Irl B. Hirsch, M.D.University of Washington, Seattle.ppt
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1、,Irl B. Hirsch, M.D. University of Washington, Seattle,Maximizing MDI,First, Why is Mealtime Insulin So Important?,Raise your hand if you or your child take 1 shot daily Raise your hand if you or your child take 2 shots daily Raise your hand if you or your child take 3 shots daily Raise your hand if
2、 you or your child take 4 or more shots daily Raise your hand if you or your child wear an insulin pump,Why do so many physicians frown when they meet patients with type 1 diabetes on one or two daily injections?,0 1 2 3 4 5 6 7 8 9,24 20 16 12 8 4 0,Risk for Retinopathy in Conventional and Intensiv
3、e Treatment: Thinking Out of the Box,Conventional,Adapted from Diabetes 44:968-983, 1995,11%,Rate Per Patient Year,10%,9%,8%,7%,Time During Study (Years),Mean HbA1c,Risk for Retinopathy in Subgroups of the DCCT,What We Now Know,The more up AND down the more damage to cells through a mechanism called
4、 “oxidative stress” Most of this is based on very basic science data, but clinical studies now supporting this finding New goal of therapy: improve A1c AND reduce glucose variability,Does Intensive Therapy (Reduced GV) Preserve Beta Cell Function?,Adapted from: DCCT Study Group: Ann Intern Med. 1998
5、;128:517-523.,0,1,2,3,4,5,6,0.0,0.1,0.2,0.3,0.4,0.5,0.6,0.7,0.8,0.9,1.0,Years Post Enrollment,Number of evaluated patients in each treatment group,Intensive,Conventional,0,131,80,53,32,8,2,108,150,63,32,22,3,0,165,Conventional,therapy,Intensive therapy,Patient probabilityof maintaining C-peptide 2.0
6、,Could some of this preservation also be related to improvement in glucose variability?,Trends in Average # Injections/Day, 2001-2005,GfK Market Measures,U=678 W=3995,Implications?,Postprandial hyperglycemia and glycemic variability Ability to proceed to more sophisticated diabetes regimens What are
7、 the main barriers why so many receiving insulin do so poorly?,Basics of MDI: What to Consider,Who Does Best With MDI (or CSII!?),Minimum of 4-6 SMBG/day Carb counting or similar system for estimation of prandial insulin dosing Frequent SMBG can make up for poor carb estimation! Understanding basics
8、 of insulin therapy, knowing how to correct ac and pc hyperglycemia,POINT 1,The Physiological Insulin Profile,Adapted from Polonsky, et al. 1988.,10,20,30,Insulin (mU/l),0,40,50,60,70,Short-lived, rapidly generated prandial insulin peaks,Low, steady, basal insulin profile,Normal free insulin levels
9、from genuine data (mean),0600,0900,1200,1500,1800,2100,2400,0300,0600,Breakfast,Lunch,Dinner,POINT 2,Definitions for Flexible Diabetes Management,Basal insulin replacement that insulin required to suppress hepatic glucose production over night and between meals Bolus (prandial or mealtime) insulin r
10、eplacement that insulin required to dispose of glucose in muscle after eating,Standardization of Terminology,Definitions for Flexible Diabetes Management,Correction dose (also called a supplement) additional insulin for premeal hyperglycemia can also be between-meal hyperglycemia this insulin can on
11、ly be regular, lispro, aspart or glulisine (Humulin R, Novolin R, Humalog, Novalog, Apidra),Standardization of Terminology,4:00,16:00,20:00,24:00,4:00,Breakfast,Lunch,Dinner,8:00,12:00,8:00,Time,Glargine or Detemir,Lispro Lispro Lispro,Aspart, Aspart, Aspart,or,or,or,Plasma insulin,Basal/Bolus Treat
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