemia but not post meal BG elevations

Suggest Premixed insulin:As lunch not so much of an issue,Novomix 30 or Humalog 25:Start 15 units bd (0.2 units/kg/dose)Stop sulphonylurea

Case Study 5 - Mr K.

Age 64. HbA1c 75mmol/mol (9%).Currently on: maximal OHA therapy.

Blood glucose (mmol/L)

Case Study 5 – Mr K.

Mr K’s blood glucose is particularly high after his main meal (dinner).

•Consider 10–12 units of pre-mixed insulin (Humalog Mix25 or Novomix30) at dinner.

Case 6: 55 yr old male, BMI 35 (116kg), known diabetes 4 yrs, Hba1c 85

• No home BG testing• Long gaps between prescription requests

– Prescribed Metformin 1gm bd, Gliclazide 160mg bd

• Microalbuminuria, background retinopathy, hypertension

Case 6

• Option 1– advice on diet, exercise, taking medication – warn of possible adverse consequences; – increase Metformin to 1500mg bd; – Start BG testing and reporting back to nurse

Case 6

• Option 2: 3 month F/U HbA1c 76: – Has achieved good reduction with compliance but

HbA1c still suboptimal and not testing much• Fasting BG 10, Pre-dinner 13

• Glargine in addition to Metformin and Gliclazide a reasonable option– Starting dose: 0.2 units / kg / day:

– Weight 116kg: start 24 units daily (morning or night)– Insulin self-adjustment in conjunction with weekly contact

with nurse

Case 6

• Option 3:– Accept failure of OHA – Prescribe pre-mixed insulin bd

• He eats 2 meals per day: brunch and dinner– NovoMix 30 or Humalog Mix 25: 24 units bd

» Could well need to double that– Stop sulphonylurea, continue Metformin

• Provide insulin self-adjustment handout or ask pt to increase each dose by 2 units every 3 days until BG 4-8

– Hopefully practice nurse will be able to contact him weekly to support/supervise

Case 7: 37 year old female, BMI 45 (weight 128kg); diabetes 3 years

• HbA1c 85• Prescribed Metformin 1gm bd; Gliclazide

160mg bd and appears to be taking them• Not testing BG• Sleep Apnoea

Case 7

• Option 1– Weight loss essential:

• Refer to dietitian for consideration of Optifast• Refer for consideration Bariatric Surgery

– Pioglitazone in addition to Metformin and Gliclazide

– Repeat HbA1c in 3 months

Case 7

• Option 2– Accept weight loss/exercise not achievable– Consider insulin, although insulin resistance will

mean large doses necessary• Eats 3 meals per day and snacks in the evening• Penmix 30 or Humulin 30/70: 26 units bd, stop

sulphonylurea– Insulin self-adjustment: may need to increase by > 4 units

each time if BG remain very high– Will probably need 60 units bd if she doesn’t change her

diet/weight

Case 8: 41 yr old male, BMI 27

• Diabetes 8 yrs, on Metformin 1500mg bd, Gliclazide 160mg bd, Pioglitazone 45mg daily

• Truck driver• HbA1c 62 mmol/mol• Microalbuminuria, erectile dysfunction, retinopathy• BG: fasting 9, pre-dinner 10• Requires heavy traffic licence medical certificate• Patient feels he is doing as much as he can re diet, exercise

Case 8

• Needs insulin but want to minimise effect on driving– Isophane at night 10 units

• Increase by 2-4 units every 3 days to achieve fasting BG < 7

– Continue OHA• NB. LTSA do not generally require specialist

reports for type 2 patients on insulin