In the first place venture into insulin treatment

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Initial step into insulin treatment (How to begin insulin in a patient not controlled on OADs) By Dr.Muhammad Tahir Chaudhry B.Sc.M.B;B.S(Pb).C.diabetology(USA)

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The leap forward: Toronto 1921 – Banting & Best

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Normal physiologic examples of glucose and insulin emission in our body

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How Is Insulin Normally Secreted?

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The fast early ascent of insulin discharge in light of a dinner is basic, since it guarantees the incite hindrance of endogenous glucose creation by the liver transfer of the mealtime starch stack, along these lines restricting postprandial glucose outings.

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Basal insulins NPH Humulin N (Eli Lilly) Insulatard (Novo) (likewise accessible as insulatard Novolet pen) Dongsulin N (Highnoon) Insuget N (Getz) =========================================== Analogs Glargine (Lantus) Lantus Solostar Pen (Sanofi Aventis) Detemir ( Levimir) by Novo

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Basal Insulins The time game-plan of any insulin may fluctuate in various people, or at various times in a similar person. As a result of this variety, eras showed here ought to be viewed as general rules as it were.

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Bolous insulins (Mealtime or prandial) Human Regular Humulin R (Eli Lilly) Actrapid (Novo) (Also accessible as Actrapid novolet pen) Dongsulin R (Highnoon) Insuget R (Getz) ========================================== Analogs Lispro (Humolog) by Eli Lilly Novorapid by Novo Aspart Glulisine (Apidra) by Sanofi Aventis

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Bolous insulins (Mealtime or prandial) The time strategy of any insulin may change in various people, or at various times in a similar person. On account of this variety, eras showed here ought to be viewed as general rules as it were.

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Pre blended 70/30 (70% N,30% R) Humulin 70/30 (Eli Lilly) Mixtard 30 (Novo) (Also accessible as Mixtard 30 Novolet Pen) Dongsulin 70/30 (Highnoon) Insuget 70/30 (Getz) =================================== Analogs Novomix 30 (Novo) Humolog Mix 25(Lilly) Humolog Mix 50(Lilly)

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Types of Insulin 1. Fast acting 2. Short-acting 3. Middle acting 4. Premixed 5. Long-acting 6. Amplified long-acting (Analogs) (Regular) (NPH) (70/30) (Lantus)

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Indications for Insulin Use in Type 2 Diabetes Pregnancy (ideally preceding pregnancy) Acute sickness requiring hospitalization Perioperative/emergency unit Postmyocardial dead tissue High-dosage glucocorticoid treatment Inability to endure or contraindication to oral antiglycemic specialists Newly determined sort 2 diabetes to have fundamentally hoisted blood glucose levels (pts with extreme side effects or DKA) Patient no longer accomplishing helpful objectives on blend antiglycemic treatment

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Proposed Algorithm of treatment for Type 2 Diabetes Inadequate Non pharmacological treatment Severe manifestations Severe hyperglycaemia Ketosis pregnancy 2 oral operators 3 oral specialists 1oral operator Add Insulin Earlier in the Algorithm

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F i rst step i nto Insulin treatment

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What we have in our pockets? Basal Insulins (NPH,Lantus) Bolus Insulins(Human Regular) Premixed (Human 70/30)

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The ADA Recommendations on the Use of Insulin in Type 2 Diabetes

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Touch Pad Question Currently, generally ____ of my patients with sort 2 diabetes are taking some type of insulin. 1. >80% 2. 60-80% 3. 40-60% 4. 20-40% 5. 0-20%

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Touch Pad Question When it comes to first-line insulin, I have a tendency to endorse: 1. A middle of the road acting insulin with quick acting insulin as required 2. A long-acting or augmented long-acting insulin with quick acting insulin as required 3. A premixed insulin

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Advantages of Insulin Therapy Oldest of the at present accessible drugs, has the most clinical experience Most powerful of the diabetes pharmaceuticals in bringing down glycemia Can diminish any level of raised HbA 1c No greatest measurement of insulin past which a helpful impact won't happen Beneficial consequences for triglyceride and HDL cholesterol levels Nathan DM et al. Diabetes Care 2006;29(8):1963-72.

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Disadvantages of Insulin Therapy Weight pick up ~ 2-4 kg May unfavorably influence cardiovascular wellbeing Hypoglycemia However, rates of serious hypoglycemia in patients with sort 2 diabetes are low… Type 1 DM: 61 occasions for each 100 patient-years Type 2 DM: 1-3 occasions for every 100 patient-years Nathan DM et al. Diabetes Care 2006;29(8):1963-72.

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Balancing Good Glycemic Control with a Low Risk of Hypoglycemia… Glycemic control Hypoglycemia

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Rates of Hypoglycemia for Premixed versus Long-Acting Insulin + OAD Mean number of affirmed hypoglycemic occasions per tolerant year in a 28-week ponder 6 p=0.0009 5.73 Premixed Insulin glargine + OADs 5 4 Events for every patient-year 3 2.62 2 p=0.0449 p=0.0702 1 1.04 0.05 0.00 0.51 0 Symptomatic Nocturnal Severe Adapted from Janka et al. Diabetes Care 2005;28:254-9 .

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Rates of Hypoglycemia for Premixed versus Long-Acting Insulin + OAD in Elderly Patients 12 Rate of occasion for every patient-year Premixed (n=63) Glargine + OAD (n=69) p=0.01 10 p=0.008 8 6 p=0.06 4 2 0 All scenes of hypoglycemia All affirmed scenes of hypoglycemia Confirmed symptomatic hypoglycemia Adapted from Janka HU et al. J Am Geriatr Soc 2007;55(2):182-8.

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The ADA Treatment Algorithm for the Initiation and Adjustment of Insulin

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Initiating and Adjusting Insulin Bedtime halfway acting insulin, or sleep time or morning long-acting insulin (start with 10 units or 0.2 units for each kg) Check FG and increment dosage until in target go. In the event that HbA 1c ≤ 7%... Pre-lunch BG out of range: include quick acting insulin at breakfast Pre-supper BG out of range: include NPH insulin at breakfast or fast acting insulin at lunch Pre-bed BG out of range: include fast acting insulin at supper If HbA 1c  7%... In the event that HbA 1c ≤ 7%... Hypoglycemia or FG >3.89 mmol/l (70 mg/dl): Reduce sleep time measurement by ≥4 units (or 10% if dosage >60 units) Target go: 3.89-7.22 mmol/L (70-130 mg/dL) If HbA 1c  7%... On the off chance that fasting BG in target go, check BG before lunch, supper, and bed. Contingent upon BG comes about, include second infusion (can for the most part start with ~4 units and change by 2 units at regular intervals until BG in range) Continue regimen; check HbA 1c like clockwork Continue regimen; check HbA 1c like clockwork Recheck pre-feast BG levels and if out of range, may need to include another infusion; if HbA 1c keeps on being out of range, check 2-hr postprandial levels and alter preprandial quick acting insulin Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.

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Step One… Bedtime moderate acting insulin, or sleep time or morning long-acting insulin (start with 10 units or 0.2 units for each kg) Check FG and increment measurements until in target run. In the event that HbA 1c ≤ 7%... Pre-lunch BG out of range: include quick acting insulin at breakfast Pre-supper BG out of range: include NPH insulin at breakfast or fast acting insulin at lunch Pre-bed BG out of range: include fast acting insulin at supper If HbA 1c  7%... On the off chance that HbA 1c ≤ 7%... Hypoglycemia or FG >3.89 mmol/l (70 mg/dl): Reduce sleep time measurement by ≥4 units (or 10% if dosage >60 units) Target run: 3.89-7.22 mmol/L (70-130 mg/dL) If HbA 1c  7%... In the event that fasting BG in target go, check BG before lunch, supper, and bed. Contingent upon BG comes about, include second infusion (can as a rule start with ~4 units and change by 2 units like clockwork until BG in range) Continue regimen; check HbA 1c at regular intervals Continue regimen; check HbA 1c at regular intervals Recheck pre-supper BG levels and if out of range, may need to include another infusion; if HbA 1c keeps on being out of range, check 2-hr postprandial levels and modify preprandial fast acting insulin Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.

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Step One: Initiating Insulin Start with either… Bedtime halfway acting insulin or Bedtime or morning long-acting Insulin regimens ought to be outlined considering way of life and supper plans Nathan DM et al. Diabetes Care 2006;29(8):1963-72.

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Step One: Initiating Insulin , cont'd Check fasting glucose and increment measurement until in target run Target go: 3.89-7.22 mmol/l (70-130 mg/dl) Typical dosage increment is 2 units like clockwork, however in the event that fasting glucose >10 mmol/l (>180 mg/dl), can increment by substantial additions (e.g., 4 units at regular intervals) Nathan DM et al. Diabetes Care 2006;29(8):1963-72.

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If hypoglycemia happens or if fasting glucose < 3.89 mmol/l (70 mg/dl)… Reduce sleep time measurements by ≥4 units or 10% if dosage >60 units Step One: Initiating Insulin , cont'd Reduction in overnight and fasting glucose levels accomplished by including basal insulin might be adequate to lessen postprandial heights in glucose amid the day and encourage the accomplishment of target A1C fixations. Nathan DM et al. Diabetes Care 2006;29(8):1963-72. While utilizing basal insulin alone, never stop or diminish continuous oral treatment

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If HbA 1c is <7%... Proceed with regimen and check HbA 1c at regular intervals If HbA 1c is ≥7%... Move to Step Two… After 2-3 Months… Nathan DM et al. Diabetes Care 2006;29(8):1963-72.

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With the expansion of basal insulin and titration to target FBG levels, just around 60% of patients with sort 2 diabetes can accomplish A1C objectives < 7%. [36] In the rest of the patients with A1C levels above objective paying little respect to satisfactory fasting glucose levels, postprandial blood glucose levels are likely hoisted.

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Step Two… Bedtime moderate acting insulin, or sleep time or morning long-acting insulin (start with 10 units or 0.2 units for every kg) Check FG and increa

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