PRACTICAL ASPECT OF USING INSULIN

IN TYPE 2 DIABETES MELLITUS

John MF Adam

Division of Endocrinology and Metabolism,

Department of Internal Medicine, Faculty of Medicine,
Hasanuddin University, Makassar
PRACTICAL ASPECT OF USING INSULIN
IN TYPE 2 DIABETES MELLITUS

INTRODUCTION
Prof Eliot P Joslin, 1921,
predict that, the next three
decades, DM will increase
worldwide, at least twice as
much
 300
1995
Persons with diabetes in the
adult population (millions)

250 2000
2025
200

150

100

50

0
Developed Developing Worldwide
countries countries

Number of people with diabetes mellitus 1995 - 2025

International Diabetes Federation 2001

King H, et al. Diabetes Care 1998; 21: 1414 - 1431
DIABETES MELLITUS IN INDONESIA
Year 1980s

Place Year Population Prevalence

Semarang 1979 2.822 2.30%

Jakarta 1983 2.720 1.50%
Makassar 1982 2.720 1.50%
Padang 1984 615 1.50%
 DIABETES MELLITUS IN INDONESIA
Year 2000s

Place Year Population Prevalence

Riskerdas 2007 24.417 5.7%

Jakarta 2008 969 14.2%
Bali 2010 1.840 5.9%
Makassar 2011 3.502 9.1%
These data showed that within 20 years, diabetes mellitus
become a major public health problem in our country
PRACTICAL ASPECT OF USING INSULIN
IN TYPE 2 DIABETES MELLITUS

THE INSULIN
CLASSIFICATION OF DIABETES

1. Type 1 diabetes
2. Type 2 diabetes
3. Gestational diabetes mellitus
4. Specific types of diabetes due to other cause
MODY, Pancreatitis, drug / glucocorticoid

Diabetes Care 2019;42(Suppl.1):S13-S28

TREATMENT OF TYPE 2 DIABETES

1. Life style modification (Medical Nutrition Therapy

and Exercise)
2. Medical treatment :
* Oral anti - diabetic
* Injection
- Insulin
- GLP – 1 RAs
3. Bariatric Surgery
CRITERIA OF GLYCEMIC CONTROL

A1C < 7.0 % (6.5%)

Fasting < 140 mg/dL
Post prandial < 180 mg/dL
 TYPE OF INSULIN

Types of insulin
1. Basal Insulin (long acting insulin)
Lantus, Levemir, Sansulin, Ezelin, Tresiba, Lantus ER
2. Short Acting Insulin (Regular insulin)
NovoRapid, Apidra
3. Premixed Formulations
Novomix
Indications For Insulin Use in Type 2 Diabetes
The most common indications for the initiation of insulin
therapy in type 2 diabetes include following :

1. Progressive β-cell dysfunction

2. Severe hyperglycemia with associated glucose toxicity
3. Hospitalization for an acute illness or surgery
4. Side effects with or contraindication to use of or
noninsulin therapies
5. Pregnancy
6. Patient preference

Olson DE, Insulin Therapy in Type 2 Diabetes, 461-479, Therapy of

Diabetes Mellitus and Related Disorders (Sixth Edition)
 Efficacy Hypoglycemia Weight
change
Natural
Metformin High No (Potential for
modest loss)
SGLTP 2 Inhibitors Intermediate No Loss
(Cana, Dapa, Empa)

GLP – 1 Ras High No Loss

(Lira, Exenatide)

DPP - 4 inhibitors Intermediate No Neutral

Thiazolidinediones High No Gain

(Pioglitazone)
Sulfonylureas High Yes Gain
(2nd generation)
Insulin Highest Yes Gain
Insulin
Human
Analogs

Diabetes Care 2019;42(Suppl.1):S90-S102

 COMBINATION WITH BASAL INSULIN
Metformin

Pioglitazone Sulfonylureas

INSULIN

DPP4 inhibitors Acarbose

Combination with basal insulin

 DOSE OF BASAL INSULIN

1. 0,1 - 0,2 U/kg or e.g 10 – 20 units

Olson DE, Insulin Therapy in Type 2 Diabetes, 461-479, Therapy of Diabetes
Mellitus and Related Disorders (Sixth Edition)

2. 0,2 Unit/kg
Petunjuk Prakstis Terapi Insulin pada Pasien Diabetes Melitus hal.23-27
Contoh kasus 1

Progressive β-cell dysfunction

Seorang wanita 60 tahun dengan riwayat menderita DM

selama 20 tahun. Ia datang ke klinik dengan riwayat sbb :

1. Saat ini mendapat obat Metformin 3x500mg dan

Glimipiride 1x4ml
2. Pemeriksaan fisis TB 150cm, BB 52kg, TD 120/80mmHg

Pertanyaan apakah perlu mendapat insulin ?

Contoh kasus 2

Severe hyperglycemia

Penderita AM 52 tahun. Ia sudah mendapat pengobatan

kombinasi 2 OAD tetapi kadar glukosa puasa 340 mg/dL.

Pengobatan seterusnya ???

Contoh kasus 3

Hospitalization for surgery

Seorang wanita 40 tahun disertai abses pada payudara kiri.

Kadar glukosa puasa 357 mg/dL. Penderita di rencanakan
untuk operasi abses payudara.

Bagaimana pengobatan TS ???

ASSESSMENT OF HYPOGLYCEMIA RISK
Factors that increase risk of treatment-associated hypoglycemia
• Use of insulin or insulin secretagogues (i.e., sulfonylureas,
meglitinides)
• Impaired kidney or hepatic function
• Longer duration of diabetes
• Frailty and older age
• Cognitive impairment
• Impaired counterregulatory response, hypoglycemia
unawareness
• Physical or intellectual disability that may impair behavioral
response to hypoglycemia
• Alcohol use
• Polypharmacy (especially ACE inhibitors, angiotensin receptor
blockers, nonselective β-blockers)
Diabetes Care 2019;42(Suppl.1):S34-S45
CLASSIFICATION OF HYPOGLYCEMIA

Level Glycemic criteria/description

Level 1 Glucose ,70 mg/dL (3.9 mmol/L) and

glucose $54 mg/dL (3.0 mmol/L)

Level 2 Glucose ,54 mg/dL (3.0 mmol/L)

Level 3 A severe event characterized by altered
mental and/or physical status requiring
assistance

Diabetes Care 2019;42(Suppl.1):S61-S70

MAKASSAR, 26 April 2018