ueda2012 insulin therapy-d.ibrahim

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Insulin Therapy Primary Care Challenges and Solutions Prof. Ibrahim El Ebrashy Head Of The Diabetes & Endocrinology Center Cairo University

Transcript of ueda2012 insulin therapy-d.ibrahim

Insulin Therapy

Primary Care Challenges and Solutions

Prof.

Ibrahim El Ebrashy Head Of The Diabetes & Endocrinology Center

Cairo University

A1C reduction with glucose – lowering medications

Oral agents A1C (%)*

Sulfonylureas 1.5

Biguanides (metformin) 1.5

Glinides 1.0–1.5

Thiazolidinediones 0.8–1.0

DPP-IV inhibitors 0.5–0.9

α-Glucosidase inhibitors 0.5–0.8

Parenteral agents

Insulin ≥2.5 GLP analogues 0.6

Amylin analogues 0.6 *Monotherapy

DPP = dipeptidyl peptidase; GLP = glucagon-like peptide Nathan DM. N Engl J Med. 2007;356:437-40.

When to Start Insulin First

ADA-EASD Consensus

• Severely catabolic patient

• Hemoglobin A1C > 10%

• FBS > 250 mg/dl (13.9 mmol/l)

• Random consistently > 300 mg/dl

(16.7 mmol/l)

Nathan et al. Diabetes Care 2006;29: 1963-1972

Replacement insulin therapy should mimic

endogenous insulin profile in

insulin-treated T2DM

Ins

ulin

(m

U/l

)

06.00 12.00 24.00 18.00 0

15

30

45

06.00

Breakfast Lunch Dinner

Endogenous insulin secretion

Ideal basal insulin

Ideal prandial insulin

Adapted from Kruszynska YT, et al. Diabetologia 1987;30:16–21.

Time (hours)

Why Basal insulin Early?

Comparison of 24-hour glucose levels in control subjects vs patients with diabetes (p<0.001).

Adapted from Hirsch I, et al. Clin Diabetes 2005;23:78–86. Time of day (hours)

400

300

200

100

0

06.00 06.00 10.00 14.00 18.00 22.00 02.00

Pla

sm

a g

luc

ose (

mg

/dl)

Normal

Meal Meal Meal

20

15

10

5

0

Pla

sm

a g

luco

se (m

mo

l/l)

Why Basal insulin Early?

Hyperglycaemia due to an increase in fasting glucose

T2DM

Treating fasting hyperglycemia lowers

the entire 24-hour plasma glucose profile

Reduced risk of nocturnal hypoglycaemia with insulin glargine

NPH

Insulin glargine

p<0.001

p<0.002

Events

per

pati

ent–

year

All nocturnal

hypoglycaemia

Confirmed nocturnal

hypoglycaemia

p<0.001

* **

Confirmed hypoglycaemia: *4 mmol/l (72 mg/dl); **3.1 mmol/l (56 mg/dl) Riddle M. et al. Diabetes Care 2003;26:3080–6.

44%

risk reduction

42%

risk reduction

48%

risk reduction

6.9

5.5

2.5

4.0

3.1

1.3

0

1

2

3

4

5

6

7

8

Risk of severe hypoglycaemia and severe nocturnal hypoglycemia reduced

by 46% (p = 0.04) and 59% (p = 0.02), respectively, with insulin glargine

Insulin glargine reduces hypoglycemic risk versus NPH in T2DM: Meta analysis

0.931 (0.771, 1.123); p = 0.455

0.591 (0.486, 0.718); p < 0.001

0.711 (0.586, 0.862); p = 0.001

Odds ratio

0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0

Overall

Nocturnal

Daytime

Symptomatic hypoglycaemic events

Increased risk Reduced risk

Risk reduction mainly observed at night

Rosenstock J, et al. Diabetes Care 2005;28:950−5.

Mean (CI)

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LANTUS-BOT: after 5 years on Insulin Glargine,

83% of patients still did not require intensification

Retrospective cohort analysis from a German database comparing

the persistence of T2DM patients on basal insulin plus OADs with

patients treated with NPH plus OADs

i

Pfohl M, et al. Adding insulin glargine to oral therapy in type 2 diabetes patients results in longer persistence with the treatment

regimen compared to NPH insulin. Poster presented at ISPOR 2008

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Schreiber SA et al. Diabetes Obes Metab 2007;9(1):31–38; Schreiber SA, et al. Diabetes Technol Ther 2008;10(2):121–127

Schreiber et al: following titration, Insulin Glargine + oral

antidiabetic drugs can provide sustained glycaemic

control Observational study initiated in 12,216 insulin-naïve subjects with T2DM,

who added Insulin Glargine to their existing OAD treatment

The study duration was 9 months, followed by optional 20- and 32-month extension

phases

i

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THIN: switching from NPH to Insulin Glargine

improves HbA1c control in real life

Gordon J, et al. ADA 2009, abstract accepted

Retrospective analysis from a UK database analysing the switch

from NPH to Insulin Glargine in patients with TD2M

i

NEW

At The End

Education For Our Patients Is A Must

Advice For Physicians

Don't wait forever. "Patient needs insulin therapy,"

Don't be afraid of hypoglycaemia, but be aware of it.

Consider combination therapy ( insulin + OAD ).

Don't under-insulinize.

Thank You