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How I Introduce Insulin in Type 2

Diabetes Mellitus
Sheena Duffus
Diabetes Specialist Nurse
Norma Alexander
Sister Diabetes Clinic

24 May 2006 1
Points to ponder
Time of diagnosis to insulin therapy
Oral therapy at maximum combination
tolerated by the patient
Patient compliance
Weight loss clinics? Metabolic
syndrome drugs
Glitazones not licensed for use with insulin

24 May 2006 2
Patients perspective
Patients resistance to insulin v
insulin resistance
Fear factor
Loss of employment / driving categories
Weight gain
Hypos (fear of)
? Feel better
24 May 2006 3
Who to target?
Persistent hyperglycaemia HbA1c > 7% despite
maximum dose OHAs
Symptomatic
Severe inter-recurrent illness
Diabetes complications present
Weight loss due to hyperglycaemia
Ketosis?! Honk
24 May 2006 4
Grampian Step 1
Review the patient HbA1c , ?
Symptomatic, ? Weight loss, Inter-recurrent
illness or complication present
Height / Weight BMI Waist
circumference
24 May 2006 5
Step 1
Review the medication Compliant
? Dose increase possible
Additional OHA Weight control
clinic Metabolic insulin
resistant drug


24 May 2006 6
Step 1
Knowledge of diabetes Start again
? Have they had any formal diabetes
education ?
24 May 2006 7
Revisiting control Step 1
Review lifestyle Exercise Do
they do any ? What could they do ?
Smoking
Psychological issues What else is happening in their
life ? stress
Motivation How do they see it ?

24 May 2006 8
Step 2
Commence home blood glucose monitoring
An essential tool !
Refer patient to diabetes dietitian
Discuss with Consultant, DSN or GP
24 May 2006 9
Step 3
A. After 2 months if there is an improvement
in HbA1c go back to Step 1
B. Negotiate commencement of insulin with
the patient.
24 May 2006 10
Next step
Be positive but address their fear factor
Seeing the needle!
Dry run Sticking the needle in!
Relief factor
24 May 2006 11
Preparation
Consent
Discuss and agree change of treatment
Employment
Driving
Hypos
Lifestyle
Exercise
Sick day rules
24 May 2006 12
Insulin regime options
Pre mix and OHAs
Novomix 30 via
preloaded Flexpen
or Novopen 3
Humalog 25 Mix via
Humapen Luxura
Basal insulin and
OHAs Lantus
(Glargine) via pre
loaded Optiset pen
* must use Penfine
needles or
Autopen 24
24 May 2006 13
Step 4
Discuss insulin regime options
Action of insulin - How insulin works
Choosing their pen device dexterity pen
needle length


24 May 2006 14
Step 4
Start doses - titration rates
Give clear verbal and written instructions of
any OHA to be discontinued!
Written instructions of insulin dosage and
titration rate
24 May 2006 15
Step 4
Injection sites and rotation
Storage of insulin expiry date
Sharps disposal
Repeat prescriptions
24 May 2006 16
Start date and time
Venue surgery ward
Time morning
Task first injection keep it simple
Injection site where? rotation
Praise discuss fear & their technique
Oral medication continue or stop written
instructions
24 May 2006 17
Follow up support
Injections
Daily contact at surgery or phone
Who should initiate contact?
Dose adjust every few days with patient
depending upon their BG results Titrate
dose slowly to prevent severe hypos
Answer questions

24 May 2006 18

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