Starting Basal Insulin After Oral Agent Failure

Agus Yuwono

Division of Endocrinology, Department of Medicine, Ulin Hospital, Medical Faculty, Lambung Mangkurat University

Serious Complications of Type 2 Diabetes are Present at Diagnosis

Complication Any complication Prevalence (%)* 50

Retinopathy
Abnormal ECG Absent foot pulses ( 2) and/or ischaemic feet Impaired reflexes and/or decreased vibration sense Myocardial infarction/angina/claudication
* Some patients had more than one complication at time of diagnosis Stroke/transient ischaemic attack ECG = electrocardiogram

21
18 14 7 ~23 ~1

Adapted from UKPDS Group. UKPDS 6. Diabetes Res 1990; 13:111.

The UKPDS
Type 2 diabetes

1% HbA1c

> 5,000 patients; 14 years

Life-style vs oral vs insulin

35% microvascular complication 14% myocardial infarction

DCCT: Results Summary

Improved control of blood glucose reduces the risk of clinically meaningful

Retinopathy Nephropathy

76% 54%

(P0.002) (P<0.04)

Neuropathy

60%

(P0.002)

Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329:9

Memilih Insulin
PUASA,PRANDIAL ATAU MIX

Insulin can be initiated anytime

Traditionally, insulin had been reserved as the last line of therapy Considering the benefits of normal glycemic status, insulin can be initiated earlier, as soon as is required.

Inadequate Lifestyle

1 OAD

2 OAD

3 OAD

Initiate Insulin

Indication: Permanent
T1DM
OAD failure OAD Contra Indication Diabetic Ketoacidosis

Not permanent
Infection
Pregnancy Hospitalized Perioperative

Treatment Based on the Pathophysiology of Hyperglycemia in Type 2 Diabetes

Fasting Hyperglycemia Prandial Hyperglycemia

Insulin long-acting (Insulin basal) Long-acting SU Metformin Glitazone

Insulin prandial Short-acting Insulin Short-acting SU Glinide Glitazones Acarbose

Physiologic Plasma Glucose and Insulin Secretion: 24-hour profile

Meals

Prandial insulin

Basal insulin

Prandial glucose Basal glucose

Starting Basal Insulin

Start dose around 10 Ajust NPH/Long-acting analogue dose by fasting SMBG Increase insulin dose every 3 to 5 days as needed (2 4 ) Treat to target basal (fasting)< 100 mg%)

Insulin Regimen Consisting of Bedtime Injection of Intermediate-acting Insulin ( NPH or LENTE )

A INSULIN EFFECT Morning Afternoon Evening Night

Oral

DETIMIR/glargin

S
MEALS

HS

Why Acting Insulin Analogs ?

Kelemahan Human Insulin (Actrapid/Mixtard)

Period of unwanted hyperglycemia

Change in serum insulin

Normal insulin secretion at mealtime Human insulin

Period of unwanted hypoglycemia

Human Insulin HARUS Baseline disuntikkan 30 menit sebelum level makan

Time (h)

SC injection