Insulin Intensification in Type 2 Diabetes (Nurses)

Research Review E-Learning Module

Begin

Insulin Intensification in Type 2 Diabetes (Nurses)

This Research Review E-Learning Module is intended for New Zealand GPs and nurses.  It provides information on New Zealand guidelines and glycaemic targets with a focus on insulin intensification, including reviewing patients on basal insulin, adding mealtime insulins and addressing patients concerns about insulin. It is based on the Research Review Educational Series publication ‘Insulin intensification in type 2 diabetes’.

Before starting the module please read the Research Review Educational Series publication, accessed through the link below:

CLICK HERE
to access the quiz source material
Educational Series - Insulin Intensification in Type 2 Diabetes

The PDF through the link above can be viewed on screen, saved and printed.

This E-Learning Module covers:

  • A brief overview of type 2 diabetes pathophysiology
  • New Zealand glycaemic targets and treatment guidelines
  • Rationale for insulin therapy in type 2 diabetes
  • Rationale for insulin intensification in type 2 diabetes
  • Insulin intensification protocols for type 2 diabetes
  • Clinical inertia in treatment of type 2 diabetes
  • Choice of insulin formulation in type 2 diabetes

Learning outcomes

After completing this module you should have an improved understanding of:

  • New Zealand glycaemic targets and treatment guidelines
  • The rationale for insulin therapy in type 2 diabetes
  • The rationale for insulin intensification in type 2 diabetes
  • Insulin intensification protocols for type 2 diabetes
  • Causes and consequences of clinical inertia in type 2 diabetes
  • Choosing and switching insulin formulations in type 2 diabetes

Contributing experts

Expert commentary is provided by endocrinologist Dr Brandon Orr-Walker. 

Module questions have been developed by Dr Chris Tofield, who works in primary care skin cancer treatment, is clinical advisor at Bay of Plenty District Health Board, and consultant to Research Review.

Accreditation

"Insulin Intensification in Type 2 Diabetes" E-Learning Module has been endorsed by The College of Nurses and has been approved for 1 hour professional development. Valid until 5 October 2022.
Further info

References

  1. American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2019. Diabetes Care. 2019;42:S13-s28.
  2. Monnier L, Lapinski H, Colette C. Contributions of fasting and postprandial plasma glucose increments to the overall diurnal hyperglycemia of type 2 diabetic patients: variations with increasing levels of HbA(1c). Diabetes Care. 2003;26:881-5.
  3. Monnier L, Colette C. Contributions of fasting and postprandial glucose to hemoglobin A1c. Endocr Pract. 2006;12 Suppl 1:42-6.
  4. Riddle MC. Basal glucose can be controlled, but the prandial problem persists-it’s the next target! Diabetes Care. 2017;40:291-300.
  5. LaSalle JR, Berria R. Insulin therapy in type 2 diabetes mellitus: a practical approach for primary care physicians and other health care professionals. J Am Osteopath Assoc. 2013;113:152-62.
  6. Ogurtsova K, da Rocha Fernandes JD, Huang Y, et al. IDF Diabetes Atlas: Global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract. 2017;128:40-50.
  7. New Zealand Guidelines Group. Guidance on the management of type 2 diabetes 2011 Wellington New Zealand Guidelines Group; 2011.
  8. American Diabetes Association. 9. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes-2019. Diabetes Care. 2019;42:S90-s102.
  9. Davies MJ, D’Alessio DA, Fradkin J, et al. Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2018;41:2669-701.
  10. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2015;38:140-9.
  11. Khunti K, Nikolajsen A, Thorsted BL, et al. Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin. Diabetes Obes Metab. 2016;18:401-9.
  12. Best Practice Advocacy Center New Zealand. Managing patients with type 2 diabetes: from lifestyle to insulin. 2015. https://bpac.org.nz/bpj/2015/december/diabetes.aspx. Accessed March 18, 2019.
  13. New Zealand Guidelines Group. New Zealand Primary Care Handbook 2012. https://www.health.govt.nz/system/files/documents/publications/nz-primary-care_handbook_2012.pdf. Accessed 1 March, 2018.
  14. Zafar A, Stone MA, Davies MJ, et al. Acknowledging and allocating responsibility for clinical inertia in the management of Type 2 diabetes in primary care: a qualitative study. Diabet Med. 2015;32:407-13.
  15. Paul SK, Klein K, Thorsted BL, et al. Delay in treatment intensification increases the risks of cardiovascular events in patients with type 2 diabetes. Cardiovasc Diabetol. 2015;14:100.
  16. Peyrot M, Barnett AH, Meneghini LF, et al. Insulin adherence behaviours and barriers in the multinational Global Attitudes of Patients and Physicians in Insulin Therapy study. Diabet Med. 2012;29:682-9.
  17. Fulcher G, Roberts A, Sinha A, et al. What happens when patients require intensification from basal insulin? A retrospective audit of clinical practice for the treatment of type 2 diabetes from four Australian centres. Diabetes Res Clin Pract. 2015;108:405-13.
  18. Marrett E, Zhang Q, Kanitscheider C, et al. Physician reasons for nonpharmacologic treatment of hyperglycemia in older patients newly diagnosed with type 2 diabetes mellitus. Diabetes Ther. 2012;3:5.
  19. Khunti K, Millar-Jones D. Clinical inertia to insulin initiation and intensification in the UK: a focused literature review. Prim Care Diabetes. 2017;11:3-12.
  20. Reach G, Pechtner V, Gentilella R, et al. Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus. Diabetes Metab. 2017;43:501-11.
  21. Khunti K, Wolden ML, Thorsted BL, et al. Clinical inertia in people with type 2 diabetes: a retrospective cohort study of more than 80,000 people. Diabetes Care. 2013;36:3411-7.
  22. Russell-Jones D, Pouwer F, Khunti K. Identification of barriers to insulin therapy and approaches to overcoming them. Diabetes Obes Metab. 2018;20:488-96.
  23. Esposito K, Chiodini P, Bellastella G, et al. Proportion of patients at HbA1c target <7% with eight classes of antidiabetic drugs in type 2 diabetes: systematic review of 218 randomized controlled trials with 78 945 patients. Diabetes Obes Metab. 2012;14:228-33.
  24. Hermansen K, Davies M, Derezinski T, et al. A 26-week, randomized, parallel, treat-to-target trial comparing insulin detemir with NPH insulin as add-on therapy to oral glucose-lowering drugs in insulinnaive people with type 2 diabetes. Diabetes Care. 2006;29:1269-74.
  25. Holman RR, Thorne KI, Farmer AJ, et al. Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes. N Engl J Med. 2007;357:1716-30.
  26. Calvert MJ, McManus RJ, Freemantle N. Management of type 2 diabetes with multiple oral hypoglycaemic agents or insulin in primary care: retrospective cohort study. Br J Gen Pract. 2007;57:455-60.
  27. Harris SB, Kapor J, Lank CN, et al. Clinical inertia in patients with T2DM requiring insulin in family practice. Can Fam Physician. 2010;56:e418-24.
  28. Blonde L, Meneghini L, Peng XV, et al. Probability of achieving glycemic control with basal insulin in patients with type 2 diabetes in real-world practice in the USA. Diabetes Ther. 2018;9:1347-58.
  29. Umpierrez GE, Skolnik N, Dex T, et al. When basal insulin is not enough: a dose-response relationship between insulin glargine 100 units/mL and glycaemic control. Diabetes Obes Metab. 2019.
  30. McMahon GT, Dluhy RG. Intention to treat - initiating insulin and the 4-T study. N Engl J Med. 2007;357:1759-61.
  31. Strain WD, Bluher M, Paldanius P. Clinical inertia in individualising care for diabetes: is there time to do more in type 2 diabetes? Diabetes Ther. 2014;5:347-54.
  32. Bailey CJ. Under-treatment of type 2 diabetes: causes and outcomes of clinical inertia. Int J Clin Pract. 2016;70:988-95.
  33. Ahren B. Avoiding hypoglycemia: a key to success for glucose-lowering therapy in type 2 diabetes. Vasc Health Risk Manag. 2013;9:155-63.
  34. Johnson EL, Frias JP, Trujillo JM. Anticipatory guidance in type 2 diabetes to improve disease management; next steps after basal insulin. Postgrad Med. 2018;130:365-74.
  35. Giugliano D, Chiodini P, Maiorino MI, et al. Intensification of insulin therapy with basal-bolus or premixed insulin regimens in type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Endocrine. 2016;51:417-28.
  36. The Royal Australian College of General Practitioners. General practice management of type 2 diabetes: 2016–18. East Melbourne, Vic: RACGP; 2016.
  37. Wu T, Betty B, Downie M, et al. Practical guidance on the use of premix insulin analogs in initiating, intensifying, or switching insulin regimens in type 2 diabetes. Diabetes Therapy. 2015;6:273-87.
  38. Meece J. Basal insulin intensification in patients with type 2 diabetes: a review. Diabetes Ther. 2018;9:877-90.
  39. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837-53.
  40. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359:1577-89.
  41. Rawshani A, Rawshani A, Franzen S, et al. Risk factors, mortality, and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2018;379:633-44.
  42. Mosenzon O, Raz I. Intensification of insulin therapy for type 2 diabetic patients in primary care: basalbolus regimen versus premix insulin analogs: when and for whom? Diabetes Care. 2013;36 Suppl 2:S212-8.
  43. Lavernia F. What options are available when considering starting insulin: premix or basal? Diabetes Technol Ther. 2011;13 Suppl 1:S85-92.
  44. Ministry of Health. New Zealand Primary Care Handbook 2012. 2012. https://www.health.govt.nz/system/files/documents/publications/nz-primary-care_handbook_2012.pdf. Accessed March 18, 2019.
  45. Rizza RA. Pathogenesis of fasting and postprandial hyperglycemia in type 2 diabetes: implications for therapy. Diabetes. 2010;59:2697-707.
  46. Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm - 2018 executive summary. Endocr Pract. 2018;24:91-120.
  47. Raccah D, Huet D, Dib A, et al. Review of basal-plus insulin regimen options for simpler insulin intensification in people with Type 2 diabetes mellitus. Diabet Med. 2017;34:1193-204.
  48. Garber AJ, Wahlen J, Wahl T, et al. Attainment of glycaemic goals in type 2 diabetes with once-, twice-, or thrice-daily dosing with biphasic insulin aspart 70/30 (The 1-2-3 study). Diabetes Obes Metab. 2006;8:58-66.
  49. Linjawi S, Lee BW, Tabak O, et al. A 32-week randomized comparison of stepwise insulin intensification of biphasic insulin aspart (BIAsp 30) versus basal-bolus therapy in insulin-naive patients with type 2 diabetes. Diabetes Ther. 2018;9:1-11.
  50. Wu T. Premixed insulin analogues: a new look at an established option. Diabetes and Primary Care Australia. 2016;1:129-33.
  51. Kalra S, Czupryniak L, Kilov G, et al. Expert opinion: patient selection for premixed insulin formulations in diabetes care. Diabetes Therapy. 2018;9:2185-99.
  52. Vora J, Cohen N, Evans M, et al. Intensifying insulin regimen after basal insulin optimization in adults with type 2 diabetes: a 24-week, randomized, open-label trial comparing insulin glargine plus insulin glulisine with biphasic insulin aspart (LanScape). Diabetes Obes Metab. 2015;17:1133-41.
  53. Deed G, Kilov G, Dunning T, et al. Use of 50/50 premixed insulin analogs in type 2 diabetes: systematic review and clinical recommendations. Diabetes Ther. 2017;8:1265-96.
‹Previous Next›