Insulinoterapia, Nuevos Retos - Dra. Jenny Cepeda
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This document discusses the history and types of insulin therapies for treating diabetes. It begins with a brief overview of the discovery of insulin in the 1920s. It then describes different types of insulin including rapid-acting, long-acting, pre-mixed, and inhaled varieties. The document provides details on the onset and duration of action for various insulin analogs. It discusses considerations for selecting insulin therapies and achieving glycemic control targets. The goals of insulin treatment are outlined. Recommendations are provided on progressing from mono- to dual- and triple-therapy when targets are not met.
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Insulinoterapia, Nuevos Retos - Dra. Jenny Cepeda
- 1. {
- 2. Banting, Best, Collip y MacLeod 1921 Islotina Mc-Collip Leonard Thompson 11 enero 1922 1936 Hagedorn 1946 NPH Scott y Fisher zinc
- 3. Entrada glucosa Inhibe producción hepática glucosa Inhibe lipólisis, proteólisis Promueve síntesis proteica Conversión del exceso glucosa a grasa
- 4. Insulinas porcinas y bovinas Insulina humana Análogos de insulina Insulina inhalada
- 5. RAZON?
- 10. Insulina rápida humana Velocidad de absorción baja Inicia 15 a 60 mins tras inyección Pico 2 a 4 horas. Acción máx.: 5-8 hrs
- 11. I. Prandiales: Lispro L p Inicia 15 mins EM: 60-90 mins Actua 4-5 hrs Flexible
- 13. Glulisina L G
- 14. INSULINA INHALADA: 1. Insulina de acción rápida 2. No pctes con asma, broncoespasmos, EPOC o cualquier otra enfermedad pulmonar crónica •No en CAD
- 15. Insulinas basales: NPH Inicia 2.5- 3 hrs Pico 5-7 hrs Duración 13-16 hrs Reducción basal
- 17. I. Basales: Glargina A A G
- 18. • Degludec • U300 glargina (Toujeo) • Peglispro INSULINAS MODERNAS http://www.medscape.com/viewarticle/
- 19. Insulinas precombinadas NPL 75/25 NPA 70/30 Insulina 70/30 Problemas autocombinación Ancianos Trastorno motricidad fina y/o visuales No fácil ajuste Inadecuadas DM 1
- 21. Objetivos de insulinoterapia Prevenir y retrasar complicaciones micro y macrovasculares Evitar CAD Detener catabolia y recuperar masa magra Reducir infecciones frecuentes Reducir morbimortalidad materno- fetal
- 22. ADA-EASD Position Statement Update: Management of Hyperglycemia in T2DM, 2015 larga (Detemir) Ultra-rápida (Lispro, Aspártica, Glulisina) Hours Larga (Glargina) 0 2 4 6 8 10 12 14 16 18 20 22 24 Rápida (Regular) Horas después injección Niveldeinsulina (Degludec) TERAPIA ANTI-HIPERGLICEMICA NPH
- 23. Healthy eating, weight control, increased physical activity & diabetes education Metformin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): Metformin + Metformin + Metformin + Metformin + Metformin + high low risk gain edema, HF, fxs low Thiazolidine- dione intermediate low risk neutral rare high DPP-4 inhibitor highest high risk gain hypoglycemia variable Insulin (basal) Metformin + Metformin + Metformin + Metformin + Metformin + Basal Insulin + Sulfonylurea + TZD DPP-4-i GLP-1-RA Insulin§ or or or or Thiazolidine- dione + SU DPP-4-i GLP-1-RA Insulin§ TZD DPP-4-ior or or GLP-1-RA high low risk loss GI high GLP-1 receptor agonist Sulfonylurea high moderate risk gain hypoglycemia low SGLT2 inhibitor intermediate low risk loss GU, dehydration high SU TZD Insulin§ GLP-1 receptor agonist + SGLT-2 Inhibitor + SU TZD Insulin§ Metformin + Metformin + or or or or SGLT2-i or or or SGLT2-i Mono- therapy Efficacy* Hypo risk Weight Side effects Costs Dual therapy† Efficacy* Hypo risk Weight Side effects Costs Triple therapy or or DPP-4 Inhibitor + SU TZD Insulin§ SGLT2-i or or or SGLT2-i or DPP-4-i If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i: Metformin + Combination injectable therapy‡ GLP-1-RAMealtime Insulin Insulin (basal) + Terapia antihiperglicémica: recomendaciones generales Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
- 24. Healthy eating, weight control, increased physical activity & diabetes education Metformin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): Metformin + Metformin + Metformin + Metformin + Metformin + high low risk gain edema, HF, fxs low Thiazolidine- dione intermediate low risk neutral rare high DPP-4 inhibitor highest high risk gain hypoglycemia variable Insulin (basal) Metformin + Metformin + Metformin + Metformin + Metformin + Basal Insulin + Sulfonylurea + TZD DPP-4-i GLP-1-RA Insulin§ or or or or Thiazolidine- dione + SU DPP-4-i GLP-1-RA Insulin§ TZD DPP-4-ior or or GLP-1-RA high low risk loss GI high GLP-1 receptor agonist Sulfonylurea high moderate risk gain hypoglycemia low SGLT2 inhibitor intermediate low risk loss GU, dehydration high SU TZD Insulin§ GLP-1 receptor agonist + SGLT-2 Inhibitor + SU TZD Insulin§ Metformin + Metformin + or or or or SGLT2-i or or or SGLT2-i Mono- therapy Efficacy* Hypo risk Weight Side effects Costs Dual therapy† Efficacy* Hypo risk Weight Side effects Costs Triple therapy or or DPP-4 Inhibitor + SU TZD Insulin§ SGLT2-i or or or SGLT2-i or DPP-4-i If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i: Metformin + Combination injectable therapy‡ GLP-1-RAMealtime Insulin Insulin (basal) + Terapia antihiperglicémica: Recomendaciones generales Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
- 25. Healthy eating, weight control, increased physical activity & diabetes education Metformin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): Metformin + Metformin + Metformin + Metformin + Metformin + high low risk gain edema, HF, fxs low Thiazolidine- dione intermediate low risk neutral rare high DPP-4 inhibitor highest high risk gain hypoglycemia variable Insulin (basal) Metformin + Metformin + Metformin + Metformin + Metformin + Basal Insulin + Sulfonylurea + TZD DPP-4-i GLP-1-RA Insulin§ or or or or Thiazolidine- dione + SU DPP-4-i GLP-1-RA Insulin§ TZD DPP-4-ior or or GLP-1-RA high low risk loss GI high GLP-1 receptor agonist Sulfonylurea high moderate risk gain hypoglycemia low SGLT2 inhibitor intermediate low risk loss GU, dehydration high SU TZD Insulin§ GLP-1 receptor agonist + SGLT-2 Inhibitor + SU TZD Insulin§ Metformin + Metformin + or or or or SGLT2-i or or or SGLT2-i Mono- therapy Efficacy* Hypo risk Weight Side effects Costs Dual therapy† Efficacy* Hypo risk Weight Side effects Costs Triple therapy or or DPP-4 Inhibitor + SU TZD Insulin§ SGLT2-i or or or SGLT2-i or DPP-4-i If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i: Metformin + Combination injectable therapy‡ GLP-1-RAMealtime Insulin Insulin (basal) + Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
- 26. Healthy eating, weight control, increased physical activity & diabetes education Metformin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): Metformin + Metformin + Metformin + Metformin + Metformin + high low risk gain edema, HF, fxs low Thiazolidine- dione intermediate low risk neutral rare high DPP-4 inhibitor highest high risk gain hypoglycemia variable Insulin (basal) Metformin + Metformin + Metformin + Metformin + Metformin + Basal Insulin + Sulfonylurea + TZD DPP-4-i GLP-1-RA Insulin§ or or or or Thiazolidine- dione + SU DPP-4-i GLP-1-RA Insulin§ TZD DPP-4-ior or or GLP-1-RA high low risk loss GI high GLP-1 receptor agonist Sulfonylurea high moderate risk gain hypoglycemia low SGLT2 inhibitor intermediate low risk loss GU, dehydration high SU TZD Insulin§ GLP-1 receptor agonist + SGLT-2 Inhibitor + SU TZD Insulin§ Metformin + Metformin + or or or or SGLT2-i or or or SGLT2-i Mono- therapy Efficacy* Hypo risk Weight Side effects Costs Dual therapy† Efficacy* Hypo risk Weight Side effects Costs Triple therapy or or DPP-4 Inhibitor + SU TZD Insulin§ SGLT2-i or or or SGLT2-i or DPP-4-i If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i: Metformin + Combination injectable therapy‡ GLP-1-RAMealtime Insulin Insulin (basal) + Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
- 27. Healthy eating, weight control, increased physical activity & diabetes education Metformin high low risk neutral/loss GI / lactic acidosis low If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): Metformin + Metformin + Metformin + Metformin + Metformin + high low risk gain edema, HF, fxs low Thiazolidine- dione intermediate low risk neutral rare high DPP-4 inhibitor highest high risk gain hypoglycemia variable Insulin (basal) Metformin + Metformin + Metformin + Metformin + Metformin + Basal Insulin + Sulfonylurea + TZD DPP-4-i GLP-1-RA Insulin§ or or or or Thiazolidine- dione + SU DPP-4-i GLP-1-RA Insulin§ TZD DPP-4-ior or or GLP-1-RA high low risk loss GI high GLP-1 receptor agonist Sulfonylurea high moderate risk gain hypoglycemia low SGLT2 inhibitor intermediate low risk loss GU, dehydration high SU TZD Insulin§ GLP-1 receptor agonist + SGLT-2 Inhibitor + SU TZD Insulin§ Metformin + Metformin + or or or or SGLT2-i or or or SGLT2-i Mono- therapy Efficacy* Hypo risk Weight Side effects Costs Dual therapy† Efficacy* Hypo risk Weight Side effects Costs Triple therapy or or DPP-4 Inhibitor + SU TZD Insulin§ SGLT2-i or or or SGLT2-i or DPP-4-i If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote any specific preference - choice dependent on a variety of patient- & disease-specific factors): If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i: Metformin + Combination injectable therapy‡ GLP-1-RAMealtime Insulin Insulin (basal) + Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442 HbA1c ≥9% Intolerancia o contraindicación metformina Hiperglicemia incontrolada (cuadros catabólicos, Gp ≥300-350 mg/dl, HbA1c ≥10-12%)
- 28. A QUIEN??
- 29. Inicio DM 1 y DM2 con síntomas Cuadros agudos, hospitalización Diabetes gestacional sin control y pregestacional Insuficiencia renal y hepática Falla terapéutica ADO CON EL TX DE INSULINA EN RECIEN DX SE HA DEMOSTRADO UN AUMENTO DE LA SECRESION DE LA MISMA TANTO 1ERA COMO 2DA FASE ORIGIN A DOSIS 0.1 A 0.15 U DE ANALOGOS REDUCIENDO 30-35 % DE LA PROGRESION DE DIABETES
- 30. • Edad/expectativa de vida • Comorbilidades • Duración de la diabetes • Hipoglicemias • Consideraciones individuales • Enf. Cardiovasculares/ complicaciones microvasculares avanzadas
- 31. more stringent less stringent Patient attitude and expected treatment efforts highly motivated, adherent, excellent self-care capacities less motivated, non-adherent, poor self-care capacities Risks potentially associated with hypoglycemia and other drug adverse effects low high Disease duration newly diagnosed long-standing Life expectancy long short Important comorbidities absent severefew / mild Established vascular complications absent severefew / mild Readily available limited Usually not modifiable Potentially modifiable HbA1c 7% PATIENT / DISEASE FEATURES Approach to the management of hyperglycemia Resources and support system Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
- 33. Add ≥2 rapid insulin* injections before meals ('basal-bolus’† ) Change to premixed insulin* twice daily Add 1 rapid insulin* injections before largest meal • Start: Divide current basal dose into 2/3 AM, 1/3 PM or 1/2 AM, 1/2 PM. • Adjust: é dose by 1-2 U or 10-15% once- twice weekly until SMBG target reached. • For hypo: Determine and address cause; ê corresponding dose by 2-4 U or 10-20%. • Start: 10U/day or 0.1-0.2 U/kg/day • Adjust: 10-15% or 2-4 U once-twice weekly to reach FBG target. • For hypo: Determine & address cause; ê dose by 4 units or 10-20%. Basal Insulin (usually with metformin +/- other non-insulin agent) If not controlled after FBG target is reached (or if dose > 0.5 U/kg/day), treat PPG excursions with meal-time insulin. (Consider initial GLP-1-RA trial.) If not controlled, consider basal- bolus. If not controlled, consider basal- bolus. • Start: 4U, 0.1 U/kg, or 10% basal dose. If A1c<8%, consider ê basal by same amount. • Adjust: é dose by 1-2 U or 10-15% once- twice weekly until SMBG target reached. • For hypo: Determine and address cause; ê corresponding dose by 2-4 U or 10-20%. • Start: 4U, 0.1 U/kg, or 10% basal dose/meal.‡ If A1c<8%, consider ê basal by same amount. • Adjust: é dose by 1-2 U or 10-15% once-twice weekly to achieve SMBG target. • For hypo: Determine and address cause; ê corresponding dose by 2-4 U or 10-20%. Enfoque para inicio y ajuste de tx insulínico Dm 2 Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
- 34. Add ≥2 rapid insulin* injections before meals ('basal-bolus’† ) Change to premixed insulin* twice daily Add 1 rapid insulin* injections before largest meal • Start: Divide current basal dose into 2/3 AM, 1/3 PM or 1/2 AM, 1/2 PM. • Adjust: é dose by 1-2 U or 10-15% once- twice weekly until SMBG target reached. • For hypo: Determine and address cause; ê corresponding dose by 2-4 U or 10-20%. • Start: 10U/day or 0.1-0.2 U/kg/day • Adjust: 10-15% or 2-4 U once-twice weekly to reach FBG target. • For hypo: Determine & address cause; ê dose by 4 units or 10-20%. Basal Insulin (usually with metformin +/- other non-insulin agent) If not controlled after FBG target is reached (or if dose > 0.5 U/kg/day), treat PPG excursions with meal-time insulin. (Consider initial GLP-1-RA trial.) low mod. high more flexible less flexible Complexity # Injections Flexibility 1 2 3+ If not controlled, consider basal- bolus. If not controlled, consider basal- bolus. • Start: 4U, 0.1 U/kg, or 10% basal dose. If A1c<8%, consider ê basal by same amount. • Adjust: é dose by 1-2 U or 10-15% once- twice weekly until SMBG target reached. • For hypo: Determine and address cause; ê corresponding dose by 2-4 U or 10-20%. • Start: 4U, 0.1 U/kg, or 10% basal dose/meal.‡ If A1c<8%, consider ê basal by same amount. • Adjust: é dose by 1-2 U or 10-15% once-twice weekly to achieve SMBG target. • For hypo: Determine and address cause; ê corresponding dose by 2-4 U or 10-20%. Enfoque para inicio y ajuste de tx insulinico Dm2 Diabetes Care 2015;38:140-149; Diabetologia 2015;58:429-442
- 35. 0.2 a 0.5 U/ kg: 50% basal (2/3 y 1/3) 50% bolus Conteo CBH: 1 U <> 15 g CBH Automonitoreo DM 1
- 36. Síntomas de hiperglicemia Contraindicación ADO HbA1c >9 % Cuadros agudos GA >250 mg/dl y GPP > 350 mg/dl Embarazo DM 2
- 38. { CenaAlmuerzoDesayuno 5am 6am 7am 8am 9 am 10am 11am 12md 1 pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12pm 1am 2am 3am 4am Horarios y tiempos de comida
- 39. { CenaAlmuerzoDesayuno 5am 6am 7am 8am 9 am 10am 11am 12md 1 pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12pm 1am 2am 3am 4am Horarios y tiempos de comida
- 40. { CenaAlmuerzoDesayuno 5am 6am 7am 8am 9 am 10am 11am 12md 1 pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12pm 1am 2am 3am 4am Horarios y tiempos de comida
- 41. { CenaAlmuerzoDesayuno 5am 6am 7am 8am 9 am 10am 11am 12md 1 pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12pm 1am 2am 3am 4am Horarios y tiempos de comida
- 42. { CenaAlmuerzoDesayuno 5am 6am 7am 8am 9 am 10am 11am 12md 1 pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12pm 1am 2am 3am 4am Horarios y tiempos de comida
- 44. Hipoglicemia Ganancia de peso Alergia Lipodistrofia Edema Presbiopenia EFECTOS ADVERSOS
- 45. Conclusión
Notas del editor
- EFICACIA BIOLOGICA. 1921 universidad toronto Islotina por banting y best para luego llamarse insulina por macleod y adecuadamente collip (bioqco) Hospital gnral toronto Protamina de pescado. Insulina protamina cinc
- SECUENCIA PROTEINICA COMPLETA. SANGER 1958 ZONAS DE INVARIABILIDAD EN AAS DE CISTEINA, CONFIEREN LA ADECUACION AL RECEPTOR DE INSULINAZ
- 1.1EROS 60 AÑOS 2.DECENIO DE LOS 80 3. ANOS 90 4. JUNIO 2014 SANOFI AVENTIS
- UKPDS 5,102 DM2 10 AÑOS. REDUCCION DE 1% A1C HAY REDUCCION 14% PARA EL IAM, 12% ICTUS, 43% PARA AMPUTACION
- DIGAMI. TX INTENSIVO CON INSULINA TRAS UN IAM REDUCE MORTALIDAD Y EL USO DE BOMBA DE INFUSION C INSULINA MAS GLUCOSA REDUJO MORTALIDAD INTRAHOSP 58% Y LA MORTALIDAD GLOBAL A 1 AÑO 52 % DCCT RETINOPATIA 76%, NEUROPATIA 69%, NEFROPATIA 34%
- VER PAG 117 DE GARCIA DR
- NO SIMULA LA SECRESION FISIOL DE INSUL POR LO TANTO DEBE DARSE 30 A 45 MINS ANTES D LA COMIDA PARA Q COINCIDA CON LA ABSORCION DE LOS HC
- LISPRO RECORDAR Q LA INSULINA SE AUTOAGREGA EN HEXAMEROS….. PAG 660 JOSLIN ESTO REDUCE LA AUTOAGREGACION FLEXIBLE: MENOS HIPOG, CONTEO CBH , COLOCAR C/COMIDAS Preferidas para la bomba de infusion HIUMALOG
- ASPARTATO EN LUGAR DE PROLINA POSICION B28. REPULSION DE LAS CARGAS POR EL ACIDO (CARGA NEGATIVA), POR LO TANTO HAY REPULSION Con esta y la lispro: menor hipoglicemia nocturna ==NOVORAPID
- Apidra SUSTITUCION DE ASPARAGINA EN B3 POR LISINA Y EN B29 SUSTITUIR LISINA POR AC GLUTAMICO UNICA Q NO TIENE ZINC
- AFREZZA Hacer espirometría APROBADA 27 DE JUNIO 2014
- HABLAR DE LA PRESENTACION U-100 Y U-500
- SE ELIMINA EL B30 TREONINA Y SE ACIDIFICA LA CADENA LAT B, ANADIENDO ACIDO TETRADECANOICO(ac miristico) AL B29 (ac graso alifatico). UNION REVERSIBLE C/ALBUMINA Y EL AC GRASO ACILADO A LA INSULINA
- SE AGREGA 2 AAS ARGININA. ESTO DESPLAZA EL PUNTO ISOELECTRICO DE LA PROT DE UN PH DE 5.4 A UN PH 6.7. ESTO MOTIVA Q LA MOLECULA SEA MAS SOLUBLE EN UN PH ACIDO Y MENOS SOLUBLE A UN PH NEUTRO. ERA NEC UNA SEGUNDA SUST PARA EVITA LA DESAMIDACION NO DESEADA DE LA ASPARAGINA A21 Q TIENE LUGAR A PH BAJOS. LA SUST DE ASN A21 POR GLICINA EVITA ESTE PROBLEMA VARIABILIDAD INTRAINDIVIDUAL
- 1. TRESIBA (NOVO) APROBADA POR LA UNIN EUROPEA DESDE JUNIO 2013, NO POR FDA. SE DA EN CUALQ MTO DEL DIA 2. Aprobada Miercoles 25 de feb (sanofi) TIENE LA CONCENTRACION DE 3 VECES DE LA GLARGINA, ES LA LIBERACION MAS GRADUAL DE LA INSULINA Y ES LLAMADA INSULINA DE ACCION ULTRALARGA. 3. TB DE ACCION ULTR LARGA LILY
- Ver pag 661 para detalles de insulinas (joslin) HUMALOG MIX
- Here is a diagrammatic representation of the approximate pharmacokinetic properties of various insulin formulations. Understanding the onset, peak and duration of action of insulin products is key for successful management of patients with diabetes.
- Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, the usual transition being vertical, from top to bottom (although horizontal movement within therapy stages is also possible, depending on the circumstances). The figure denotes relative glucose lowering efficacy, risk of hypoglycemia, effect on body weight, other side effects and approximate relative cost for each drug class. In most patients, begin with lifestyle changes; metformin monotherapy is added at, or soon after, diagnosis, unless there are contraindications.
- Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, the usual transition being vertical, from top to bottom (although horizontal movement within therapy stages is also possible, depending on the circumstances). The figure denotes relative glucose lowering efficacy, risk of hypoglycemia, effect on body weight, other side effects and approximate relative cost for each drug class. In most patients, begin with lifestyle changes; metformin monotherapy is added at, or soon after, diagnosis, unless there are contraindications.
- Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, the usual transition being vertical, from top to bottom (although horizontal movement within therapy stages is also possible, depending on the circumstances). The figure denotes relative glucose lowering efficacy, risk of hypoglycemia, effect on body weight, other side effects and approximate relative cost for each drug class. In most patients, begin with lifestyle changes; metformin monotherapy is added at, or soon after, diagnosis, unless there are contraindications.
- Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, the usual transition being vertical, from top to bottom (although horizontal movement within therapy stages is also possible, depending on the circumstances). The figure denotes relative glucose lowering efficacy, risk of hypoglycemia, effect on body weight, other side effects and approximate relative cost for each drug class. In most patients, begin with lifestyle changes; metformin monotherapy is added at, or soon after, diagnosis, unless there are contraindications.
- Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed, the usual transition being vertical, from top to bottom (although horizontal movement within therapy stages is also possible, depending on the circumstances). The figure denotes relative glucose lowering efficacy, risk of hypoglycemia, effect on body weight, other side effects and approximate relative cost for each drug class. In most patients, begin with lifestyle changes; metformin monotherapy is added at, or soon after, diagnosis, unless there are contraindications.
- RECODAR GA MAYOR 250, AL AZAR MAYOR DE 300, A1C MAYOR 9 %
- This slide shows glycemic targets for nonpregnant adults with diabetes from the 2015 ADA guidelines. Refer to source document for full recommendations, including level of evidence rating. American Diabetes Association. Standards of medical care in diabetes—2015. Diabetes Care. 2015;38(suppl 1):S1-S93. January 2014 This slide was created by Ashfield Healthcare Communications and was not associated with funding via an educational grant or a promotional/commercial interest.
- This is a depiction of the elements of decision-making used to determine the intensivenss of efforts to achieve glycemic targets. Greater concerns about a particular domain are represented by increasing height of the ramp. Thus, characteristics/predicaments towards the left justify more stringent efforts to lower HbA1c, whereas those towards the right are compatible with less stringent efforts. In general, most patients should be targeted to <7%, but as previously discussed, tighter targets may benefit younger patients whereas in older individuals, a more conservative approach is necessary. Where possible, such decisions should be made in conjunction with the patient, reflecting his or her preferences, needs and values. This ‘scale’ is not designed to be applied rigidly but to be used as a broad construct to help guide clinical decisions. (Adapted with permission from Ismail-Beigi et al, Ann Intern Med 2011;154:554-559.)
- Basal insulin alone is usually the optimal initial regimen, beginning at 0.1-0.2 U/kg body weight, depending on the degree of hyperglycemia. It is usually prescribed in conjunction with 1-2 non-insulin agents, although insulin secretagogues (sulfonylureas, meglitinides) are typically stopped once more complex regimens beyond basal insulin are utilized. In patients still not at target after basal insulin has been adequately titrated, and the patient is willing to take >1 injections, there are several options. First, consider GLP-1 receptor agonists (see Fig. 2). The combination of basal insulin + GLP-1RA is becoming well established after several studies confirmed its efficacy on par with more complex multi-dose insulin regimens, but with less hypoglycemia and with weight loss instead of weight gain. If such an approach is not possible or has been tried and proven unsuccessful, there are 3 possible advanced insulin regimens: Adding 1 injection of a rapid acting insulin analogue before the largest meal, Adding 2-3 injections of a rapid acting insulin analogue before 2-3 meals, or Using premixed insulin BID Each approach has its advantages and disadvantages. The figure describes the number of injections required at each stage, together with the relative complexity and flexibility. A fourth, less common method (not shown) is referred to as ‘self-mixed split’ and involves 2 injections of NPH mixed with regular human insulin (or mixed with a rapid acting insulin analogue), administered before breakfast and the evening meal. This is a more cost-effective approach, using human insulins in vials, and allows self-adjustment by the patient of the short/rapid-acting component, based on pre-meal blood glucose or anticipated carbohydrate intake (or both.) Once a strategy is initiated, titration of the insulin dose is important, with dose adjustments made based on the prevailing BG levels as reported by the patient. Comprehensive education regarding self-monitoring of BG, diet, exercise, and the avoidance of, and response to, hypoglycemia are critical in any patient on insulin therapy.
- Basal insulin alone is usually the optimal initial regimen, beginning at 0.1-0.2 U/kg body weight, depending on the degree of hyperglycemia. It is usually prescribed in conjunction with 1-2 non-insulin agents, although insulin secretagogues (sulfonylureas, meglitinides) are typically stopped once more complex regimens beyond basal insulin are utilized. In patients still not at target after basal insulin has been adequately titrated, and the patient is willing to take >1 injections, there are several options. First, consider GLP-1 receptor agonists (see Fig. 2). The combination of basal insulin + GLP-1RA is becoming well established after several studies confirmed its efficacy on par with more complex multi-dose insulin regimens, but with less hypoglycemia and with weight loss instead of weight gain. If such an approach is not possible or has been tried and proven unsuccessful, there are 3 possible advanced insulin regimens: Adding 1 injection of a rapid acting insulin analogue before the largest meal, Adding 2-3 injections of a rapid acting insulin analogue before 2-3 meals, or Using premixed insulin BID Each approach has its advantages and disadvantages. The figure describes the number of injections required at each stage, together with the relative complexity and flexibility. A fourth, less common method (not shown) is referred to as ‘self-mixed split’ and involves 2 injections of NPH mixed with regular human insulin (or mixed with a rapid acting insulin analogue), administered before breakfast and the evening meal. This is a more cost-effective approach, using human insulins in vials, and allows self-adjustment by the patient of the short/rapid-acting component, based on pre-meal blood glucose or anticipated carbohydrate intake (or both.) Once a strategy is initiated, titration of the insulin dose is important, with dose adjustments made based on the prevailing BG levels as reported by the patient. Comprehensive education regarding self-monitoring of BG, diet, exercise, and the avoidance of, and response to, hypoglycemia are critical in any patient on insulin therapy.
- ESPERAR AL MENOS 3 DIAS PARA LOS CAMBIOS ( ESPERAR ESTABILIZACION DEL ANALOGO)
- Insuf hepatica, renal, o cardiaca severa RECORDAR EL SLIDING SCALE DEL JOSLIN ( 1934) QUE SE USA EN PCTES HOSP, AGUDOS, PREQX NO SEGURO DE SU TX, HOSP EN GRAL, ETC. PARA PASAR DE ESTA FORMA DE TX A OTRA ( COMO BASAL/BOLUS) DEBEMOS REDUCIR 20 % DE LA DOSIS TOTAL A MENOS Q SEA DETEMIR
- This slide reviews recommended pharmacologic therapy for treating and managing type 2 diabetes from the 2015 ADA guidelines PREFERENCIA DEL PCTE. USO DE INSULINA EN EL DM2 DE INICIO RECIENTE YA QUE ES UNO DE LAS POCAS TX CON BENEFICIO DOCUMENTADO EN REDUCCION DE COMPLICACIONES A LARGO PLAZO. TB COMO METODO EFECTIVO PARA PRESERVACION DE LA FUNCION DE CELS BETA QUE ESTA ASOC A MEJOR CONTROL GLICEMICO A LARGO PLAZO. ADA PAG 473 Refer to source document for full recommendations, including level of evidence rating. American Diabetes Association. Standards of medical care in diabetes—2015. Diabetes Care. 2015;38(suppl 1):S1-S93. January 2014 Any pharmacologic agents discussed are approved for use in the United States by the U.S. Food and Drug Administration (FDA) unless otherwise noted. Consult individual prescribing information for approved uses outside of the United States. This slide was created by Ashfield Healthcare Communications and was not associated with funding via an educational grant or a promotional/commercial interest.
- ESTUDIO TREAT TO TARGET AGREGAR INSULINA BASAL A ADO CON A1C PROMEDIO 8.6% ALCANZARON AIC EL 60 % EN 24 SEMS ( UN GRUPO CON ANALOGOS, OTRO CON INSULINA) GRALMT AL INICIAR INSULINOTX
- AUMENTAR DE 10 AL 20% HASTA ALCANZAR META
- SE DEBE ELIMNAR LOS SECRETAGOGOS CON LOS BOLOS PRANDIALES PORQ SE SINERGIZA LAS HIPOGLICEMIAS, SE DEBEN DEJAR LOS INSULINOSENSIBILIZADORES YA Q LA INSULINORESISTENCIA PERSISTE MEJORA GLICEMIA POSTINGESTA REQUIERE MERIENDA 4HRS DESP DE INYECCION PARA EVITAR HIPOG TARDIAS
- RECORDAR ROTAR, TEMPERATURA Y MASAJE NPH 20-50% SE DEGRADA LOCALMENTE DETEMIR TIENE MENOR VARIABILIDAD INTRAINDIVIDUAL TB MEDICAMENTOS Y PATOLOGIAS ENDORINOL
- 2. Efecto anabolico 4. ATROFICA E HIPERTROFICA 3. AUMENTO DEL SODIO NEUROPATIA INSULINICA 6. DISMINUCION TRANSITORIA DE LA AGUDEZA VISUAL POR HIDRATAX DEL CRISTALINO