Initiating insulin in type 2 diabetes in primary care,como hacer remedios caseros para la diabetes,diabetes insipidus breakthrough,traitement diabete type 2 2013 3d - Videos Download


Intensive therapy to achieve glycemic target has become the standard of care in management of patients with type 2 diabetes mellitus (DM). The last two decades have seen an explosive increase in the number of people with diabetes globally due to changes in lifestyle and genetic predisposition 1,2 Patients with diabetes mellitus have an impaired capacity to regulate blood glucose.
The percentage of glycated haemoglobin type A1c (% HbA1c) represents a 2a€“3 month average of overall blood glucose control, which is a reflection of both fasting and prandial blood glucose. The aim of this review is to consider the evidence for the premix analogue insulin, biphasic insulin aspart 30 (BIAsp 30, NovoMixA® 30, Novo Nordisk), as a viable treatment option when initiating insulin in patients with type 2 diabetes.
Insulin injections are the standard treatment for type 1 diabetes, and often need to be initiated in the later stages of type 2 diabetes. The relative contributions of fasting and postprandial blood glucose to HbA1c and the associated risks have been much studied and debated.
The role of postprandial BG as an independent contributor to diabetes complications and the need to target it for prevention of cardiovascular events are a matter of intense debate.In Diabetes Intervention Study (DIS), plasma glucose after breakfast, but not fasting plasma glucose, has been found to predict myocardial infarction and mortality in newly diagnosed type 2 diabetic patients15. To mimic the a€?normala€™ prandial release of insulin and control blood glucose excursions, short-acting insulin injected subcutaneously must be absorbed quickly. In recent years, analogues of human insulin have been developed by introducing small changes to the amino acid sequence that alter the kinetic profile of the insulin, while retaining its metabolic actions.22 One of these analogues, insulin aspart, has aspartic acid inserted at position B28 in place of the usual proline (Fig 1). The development of insulin aspart has been followed by the addition of a novel premix analogue insulin: dual-release or a€?biphasica€™ insulin aspart (BIAsp 30, NovoMixA® 30, Novo Nordisk). When combined with protamine-crystallised insulin aspart in BIAsp 30, insulin aspart retains its pharmacological profiles.25 This has been demonstrated in several studies comparing the pharmacokinetic and pharmacodynamic properties of BIAsp 30 with those of biphasic human insulin (BHI 30, consisting of 30% soluble human insulin and 70% neutral protamine Hagedorn), intermediate-acting insulin and other insulin analogues (Table 1). Boehm et al compared postprandial and overall glycemic control in a population of patients with type I or type II diabetes (n=294) treated with BIAsp 30 or human insulin 30 in a randomised, open label parallel group study. Raskin et al.33 compared twice-daily BIAsp 30 with once-daily IGlarg in insulin-naA?ve patients with type 2 diabetes who were poorly controlled on OADs (only continuation with pioglitazone was allowed during the treatment phase).
The first insulin treatment for patients with type 2 diabetes is often a basal insulin in a once- or twice-daily regimen, initially in combination with an OAD. In this 48-week, open-label trial of 100 type 2 patients poorly controlled on OADs (with or without once-daily basal insulin), all patients were started on once-daily BIAsp 30 before dinner (phase 1). Bebakar et al 200741, randomised 192 type 2 diabetic patients in a 2 : 1 ratio either to receive BIAsp30 or OAD only. Therefore, it may be appropriate to commence with one injection at dinnertime (or the largest meal) and add additional injections i.e intensify therapy to twice and thrice daily35-38, if patient has not achieved the target blood glucose control. To reduce the risk of long-term complications of diabetes such as neuropathy, retinopathy and atherosclerosis, blood glucose must be tightly controlled.7,9,10 However, there has to be a balance between achieving good glycaemic control and avoiding hypoglycaemia.
Increasing the dosing frequency of BIAsp 30 does not necessarily lead to a greater risk of hypoglycaemia36 . A largest clinical experience observational study (PRESENT) with BIAsp 30 was done to provide complementary data to support the clinical trial data already existing on BIAsp 30 treatment in type 2 diabetes.
A user-friendly insulin delivery system may improve patient compliance, and consequently improve glycaemic control.48 It is important, therefore, to ensure that the delivery system is simple, easy to operate and discreet. Patients generally prefer a pen-type delivery device to the conventional vial and syringe, for improved quality of life.48a€“51 BIAsp 30 uses the FlexPenA® delivery system, which incorporates a number of features designed to maximise user confidence, such as an audible a€?clicka€™ when dialling-up the dose.
Insulin analogues are chemically modified to alter their pharmacokinetic profiles, without compromising their metabolic actions.
This better glycemic control has been achieved with significantly less number of hypoglycaemic events (both major and nocturnal) in comparison to other regimens, which have not increased despite intensification with BIAsp 30.
Wright A, Felix Burden AC, Paisey RB, Cull CA, Holman RR, for the UK Prospective Diabetes Study Group.
You will receive an email whenever this article is corrected, updated, or cited in the literature. Abstract Progressive hyperglycemia is a characteristic of type 2 diabetes mellitus (T2DM) that poses a challenge to maintaining optimal glycemic control.
Approximately 26 million Americans were living with diabetes in 2010.1 Data from a 2012 report2 indicated a substantial increase in the prevalence of diagnosed diabetes mellitus throughout the 50 states, Washington, DC, and Puerto Rico during a 16-year period (1995-2010), with the age-adjusted prevalence increasing by more than 50% in most states and by 100% or greater in 18 states. Figure 2.Proportion of 18-year-olds in the United States who will develop diabetes, by sex, body mass index (BMI), and period, as determined by the American Diabetes Association. Like many chronic conditions, type 2 diabetes mellitus (T2DM) has a prolonged asymptomatic phase. Type 2 diabetes mellitus is a disease of dysfunctional glucose metabolism that is characterized by worsening hyperglycemia and a loss of response to therapy over time. In many patients, the metabolic abnormalities associated with persistent hyperglycemia lead to complications such as vision loss, renal failure, and neuropathy.
The goal of T2DM therapy is to reestablish normoglycemia and avoid both the excesses of hyperglycemia and the dangers associated with hypoglycemia.
The abovementioned OS markers were measured in 50 subjects for each of the following groups: type 2 diabetes mellitus (DM) diabetic foot ulcer (Care and treatment) Oxidative stress (Complications and side effects) Oxidative stress (Research) Type 2 diabetes (Risk factors) Type 2 diabetes one of the most important things you can do to avoid diabetes is to change your diet and increase your exercise.
Type B ultraviolet light can relieve itching but can cause sunburn-like effects and increases the risk of Most people will have some warning that their blood glucose levels are too low which Symptoms usually occur when blood sugar levels drop to between 3 and 4 millimoles per litre (mmol). If high blood glucose and ketones are not premixed insulins make it impossible to increase or decrease medicare glucose monitor local coverage determination 1 causes hypoglycemia type the dose of one insulin type without also changing Side Effects Of Undiagnosed Diabetes Type 2 Abs Statistics the other.
This approach has been predicted to reduce the occurrence of long term diabetic complication and can be achieved only with early and aggressive use of insulin. In type 1 diabetes, autoimmune destruction of pancreatic beta cells results in a diminished and rapidly absent ability to produce insulin. However, many treatment options exist for patients with type 2 DM, including dietary changes, physical activity, oral antidiabetic drugs (OADs) and the new injectable medications (eg, pramlintide, exenatide). Basal bolus therapy with multiple daily injections or an insulin pump is the most physiological approach to insulin replacement therapy.
During the early stages of type 2 diabetes, the first-line treatment comprises altered diet and exercise, although oral antidiabetic drugs (OADs) are usually soon required to stimulate pancreatic insulin secretion (e.g. The DECODE Study Group, by analyzing both fasting and postchallenge glucose concentrations from 14 prospective European cohorts also found the strong correlation between cardiovascular mortality and post prandial glycemia16. This combines rapid-acting soluble insulin aspart (30%), which addresses prandial insulin needs, with protamine-crystallised insulin aspart (70%), which has a delayed action of intermediate duration, for between meal and nocturnal insulin requirements.
The study was initially planned for 12 weeks then serially extended for one, two and four years.31,34 The HbA1c-lowering effect of BIAsp 30 is equal to that of BHI 30 (twice-daily in patients with type 1 or type 2 diabetes) but treatment with BIAsp 30 resulted in a more favourable degree of postprandial blood glucose control than BHI 30.
In type 1 patients37 significant improvement in long term glycemic control was found, without increasing the risk of hypoglycaemia and there was minimum inter day variation in BIAsp 30 pharmacokinetics. Patients switched to 2 or 3 daily injections after 3, 6 or 9 months if targetglycaemic goals were not reached. This can enable patients to be managed with single premixed insulin analogue throughout the course of their disease. In a recent study, 308 insulin-naA?ve type 2 patients poorly controlled on OADs were randomised to BIAsp 30 thrice-daily, BIAsp 30 twice-daily plus metformin, or optimised OAD therapy.


This was a 6-month, prospective, multinational, multiethnic observational study involving 21,977 patients from 13 countries. However, efficacy is not significantly reduced when the injection time is delayed relative to the start of a meal.46 When administered immediately before a meal, BIAsp 30 produces a lower 5-h postprandial serum glucose profile (AUCsg) than that of BHI 30 when given either 15 minutes before or immediately before a meal. Responses showed the FlexPenA® to be superior for ease of use, utility and convenience, and confidence in optimal diabetes management. BIAsp 30, a premix insulin analogue is a simple regimen for insulin initiation in patients with type 2 diabetes. Its availability in the patient-friendly FlexPenA® and meal time flexibility adds to the convenience of the patient resulting in better compliance to regimen.
A glimpse of the a€?natural historya€™ of established type 2 (non-insulin dependent) diabetes mellitus from the spectrum of metabolic and hormonal responses to a mixed meal at the time of diagnosis. High blood glucose concentration is a risk factor for mortality in middle-aged nondiabetic men. Glucose tolerance and mortality: comparison of WHO and American Diabetes Association diagnostic criteria.
The absence of a glycemic threshold for the development of long-term complications: the perspective of the Diabetes Control and Complications Trial.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Sulfonylurea inadequacy: efficacy of addition of insulin over 6 years in patients with type 2 diabetes in the UK Prospective Diabetes Study (UKPDS 57).
United Kingdom Prospective Diabetes Study 17: a 9-year update of a randomized, controlled trial on the effect of improved metabolic control on complications in non-insulin-dependent diabetes mellitus. 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). Risk factors for myocardial infarction and death in newly detected NIDDM: the diabetes intervention study, 11-year follow-up. Comparative pharmacokinetics of the novel rapid-acting insulin analogue, insulin aspart, in healthy volunteers. Pharmacokinetics and pharmacodynamics of a premixed formulation of soluble and protamine-retarded insulin aspart.
Postprandial glycemic control with biphasic insulin aspart in patients with type 1 diabetes.
Improved postprandial glycemic control with biphasic insulin aspart relative to biphasic insulin lispro and biphasic human insulin in patients with type 2 diabetes. Comparison of the pharmacokinetics and pharmacodynamics of biphasic insulin aspart and insulin glargine in people with type 2 diabetes.
Twice-daily biphasic insulin aspart 30 vs biphasic human insulin 30: a double-blind crossover study in adults with type 2 diabetes mellitus.
Twice daily biphasic insulin aspart improves postprandial glycaemic control more effectively than twice daily NPH insulin, with low risk of hypoglycaemia, in patients with type 2 diabetes.
Multiple mealtime administration of biphasic insulin aspart 30 versus traditional basal-bolus human insulin treatment in patients with type 1 diabetes. Biphasic Insulin Aspart Given Thrice Daily is as Efficacious as a Basal-Bolus Insulin Regimen with Four Daily Injections A Randomised Open-Label Parallel Group Four Months Comparison in Patients with Type 2 Diabetes. Effect of BIAsp30 in combination with oral hypoglycaemic agents on glycemic control in nonobese patients with type 2 diabetes mellitus. Adding biphasic insulin aspart 30 once or twice daily is more efficacious than optimizing oral antidiabetic treatment in patients with type 2 diabetes Diabetes Obes Metab.
Insulin treated patients with type 2 diabetes mellitus have higher rates of nocturnal than day time hypoglycaemia: continuous blood glucose monitoring (CBGM) run-in data from the REACH study.
Patients with type 2 diabetes mellitus have lower rates of nocturnal hypoglycaemia on biphasic insulin aspart (BIAsp 30) than on biphasic human insulin-30 (BHI30): data from the REACH study.
Biphasic insulin aspart 30 treatment improves glycaemic control in patients with type 2 diabetes in a clinical practice setting: experience from the PRESENT study. Transferring type 2 diabetes patients with uncontrolled glycaemia from biphasic human insulin to biphasic insulin aspart 30: experiences from the PRESENT study. Postprandial versus preprandial dosing of biphasic insulin aspart in elderly type 2 diabetes patients. Insulin-pen treatment, quality of life and metabolic control: retrospective intra-group evaluations. Comparative evaluation of FlexPena„?, a new prefilled insulin delivery system, among patients and healthcare professionals. Randomized, multinational, open-label, 2-period, crossover comparison of biphasic insulin aspart 30 and biphasic insulin lispro 25 and pen devices in adult patients with type 2 diabetes mellitus. Identifying and Addressing Barriers to Insulin Acceptance and Adherence in Patients With Type 2 Diabetes Mellitus.
Achieving glycemic control early in the course of disease can minimize or prevent serious complications. Reprinted with permission from the American Diabetes Association, from Cunningham SA, et al. Even after T2DM has been diagnosed, symptoms (eg, fatigue, weight loss, increased thirst, frequent urination, blurred vision) are nonspecific rather than acute. Insulin resistance is an early factor in the pathophysiologic profile of T2DM, which may be associated with unhealthy lifestyle choices and weight gain.
Moreover, T2DM is the leading cause of kidney failure, non-traumatic lower-limb amputations, and new cases of blindness among adults in the United States, and it is a major cause of heart disease and stroke.1 It is imperative that increased measures are taken to improve rates of glycemic control in patients with T2DM. Side Effects Of Undiagnosed Diabetes Type diabetic gluten free cake recipes glucose monitor costco 2 Abs Statistics diabetes Wiki is a place where people with diabetes can share their personal stories and build a database of helpful information. While many of the signs and symptoms of diabetes can also be related to other causes testing for diabetes is very easy and the Type 2 diabetes can be prevented with lifestyle changes and weight control. The most acceptable choice will be a regimen which mimics physiologic pattern of insulin secretion from healthy pancreatic I?-cells. With type 2 diabetes, the disease is progressive, typically starting with peripheral insulin resistance.
UKPDS 57 has shown that majority of patients with type II diabetes mellitus also eventually require insulin11. However, regimen complexity, patient preference, and other practical factors may dictate the treatment option chosen. Also Cavalot et al 2006, in 529 type 2 diabetic patients concluded that postprandial, but not fasting, blood glucose is an independent risk factor for cardiovascular events in type 2 diabetes, with a stronger predictive power in women than in men, suggesting that more attention should be paid to postprandial hyperglycemia, particularly in women17. After completion of 3 month trial, the study patients with type 2 diabetes (n=125) were allowed to continue treatment in an open a€“ label fashion for an additional 21 months. The patients were either insulin-naA?ve or previously treated with insulin glargine or NPH.35 Furthermore, for patients who do not reach HbA1c targets on once- or twice-daily BIAsp 30, intensification to thrice-daily administration has been shown to be effective 35,36.


After 16 weeks of therapy, those patients that had not attained an HbA1c a‰¤6.5% had their dosing frequency increased to twice-daily (phase 2). Once daily start with a premix insulin is simple and better as it takes care of both prandial and basal insulin requirements.
Although improvement in glycaemic control for all treatment groups was associated with a slight increase in minor hypoglycaemia (no significant difference between BIAsp 30 twice- or thrice-daily), no major hypoglycaemia was reported in any treatment group during the 16 weeks of the trial36. These findings concurred with those from clinical trials, and showed that the use of BIAsp 30 treatment in clinical practice was both effective and safe in patients with type 2 diabetes mellitus who were considered to be poorly controlled on prior diabetes therapy45. If the injection of BIAsp 30 is delayed 15 minutes after the start of a meal, the resulting AUCsg is similar to that of BHI 30 injected either immediately before or 15 minutes before a meal.47 BIAsp 30 therefore offers the patient a degree of flexibility in terms of injection timing, allowing individual adjustment for meal size and content without significantly affecting efficacy.
It can be started once daily in combination with oral antidiabetics and then can be intensified to twice and thrice daily dosing. Given the importance of post prandial glycemic control along with simplicity of dosing regimen, BIAsp 30 is an obvious choice for initiating insulin therapy and reducing the long term morbidity and mortality in patients with type 2 diabetes. 20-year follow-up in the Whitehall Study, the Paris Prospective Study, and the Helsinki Policemen Study. Efficacy of addition of insulin over 6 years in patients with type 2 diabetes in the UK Prospective Diabetes Study (UKPDS 57).
Initiating insulin therapy in type 2 diabetes: a comparison of biphasic and basal insulin analogs. Most patients with T2DM eventually require insulin replacement therapy to attain and preserve satisfactory glucose control. These characteristics of T2DM contribute to the challenges of achieving early diagnosis, intervention, and active follow-up.
In the early disease state, the first phase of the prandial insulin response is lost, resulting in hyperglycaemia. Thus, aggressive therapy is becoming the standard of care to prevent long-term complications of DM.
Premix insulin analogue preparations are composed of a single type of insulin that is modified to have dual-action PK profiles (a short-acting peak and a longer basal release) and are biphasic rather than truly premixed. Thus, there is ample evidence which demands a better PPG control along with FPG, making premix insulin a desirable alternative regimen for targeted glycemic control. This was then increased to thrice-daily (phase 3) after 32 weeks for patients that had not achieved this target. The finding of 41% patients achieving target HbA1c of < 7% with BIAsp 30 in Garber study35 has been corroborated by many other studies.
Similarly Garber et al35 2006 found that inspite of increament in dasage from once to thrice daily, there were no major nocturnal hypoglycaemic events, and none of the patient withdrew from the study due to any hypoglycaemic event. Being more physiological, it provides a significantly better postprandial blood glucose and HbA1c control compared with BHI 30, biphasic insulin lispro 25, NPH and insulin glargine. Postprandial Blood Glucose Is a Stronger Predictor of Cardiovascular Events Than Fasting Blood Glucose in Type 2 Diabetes Mellitus, Particularly in Women: Lessons from the San Luigi Gonzaga Diabetes Study. For decades, the use of insulin to address the primary defect of T2DM has been a cornerstone of diabetes therapy.
Unlike patients with acute diseases, patients with diabetes mellitus who have few or no symptoms may not visit a physician.
Insulin release declines progressively in patients with T2DM and begins well before diagnosis. Diabetics who exercise before eakfast usually have a lower Side Effects Of Undiagnosed Diabetes Type 2 Abs Statistics Side Effects Of Undiagnosed Diabetes Type 2 Abs Statistics chance of becoming hypoglycemic. However, considerable variability has been found in onset and duration of action, as well as peak insulin levels, with premixed human insulin.Therefore, premixed insulin analogues have been developed to more closely mimic physiological endogenous insulin secretion and meet the needs of patients. A compensatory mechanism may be initiated in the form of increased insulin production during the second stage of the prandial insulin response.
Premixed insulin is always an acceptable option as it provides both basal and prandial coverage in one injection.
The cumulative proportions of patients (per protocol population) that achieved HbA1c a‰¤6.5% was 24%, 66% and 77% for once-, twice- and thrice-daily BIAsp 30, respectively35.
Insulin is indicated for patients with T2DM presenting with clinically significant hyperglycemia, and it is mandatory for patients exhibiting signs of catabolism. In fact, studies suggest that 50% to 80% of ?-cell function is lost by the time of diagnosis.5-7 The decline continues as the disease progresses, from impaired fasting glucose levels and impaired glucose tolerance to full-blown T2DM, and it continues to progress until the patient becomes increasingly insulin deficient. BIAsp 30 is a new premix analogue containing 30 % insulin aspart (rapid acting component) and 70% protaminated insulin aspart (intermediate acting component).
These data show that the variable dosing regimen with BIAsp 30 enables patients to start and stay on premix analogue, allowing treatment intensity to keep pace with disease progression. Insulin should be considered for patients in whom hyperglycemia persists despite attempts to control the condition through diet and exercise modifications and the use of noninsulin therapies.
The higher the sugar and starch content of a food After many years with diabetes some sell your diabetic supplies type 1 define type 2 patients lose warning symptoms of low blood sugar.
It has been shown to have better post prandial and overall glycemic control than premix human insulin (BHI 30), lispro Mix 25 or neutral protamine Hagedorn (NPH) & insulin glargine in several randomised control trials. The inability of beta cells to maintain this over-production of insulin results in a reduced prandial insulin response and subsequent postprandial hyperglycaemia,3.4 a pre-diabetic state called impaired glucose tolerance (IGT). Many physicians delay initiation of insulin until absolutely necessary, sometimes overestimating patient concerns about its use. Monitor the response to an insulin dose – especially at the start of treatment or after a change in insulin dose. Moreover, compared with BHI 30, the reduction in mean daily blood glucose with BIAsp 30 is achieved with fewer hypoglycaemic events.
Modern insulin analogs, treatment regimens, and delivery devices make insulin more user friendly, and physicians can promote patient acceptance of insulin by reviewing the benefits of controlled glycated hemoglobin levels and addressing patient concerns. Significant proportion of patients have achieved glycosylated hemoglobin target of <7%, even with once daily start in combinations with OADs. Thus it has proved to be a better choice for insulin initiation in type 2 diabetic patients.
Also, therapy with BIAsp 30 can be intensified to twice and thrice daily in patients not achieving the targeted glycemic control. Its unique pharmacokinetic profile offers patients flexibility with regard to injection time, as efficacy is maintained even if injection is delayed 15 minutes after the start of a meal.



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