when basal insulin fails -john adam

8/9/2019 When Basal Insulin Fails -John Adam

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John MFJohn MF

AdamAdam

Sub-Division of Endocrinology and Metabolism,Sub-Division of Endocrinology and Metabolism,

Department of Internal Medicine, asanuddinDepartment of Internal Medicine, asanuddin

!niversity, Ma"assar!niversity, Ma"assar

#A$ %E&$,#A$ %E&$,

#E% 'ASA( I%S!(I% FAI(S)#E% 'ASA( I%S!(I% FAI(S)


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$*EA$ME%$ +F DIA'E$ES$*EA$ME%$ +F DIA'E$ES

ME((I$!SME((I$!S%on-pharmacology%on-pharmacology

Medical nutrition therapy,Medical nutrition therapy,

Eercise orEercise orincreased activityincreased activity

harmacologyharmacology +ral hypoglycemic agents+ral hypoglycemic agents

InsulinInsulinEducationEducation


3/49

E.E*/E.E*/0101reduction inreduction in

A02A02

*ED!2ED*ED!2ED*IS34*IS34

Deaths fromDeaths from

diabetesdiabetes

earteart

attac"sattac"s

MicrovascularMicrovascular

complicationscomplications

eripheral vasculareripheral vascular

disordersdisordersUKPDS 35. BMJ 2000; 321: 405-12.UKPDS 35. BMJ 2000; 321: 405-12.

-561-561

-751-751

4p89:99904p89:9990

-071-071

-;01-;01

0011

(ESS+%S F*+M !3DS


4/49

Frederic"Frederic"'anting'anting

andand

2harles 'est2harles 'est=$oronto, 0>;0?=$oronto, 0>;0?

Mar@oriMar@ori

ee


5/49

(eonard $hompson(eonard $hompson$he rst patient to receive insulin$he rst patient to receive insulin

in January 0>;;, 2anadain January 0>;;, 2anada

The insulin1922 -- 2013


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2A%BI%B A$$E*%2A%BI%B A$$E*%

+F $/E ; DIA'E$ES MA%ABEME%$+F $/E ; DIA'E$ES MA%ABEME%$

For decades the treatment depends onFor decades the treatment depends on

the diabetic clinics or even personalthe diabetic clinics or even personal

eperienceeperience

Standard treatment, the non-Standard treatment, the non-pharmacology and pharmacology, Caspharmacology and pharmacology, Cas

used since the invention of insulin andused since the invention of insulin and

oral anti-diabetic drugsoral anti-diabetic drugs

Even though, no international consensusEven though, no international consensusof medical management ofof medical management of

hyperglycemia, hoC or Chich drug tohyperglycemia, hoC or Chich drug to

startstart

%eC +A%eC +A andand neC insulinneC insulin, needs, needs


7/49

ELLIOT T P JOSLIN, and frontpiee of his 191! te"t#oo$ELLIOT T P JOSLIN, and frontpiee of his 191! te"t#oo$


8/49

+ld 'oo"+ld 'oo"J+S(I%SJ+S(I%S

DIA'E$ESDIA'E$ES

ME((I$!SME((I$!S

'efore ;99'efore ;99

there Cas nothere Cas no

algorithmalgorithm


9/49

$E J+S(I%S 2(I%I2 $*EA$ME%$ +F$E J+S(I%S 2(I%I2 $*EA$ME%$ +F

DIA'E$ES ME((I$!S I% /EA* 0>60DIA'E$ES ME((I$!S I% /EA* 0>60

Joslins Diabetes Mellitus, Beneral plan of treatment ofJoslins Diabetes Mellitus, Beneral plan of treatment of

diabetes, Marble A et al, 0>60diabetes, Marble A et al, 0>60

$he teaching program in the$he teaching program in theospitalospital

$eaching !nit


10/49

First international algorithm, introducedFirst international algorithm, introducedin ;99in ;99 byby ADA and EASDADA and EASD

Since ;99, at least 7 algorithms CasSince ;99, at least 7 algorithms Cas

introduced by the Internationalintroduced by the InternationalDiabetes AssociationDiabetes Association

All the algorithms, tCo importantAll the algorithms, tCo important

informations


11/49

A1C 7%A1C 7%

Lifestyle Intervention +Lifestyle Intervention + MetforminMetformin

(Reinforce at every visit)(Reinforce at every visit)

NoNo Yes*Yes*

A !asalA !asalIns"linIns"lin

(Most e#ective)(Most e#ective)

AA$"lfonyl"rea$"lfonyl"rea

(Least(Leaste&ensive)e&ensive)

A 'litaoneA 'litaone(No(No

y&olycemia)y&olycemia)

Intensive Ins"lin+ Metformin + 'litaoneIntensive Ins"lin+ Metformin + 'litaone

A !asal or Intensive Ins"linA !asal or Intensive Ins"lin

A1C 7%A1C 7%NoNo Yes*Yes*A1C 7%A1C 7%NoNo Yes*Yes*

IntensiveIntensiveIns"linIns"lin

A 'litaoneA 'litaone AA!asal Ins"lin!asal Ins"lin

AA$"lfonyl"rea$"lfonyl"rea

A1C 7%A1C 7%NoNo Yes*Yes* A1C 7%A1C 7%NoNo Yes*Yes* A1C 7%A1C 7%NoNo Yes*Yes*

$,-. 1$,-. 1

$,-. /$,-. /

$,-. 0$,-. 0

AA2-A$3 Meta4olic Manaement of ,y&e / ia4etes /556AA2-A$3 Meta4olic Manaement of ,y&e / ia4etes /556

Natan M et alNatan M et al Diabetes CareDiabetes Care /5568 /93 1960: /5568 /93 1960:

*Cec; A1c every 0 mont "ntil < 7% an ten*Cec; A1c every 0 mont "ntil < 7% an ten

atat

least every 6 montleast every 6 montalto" 0 oral aents can 4e "se=alto" 0 oral aents can 4e "se=

initiation an intensi>cation of ins"lininitiation an intensi>cation of ins"lin

tera&y is &referre 4asetera&y is &referre 4ase

on e#ectiveness an e&enseon e#ectiveness an e&ense


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HEALTHY, EATING, WEIGHT CONTROL, INCREASED PHYSICAL ACTIVITYHEALTHY, EATING, WEIGHT CONTROL, INCREASED PHYSICAL ACTIVITY

MetfominMetfominIf needed to reach individualized HbA1c target after 3 months, proceed to two-drug combination (order notIf needed to reach individualized HbA1c target after 3 months, proceed to two-drug combination (order not

meant to denote an specific preference!meant to denote an specific preference!

MetfominMetfomin

++SUSUbb

MetfominMetfomin

++"#$"#$

MetfominMetfomin

++$%%-& I$%%-& I

MetfominMetfomin

++Ins!in b"s"!Ins!in b"s"!

MetfominMetfomin

++'%-1 )A'%-1 )A

If needed to reach individualized HbA1c target after 3 months, proceed to three-drug combinationIf needed to reach individualized HbA1c target after 3 months, proceed to three-drug combination

(order not meant to denote an specific preference!(order not meant to denote an specific preference!

*etfomin*etfomin

++

bb

++

"#$"#$

oror

$%%-& I$%%-& I

oror

InsulinInsulinddoror

'%-1 )A'%-1 )A

*etfomin*etfomin

++

"#$"#$++

bb

oror

$%%-& I$%%-& I

oror

InsulinInsulinddoror

'%-1 )A'%-1 )A

*etfomin*etfomin

++

$%%-& I$%%-& I++

bb

oror

"#$"#$

oror

InsulinInsulindd

*etfomin*etfomin

++

Insulin basalInsulin basal++

"#$"#$

oror

$%%-& I$%%-& I

oror

'%-1 )A'%-1 )A

*etfomin*etfomin

++

'%-1 )A'%-1 )A++

bb

oror

"#$"#$

oror

InsulinInsulindd

If combination therap that includes basal insulin has failed to achieve HbA1c target after 3-. months,If combination therap that includes basal insulin has failed to achieve HbA1c target after 3-. months,

proceed to more comple/ insulin strateg, usuall in combination with one or two non-insulin agentsproceed to more comple/ insulin strateg, usuall in combination with one or two non-insulin agents

Ins!inIns!inee#m!ti$!e %"i!& %oses#m!ti$!e %"i!& %oses!!

Initial drugInitial drug

monotherapmonotherap

"wo-drug"wo-drug

combinationscombinations

"hree-drug"hree-drug


*ore comple/*ore comple/

insulin strategiesinsulin strategiesInzucchi 0, et al A$A and 0A$ $iabetes 2are 415 16 AprilInzucchi 0, et al A$A and 0A$ $iabetes 2are 415 16 April


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$E I%S!(I%$E I%S!(I%


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*apid acting insulin*apid acting insulin Aspart =%ovorapid?, BlulisineAspart =%ovorapid?, Blulisine

=Apidra ?,=Apidra ?,

(ispro =umalog?(ispro =umalog?

(ong acting insulin(ong acting insulin Blargine =(antus?, DetemirBlargine =(antus?, Detemir

=(evemir ?=(evemir ?

remi insulinremi insulin %ovomi%ovomi

umalog Mi ;umalog Mi ;

$E A%A(+B$E A%A(+B

I%S!(I%I%S!(I%


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rol farma"o"ineti" insulin manusia danrol farma"o"ineti" insulin manusia dan

insulin analoginsulin analog

55 11 // 00 ?? @@ 66 77 99 1515 1111 1/1/ 1010 1?1? 1@1@ 1616 1717 11 1919 /5/5 /1/1 //// /0/0 /?/?

Ba;t"Ba;t"

(am)(am)

Daarins"lin

D

aarins"lin

&lasma

&

lasma

Ins"lin analo ;era ce&atIns"lin analo ;era ce&at

(as&art= l"lisine= lis&ro E?:6 amF)(as&art= l"lisine= lis&ro E?:6 amF)

Ins"lin man"sia ;era &ene;Ins"lin man"sia ;era &ene;

(ins"lin re"lar E6: amF)(ins"lin re"lar E6: amF)

Ins"lin man"sia ;era menenaIns"lin man"sia ;era menena

(N.G E1/:/5 amF)(N.G E1/:/5 amF)

Ins"lin man"sia ;eraIns"lin man"sia ;era

&anan&anan

("ltralente E1:/? amF)("ltralente E1:/? amF)Ins"lin analo ;eraIns"lin analo ;era

&anan&anan

(larine= etemir E/?(larine= etemir E/?

amF)amF)

3+%SE%S!S $E*AI I%S!(I% - E*3E%I3+%SE%S!S $E*AI I%S!(I% - E*3E%I


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I%S!(I%I%S!(I% I%JE2$I+%


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I%

S!(I%E

FFE2$

I%

S!(I%E

FFE

2$

MorninMornin

ggAfterAfter

noonnoonEveningEvening %ight%ight

*AID A2$I%B I%S!(I%*AID A2$I%B I%S!(I%

I%JE2$I+%I%JE2$I+%

dinnerdinner

(unch(unch'rea"fas'rea"fas

tt


18/49

'ASA( I%S!(I%'ASA( I%S!(I%

I%S!(I%E

F

FE2$

I%S!(I%E

F

FE2$

DetemDetem

irir

%igh%igh

tt

'rea"fast'rea"fast (unch(unch DinnerDinner


19/49

I%S!(I%E

FFE2$

I%S!(I%E

FFE2$

*EMI& I%S!(I%*EMI& I%S!(I%

I%JE2$I+%I%JE2$I+%

remi Gremi G %ovomi%ovomi

'rea"fas'rea"fas

tt(unch(unch DinnerDinner


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I%DI2A$I+%S +F I%S!(I%I%DI2A$I+%S +F I%S!(I%

F+* $/E ; DIA'E$ESF+* $/E ; DIA'E$ES

Acute complications H "etoacidosis etcAcute complications H "etoacidosis etc

Diabetes and pregnancyDiabetes and pregnancy

Diabetes and infections H acute septicDiabetes and infections H acute septicinfections, tuberculosisinfections, tuberculosis

reparing for operationreparing for operation

FailedFailed =poor control?=poor control? Cith oral anti-Cith oral anti-diabetic agents = the most cases indiabetic agents = the most cases inclinical practice ?clinical practice ?


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INS%LIN INITI&TIONINS%LIN INITI&TION'O( T)E T(E&T*ENT O' )+PE(L+E*I&'O( T)E T(E&T*ENT O' )+PE(L+E*I&

IN T+PE 2 .I&/ETETES *ELLIT%SIN T+PE 2 .I&/ETETES *ELLIT%SP&TIENT- ENTE(E. &PP(O&)P&TIENT- ENTE(E. &PP(O&)

&.& E&S. ST&TE*ENT 2012&.& E&S. ST&TE*ENT 2012

)EN TO ST&(T INS%LIN )EN TO ST&(T INS%LIN


22/49


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I%S!(I% I%I$A$I+%I%S!(I% I%I$A$I+%

F+* $E $*EA$ME%$ +F /E*B(/2EMIAF+* $E $*EA$ME%$ +F /E*B(/2EMIA

I% $/E ; DIA'E$I2I% $/E ; DIA'E$I2

Due to the beta-cell dysfunction thatDue to the beta-cell dysfunction that

characteries type ; diabetes, insulincharacteries type ; diabetes, insulin

replacement therapy is freuentlyreplacement therapy is freuently

reuiredreuired =Int J 2lin ract ;99KL;5K?


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#A$ %E&$,#A$ %E&$,

#E% 'ASA( I%S!(I%#E% 'ASA( I%S!(I%

FAI(S )FAI(S )

I%S!(I% 2A% 'E !SED


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I%S!(I% 2A% 'E !SEDA%/$IME

InaeH"ateInaeH"ate

LifestyleLifestyle+1 A

+/ A

+0 A

InitiateIns"lin

J $raditionally ins"lin a 4een reserve as te last line of

J Consierin te 4ene>ts of normal lycemic stat"s= insulinbe initiated earlier, as soon as is reuired

1 Kastin !' /@5m2L

/ Ranom !' 055m2L

0 G4 A1c 15 %

? Beit loss ++

Indications

HEALTHY EATING WEIGHT CONTROL INCREASED PHYSICAL ACTIVITYHEALTHY EATING WEIGHT CONTROL INCREASED PHYSICAL ACTIVITY


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HEALTHY, EATING, WEIGHT CONTROL, INCREASED PHYSICAL ACTIVITYHEALTHY, EATING, WEIGHT CONTROL, INCREASED PHYSICAL ACTIVITY

MetfominMetfominIf needed to reach individualized HbA1c target after 3 months, proceed to two-drug combination (order notIf needed to reach individualized HbA1c target after 3 months, proceed to two-drug combination (order not

meant to denote an specific preference!meant to denote an specific preference!

MetfominMetfomin

++SUSUbb

MetfominMetfomin

++"#$"#$

MetfominMetfomin

++$%%-& I$%%-& I

MetfominMetfomin

++Ins!in b"s"!Ins!in b"s"!

MetfominMetfomin

++'%-1 )A'%-1 )A

If needed to reach individualized HbA1c target after 3 months, proceed to three-drug combinationIf needed to reach individualized HbA1c target after 3 months, proceed to three-drug combination

(order not meant to denote an specific preference!(order not meant to denote an specific preference!

*etfomin*etfomin

++

bb

++

"#$"#$

oror

$%%-& I$%%-& I

oror

InsulinInsulindd

oror

'%-1 )A'%-1 )A

*etfomin*etfomin

++

"#$"#$++

bb

oror

$%%-& I$%%-& I

oror

InsulinInsulindd

oror

'%-1 )A'%-1 )A

*etfomin*etfomin

++

$%%-& I$%%-& I++

bb

oror

"#$"#$

oror

InsulinInsulindd

*etfomin*etfomin

++

Insulin basalInsulin basal++

"#$"#$

oror

$%%-& I$%%-& I

oror

'%-1 )A'%-1 )A

*etfomin*etfomin

++

'%-1 )A'%-1 )A++

bb

oror

"#$"#$

oror

InsulinInsulindd

If combination therap that includes basal insulin has failed to achieve HbA1c target after 3-. months,If combination therap that includes basal insulin has failed to achieve HbA1c target after 3-. months,

proceed to more comple/ insulin strateg, usuall in combination with one or two non-insulin agentsproceed to more comple/ insulin strateg, usuall in combination with one or two non-insulin agents

Ins!inIns!inee#m!ti$!e %"i!& %oses#m!ti$!e %"i!& %oses!!

Initial drugInitial drug

monotherapmonotherap

"wo-drug"wo-drug


"hree-drug"hree-drug


*ore comple/*ore comple/

insulin strategiesinsulin strategiesInzucchi 0, et al A$A and 0A$ $iabetes 2are 415 16 AprilInzucchi 0, et al A$A and 0A$ $iabetes 2are 415 16 April


27/49

#A$ %E&$#A$ %E&$

#E% I%S!(I% 'ASA( FAI(S )))#E% I%S!(I% 'ASA( FAI(S )))

11 /asal insulin 4 2 O&. /asal insulin 4 2 O&. -- *etfor5in 4 T6.*etfor5in 4 T6.

22 /asal #olus insulin /asal #olus insulin - Le7e5ir 4- Le7e5ir 4

No7orapidNo7orapid

33 Pre5i" insulin, 2 - 3 ti5es dail8 Pre5i" insulin, 2 - 3 ti5es dail8


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'ASA( '+(!S'ASA( '+(!SI%S!(I%I%S!(I%

I%$E%SIFI2A$I+%I%$E%SIFI2A$I+%*+B*AMS*+B*AMS

$tartin ins"lin$tartin ins"lin Intensi>cation &roramsIntensi>cation &rorams


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.lasmain

s"lin

.lasmain

s"lin

'asal'asal

insulininsulin

4:00 16:00 20:00 24:00 4:00

!rea;fast!rea;fast L"ncL"nc innerinner

12:008:00

$tartin ins"lin$tartin ins"lin

&rorams&rorams

,ime,ime

.lasm

a

ins"lin

.lasm

a

ins"lin

'asal bolus'asal bolus

insulininsulin

4:00 16:00 20:00 24:00 4:00


12:008:00

Intensi>cation &roramsIntensi>cation &rorams

$tartin ins"lin &rorams for ty&e / ia4etes$tartin ins"lin &rorams for ty&e / ia4etes!asal ins"lin= 0:times aily &ranial ins"lin!asal ins"lin= 0:times aily &ranial ins"lin

Intensi>cation &rorams 3 4asal 4ol"s ins"linIntensi>cation &rorams 3 4asal 4ol"s ins"lin

,e 4ac;ro"n of eac iaram e&icts te,e 4ac;ro"n of eac iaram e&icts te

normal &attern of ins"lin levels in nonia4eticnormal &attern of ins"lin levels in nonia4etic

inivi"als eatin 0 aily meals ,e arrosinivi"als eatin 0 aily meals ,e arros

so te &roression from startin toso te &roression from startin to

intensi>cation ins"lin &rorams in te ?:, trial=intensi>cation ins"lin &rorams in te ?:, trial=

as escri4e in te tetas escri4e in te tet

$tartin ins"lin$tartin ins"lin Intensi>cation &roramsIntensi>cation &rorams


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.lasmain

s"lin

.lasmains"lin

'asal'asal

insulininsulin

4:00 16:00 20:00 24:00 4:00


12:008:00


&rorams&rorams

,ime,ime

.lasma

ins"lin

.lasma

ins"lin


insulininsulin

16:00 20:00 24:00 4:00


12:008:00

Intensi>cation &roramsIntensi>cation &rorams

,ime,ime

.lasma

ins

"lin

.lasma

ins

"lin


insulininsulin

4:00 16:00 20:00 24:00 4:00


12:008:00


31/49

*EMI& I%S!(I% ;-5*EMI& I%S!(I% ;-5

$IMES$IMES

I%$E%SIFI2A$I+%I%$E%SIFI2A$I+%

*+B*AMS*+B*AMS


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,ime,ime

remiedremied

insulininsulin

4:00 16:00 20:00 24:00 4:00


12:008:00

.

lasma

ins"lin

.

lasma

ins"lin

,ime,ime

.lasma

ins"lin

.lasma

ins"lin

Intensied premiedIntensied premied

insulininsulin

4:00 16:00 20:00 24:00 4:00

!rea;fast!rea;fastL"ncL"nc innerinner

12:008:00


&rorams&roramsIntensi>cation &roramsIntensi>cation &rorams

Starting insulin programs for type ; diabetes: $Cice H daily analogue premi:Starting insulin programs for type ; diabetes: $Cice H daily analogue premi:Intensication programs < tCice H daily premied analogue Cith prandial insulin addedIntensication programs < tCice H daily premied analogue Cith prandial insulin added

at lunch: $he bac"ground of each diagram depicts the normal pattern of insulin levelsat lunch: $he bac"ground of each diagram depicts the normal pattern of insulin levels

in nondiabetic individuals eating 5 daily meals: $he arroCs shoC the progression fromin nondiabetic individuals eating 5 daily meals: $he arroCs shoC the progression from

starting to intensication insulin programs in the 7-$ trial, as described in the tet:starting to intensication insulin programs in the 7-$ trial, as described in the tet:(eahy Jl: Insulin therapy in type ; diabetes mellitus: In Endocrinology and Metabolism 2linics of %orth(eahy Jl: Insulin therapy in type ; diabetes mellitus: In Endocrinology and Metabolism 2linics of %orth

America, Insulin $herapy: (e*oith D, (eahy J(, 2efalu #$, eds: Saunders company, hiladelphia,America, Insulin $herapy: (e*oith D, (eahy J(, 2efalu #$, eds: Saunders company, hiladelphia,

ennsylvaniaL ;90;: 00> H 077:ennsylvaniaL ;90;: 00> H 077:

%ovo*api%ovo*api

dd


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#A$ %E&$,#A$ %E&$,

#E% 'ASA( I%S!(I%#E% 'ASA( I%S!(I%

FAI(S )FAI(S )


34/49

/asal insulin onl8/asal insulin onl8usuall8 :ith oral a;ents>22

*ealti5e< rapid-atin;*ealti5e< rapid-atin;

insulin in=etionsinsulin in=etions

Pre-5i"ed insulinPre-5i"ed insulin

t:ie dail8t:ie dail8

11

22

3434

Lo:Lo:

*od*od

)i;h)i;h

Nu5#erNu5#er

of in=etionof in=etion(e;i5en(e;i5en

o5ple"it8o5ple"it8

*ore fle"i#el Less fle"i#el 'le"i#illit8'le"i#illit8Se?uential insulin strate;ies in t8pe 2 dia#etes /asal insulin alone is usuall8 the opti5al initial re;i5en, #e;innin; at 0102 units@$; #od8 :ei;ht,Se?uential insulin strate;ies in t8pe 2 dia#etes /asal insulin alone is usuall8 the opti5al initial re;i5en, #e;innin; at 0102 units@$; #od8 :ei;ht,dependin; on the de;ree of h8per;l8e5ia It is usuall8 presri#ed in on=untion :ith one to t:o noninsulin a;ents In patients :illin; to ta$e 5oredependin; on the de;ree of h8per;l8e5ia It is usuall8 presri#ed in on=untion :ith one to t:o noninsulin a;ents In patients :illin; to ta$e 5ore

than one in=etion and :ho ha7e hi;her )#&1 le7els A90B


35/49

*+B*AM F+* I%$E%SIFI2A$I+% +F*+B*AM F+* I%$E%SIFI2A$I+% +F

I%S!(I% $E*A/I%S!(I% $E*A/

$he daily used regimen$he daily used regimen

$he$he basal - bolusbasal - bolus regimenregimen

Starting Cith basal and add rapid insulinStarting Cith basal and add rapid insulin Freuently used in daily oce practiceFreuently used in daily oce practice

for better glycemic controlfor better glycemic control

$he$he bolus - basalbolus - basal - regimenregimen MMostly in hospital cases, need rapidostly in hospital cases, need rapid

glycemic control =for operation ?glycemic control =for operation ?


36/49

*r J, HH 8rs a5e to see the*r J, HH 8rs a5e to see the

dotor :ith lassial dia#etidotor :ith lassial dia#eti

s85pto5s, pol8uria loosin;s85pto5s, pol8uria loosin;:ei;ht, polid8ps8:ei;ht, polid8ps8

)is '/S 1!H 5;@dL, &1 0B)is '/S 1!H 5;@dL, &1 0B

Trea5ent Trea5ent

Lifest8le 5odifiation 4Lifest8le 5odifiation 4

5etfor5in5etfor5in oorr

Lifest8le 5odifiation 4Lifest8le 5odifiation 4

5etfor5in 45etfor5in 4

#asal insulin #asal insulin


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N8 S, H0 tahun datan; den;anN8 S, H0 tahun datan; den;an

#isul di pun;;un; T. 120@0#isul di pun;;un; T. 120@0

55);55);

)asil la#oratoriu5)asil la#oratoriu5

.P 10 5;@dl, &1 10,.P 10 5;@dl, &1 10,

Pen;o#atan Pen;o#atan

/olus - #asal insulin


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& patient 5r & :ith dia#eti $etoaidosis& patient 5r & :ith dia#eti $etoaidosis

Treat5entTreat5entontinuous insulin dripsontinuous insulin drips

(apid atin;(apid atin;

/asal - #olus/asal - #olus

Patient &, 33 8rs, :ith se7ere :ea$-Patient &, 33 8rs, :ith se7ere :ea$-

ness, unonious, /P 90@!0 55);,ness, unonious, /P 90@!0 55);,

(/ !H 5;@dL(/ !H 5;@dL

.ia#eti $etoaidosis.ia#eti $etoaidosis


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oC is the insulinoC is the insulin

regimen))regimen))

Mr: A 5 yrs, 5 yrsMr: A 5 yrs, 5 yrs

laterlater

Multiple insulinMultiple insulinin@ectionsin@ections

%ovorapid 5 times N%ovorapid 5 times N

(evemir in the(evemir in the

eveningevening


40/49

*alan; &P(IL 2,2013


41/49


42/49

M3S ;K H 97 ;905M3S ;K H 97 ;905

$tartin ins"lin Intensi>cation &rorams


43/49

.lasmain

s"lin

!asal ins"lin

4:00 16:00 20:00 24:00 4:00

!rea;fast L"nc inner

12:008:00

&rorams

,ime

.lasmain

s"lin

.ranial ins"lin

4:00 16:00 20:00 24:00 4:00


12:008:00

,ime

.lasma

ins"lin

!asal 4ol"s ins"lin

4:00 16:00 20:00 24:00 4:00


12:008:00

&

tartin! insulin pr"!rams Intensificati"n pr"!rams


44/49

Time

Premixed insulin

4:00 16:00 20:00 24:00 4:00

Breakfast Lunch Dinner

12:008:00

P

lasma

insulin

Time

Pla

sma

insulin

Intensified premixed insulin

4:00 16:00 20:00 24:00 4:00


12:008:00

tartin! insulin pr"!rams Intensificati"n pr"!rams

tartin! insulin pr"!rams f"r t#pe 2 dia$etes% T&ice ' dail# anal"!ue premix% Intensificati"n pr"!rams : t&ice 'dail# premixed anal"!ue &ith prandial insulin added at lunch% The $ack!r"und "f each dia!ram depicts the

n"rmal pattern "f insulin le(els in n"ndia$etic indi(iduals eatin! ) dail# meals% The arr"&s sh"& the pr"!ressi"n

fr"m startin! t" intensificati"n insulin pr"!rams in the 4*T trial+ as descri$ed in the text% Leah# ,l% Insulin therap# int#pe 2 dia$etes mellitus% In -nd"crin"l"!# and .eta$"lism /linics "f "rth merica+ Insulin Therap#% Le"ith D+ Leah# ,L+ /efalu

3T+ eds% aunders c"mpan#+ Philadelphia+ Penns#l(ania 2012% P115 ' 144%

"("apid

Intensificati"n pr"!rams


45/49

Time

Plasma

insulin

Basal $"lus insulin

4:00 16:00 20:00 24:00 4:00


12:008:00

Intensificati"n pr"!rams

tartin! insulin pr"!rams f"r t#pe 2 dia$etes% Basal insulin+ )*times dail# prandial insulin% Intensificati"n

pr"!rams : $asal $"lus insulin% The $ack!r"und "f each dia!ram depicts the n"rmal pattern "f insulin le(els in

n"ndia$etic indi(iduals eatin! ) dail# meals% The arr"&s sh"& the pr"!ressi"n fr"m startin! t" intensificati"n

insulin pr"!rams in the 4*T trial+ as descri$ed in the text% Leah# ,l% Insulin therap# in t#pe 2 dia$etes mellitus% In

-nd"crin"l"!# and .eta$"lism /linics "f "rth merica+ Insulin Therap#% Le"ith D+ Leah# ,L+ /efalu 3T+ eds% aundersc"mpan#+ Philadelphia+ Penns#l(ania 2012% P115 ' 144%


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--7 1reducti"n in 1/ -D9/-DI;

Deaths fr"m dia$etes

0%0001

*14

*21

1

$tartin ins"lin Intensi>cation


47/49

.lasmain

s"lin

!asal ins"lin

4:00 16:00 20:00 24:00 4:00


12:008:00

&rorams

,ime

.lasmains"lin

.ranial ins"lin

4:00 16:00 20:00 24:00 4:00


12:008:00

,ime

.lasma

ins"lin

!asal 4ol"s ins"lin

4:00 16:00 20:00 24:00 4:00


12:008:00

&rorams


48/49

In

sulinplasma

Insulin $asal

4:00 16:00 20:00 24:00 4:00

.akan

pa!i

.akan

sian!

.akan

malam

12:008:00

Insulinplasma

Basal $"lus insulin

4:00 16:00 20:00 24:00 4:0012:008:00

3aktu3aktu

.akan

pa!i

.akan

sian!

.akan

malam

Insulin prandial Basal $"lus insulin


49/49

Ins

ulinplasma

Insulin prandial

4:00 16:00 20:00 24:00 4:00

.akan

pa!i

.akan

sian!

.akan

malam

12:008:00

3aktu

Basal $"lus insulin

Ins

ulinplasma

4:00 16:00 20:00 24:00 4:00

.akan

pa!i

.akan

sian!

.akan

malam

12:008:00

3aktu

when basal insulin fails -john adam

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