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Joslin's Insulin Deskbook: Designing And Initiating Insulin Treatment Programs. Boston, MA: Joslin Diabetes Center. 138 p.
This handbook helps health care providers understand the complexities of insulin therapy for their patients with diabetes. The book contains three key chapters from the larger Joslin's Diabetes Deskbook, which discuss insulin and its use in the clinical arena. The first chapter reviews the general principles of insulin therapy, covering endogenous insulin; insulin for exogenous therapy; insulin purity; insulin types, brands, and modes of delivery; insulin antibodies; insulin allergy; storage considerations; syringes and other injection devices; syringe preparation techniques; injection techniques; common mixtures; insulin pens; automatic injection aids and jet injectors; injection aids for people with low vision; injection sites; syringe reuse; and disposal of syringes. Chapter 2 walks readers through the design of a conventional insulin treatment program. Topics include the indications for insulin therapy in type 1 diabetes and in type 2 diabetes; the goals of insulin treatment; glucose monitoring programs for patients using insulin; the initiation of insulin therapy for type 1 diabetes, including choosing and designing an appropriate program; the initiation of insulin therapy for type 2 diabetes; the implications of insulin quality; specific insulin regimens; intensified conventional therapy; modifying the insulin treatment program; rebound hyperglycemia; and adjustment guidelines. The final chapter addresses physiologic insulin treatment programs, including patient selection, replacement therapy, estimating starting doses, descriptions of basal insulin patterns, preparing patients to start physiologic insulin, the health care providers most appropriate for managing replacement therapy, treatment adjustments, coping with hyperglycemia and hypoglycemia, weight gain and loss on physiologic insulin, insulin pump therapy, complications of insulin therapy, exercise and sick day adjustments, going off the insulin pump, and the role of pramlintide. Each chapter is illustrated with line drawings and tables.
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Long-Acting Insulin Analogs Versus Insulin Pump Therapy for the Treatment of Type 1 And Type 2 Diabetes. Diabetes Care. 31(Suppl 2): S140-S145. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reports on the use of long-acting insulin analogs versus insulin pump therapy for the treatment of patients with either type 1 or type 2 diabetes. The authors consider whether multiple daily injection (MDI) regimens based on new long-acting insulin analogs such as glargine and detemir have now replaced the need for continuous subcutaneous insulin infusion (CSII). They discuss hypoglycemia, elevated glycosylated hemoglobin (A1C ) levels and glycemic variability, the dawn phenomenon, the problems of poor control in type 2 diabetes, and CSII as a management strategy in type 2 diabetes. They conclude that long-acting insulin analogs have not yet replaced the need for insulin pump therapy in type 1 diabetes, and CSII is the best current treatment option for some people with type 1 diabetes. In type 2 diabetes, CSII and MDI produce similar glycemic control, although there is little research on the use of MDI based on long-acting analogs compared with insulin pumps. 4 figures. 2 tables. 47 references.
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Managing Preexisting Diabetes for Pregnancy: Summary of Evidence And Consensus Recommendations for Care. Diabetes Care. 31(5): 1060-1079. May 2008.
This article presents consensus panel recommendations for the medical care of pregnant women with preexisting diabetes, including type 1 and type 2 diabetes. The document is designed to help clinicians deal with the broad spectrum of problems that arise in the management of diabetes before and during pregnancy, and to prepare women with diabetes for treatment that may reduce complications in the years after pregnancy. Guidelines are presented in two sections. The first section addresses managing preexisting diabetes for pregnancy, including the organization of preconception and pregnancy care, initial evaluation, glycemic control, perinatal outcome and glycemic goals, assessment of metabolic control, medical nutrition therapy, insulin therapy, oral antihyperglycemic agents for type 2 diabetes, physical activity and exercise, and behavioral therapy. The second section covers the management of diabetes complications, including diabetic ketoacidosis (DKA), maternal hypoglycemia, thyroid disorders, management of cardiovascular risk factors, screening for cardiovascular disease (CVD), hypertension, diabetic nephropathy, diabetic retinopathy, and diabetic neuropathies. Practical suggestions, including recommended laboratory values and goals, are highlighted. The recommendations for diagnostic and therapeutic actions are based on a grading system adapted by the American Diabetes Association that was used to clarify and codify the research evidence available.
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Nuts And Bolts of Achieving End Points with Real-Time Continuous Glucose Monitoring. Diabetes Care. 31(Suppl 2): S146-S149. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reviews the basics of using real-time continuous glucose monitoring (RT-CGM) as a component of comprehensive diabetes management. The author cautions that RT-CGM is most appropriate in patients who are skilled in diabetes self-management. Training issues include the implications of the physiologic lag between interstitial and capillary blood glucose levels, as well as the increased risk among RT-CGM users for hypoglycemia related to blind postprandial bolusing. Patients must understand the importance of calibrating their equipment during steady-state conditions to improve sensor accuracy. In addition, they need to use fingerstick measurements for treatment decision making when the glucose level is changed rapidly. The author notes that consideration of “insulin on board” and the impact of the glycemic index of different foodstuffs on postprandial glucose patterns can help minimize the risk for hypoglycemia from supplemental boluses taken to correct postprandial hyperglycemia. The article includes colorful figures that help readers learn to translate the data received from RT-CGM. 4 figures. 9 references.
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Physiologic Insulin Treatment Programs. IN: Beaser, R.S. Joslin's Insulin Deskbook: Designing And Initiating Insulin Treatment Programs. Boston, MA: Joslin Diabetes Center. pp 77-134.
This chapter is from a handbook that helps health care providers understand the complexities of insulin therapy for their patients with diabetes. The author addresses physiologic insulin treatment programs, including patient selection, replacement therapy, estimating starting doses, descriptions of basal insulin patterns, preparing patients to start physiologic insulin, the health care providers most appropriate for managing replacement therapy, treatment adjustments, coping with hyperglycemia and hypoglycemia, weight gain and loss on physiologic insulin, insulin pump therapy, complications of insulin therapy, exercise and sick day adjustments, going off the insulin pump, and the role of pramlintide. The author concludes by cautioning that developing a proper routine for, and method of, physiologic insulin replacement therapy takes time and effort. Developing a routine requires a major, long-term commitment on the part of the patient and medical and educational support from a skilled health care team. The chapter is illustrated with line drawings and tables. Readers are referred to the more comprehensive Joslin's Diabetes Deskbook: A Guide for Primary Care Providers for more information. 8 figures. 1 table.
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Prevention of Hypoglycemia While Achieving Good Glycemic Control in Type 1 Diabetes: The Role of Insulin Analogs. Diabetes Care. 31(Suppl 2): S113-S120. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the prevention of hypoglycemia while achieving good glycemic control in patients with type 1 diabetes. The authors focus on the role of insulin analogs as a tool to achieve good glycemic control and prevent hypoglycemia. Topics include the physiology of plasma glucose homeostasis, a definition of hypoglycemia, the frequency of hypoglycemia, normal responses to hypoglycemia and their pathophysiology in diabetes, antecedent hypoglycemia as a primary cause of hypoglycemia unawareness, the mechanisms of hypoglycemia unawareness, the benefits of insulin analogs versus human nonmodified insulin, and regimens of multiple daily injections and continuous subcutaneous insulin infusion (CSII). Now that soluble long-acting insulin analogs are available, multiple daily injections are no longer considered inferior to CSII in terms of A1C and frequency of hypoglycemia. The authors conclude that, when combined with appropriate patient education and motivation of the subjects with type 1 diabetes, insulin regimens based on insulin analogs—either multiple daily injections or CSII—can successfully achieve appropriate glycemic targets, thus protecting against the risk of long-term complications; prevent hypoglycemia unawareness; and improve quality of life. 3 figures. 76 references.
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Standards of Medical Care in Diabetes: 2008. Diabetes Care. 31(Suppl 1): S12-S54. January 2008.
This section is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. Targets that are desirable for most patients with diabetes are provided. The recommendations included are screening, diagnostic, and therapeutic actions known or believed to favorably affect health outcomes of patients with diabetes. For each recommendation, the ADA has assigned a letter grade that represents the level of supporting evidence. Standards of care are categorized into 11 sections: classification and diagnosis; testing for pre-diabetes and diabetes in asymptomatic patients; detection and diagnosis of gestational diabetes mellitus (GDM); the prevention or delay of type 2 diabetes; diabetes care, including medical nutrition therapy (MNT) and diabetes self-management education (DSME); the prevention and management of diabetes complications, including hypertension, cardiovascular disease, dyslipidemia, nephropathy, retinopathy, neuropathy, and foot care; diabetes care in specific populations, including children, adolescents, and older adults; diabetes care in specific settings, such as hospitals, schools, daycare settings, diabetes camps, and correctional institutions; hypoglycemia and employment/licensure; third-party reimbursement for diabetes care, self-management education, and supplies; and strategies for improving diabetes care. 15 tables. 332 references.
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Treatment of Type 2 Diabetes with Combined Therapy: What Are the Pros and Cons?. Diabetes Care. 31(Suppl 2): S131-S135. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the advantages and limitations of the treatment of type 2 diabetes with combination therapy. The authors recommend a stepwise approach for the treatment of type 2 diabetes, tailored according to the natural course of the disease, including adding insulin when hypoglycemic oral agents fail. They stress that treatment with insulin alone should eventually be considered in a relevant number of cases. Insulin can result in protective effects on beta-cell survival and function, resulting in more stable metabolic control. In comparison, treatment with most insulin secretagogues has been associated with increased beta-cell apoptosis, reduced responsiveness to high glucose, and impairment of myocardial function during ischemic conditions. Insulin treatment, particularly with rapid-acting analogs, has been demonstrated to successfully control postprandial hyperglycemia. The authors voice a final concern about combination regimens in the evidence that polypharmacy can reduce patient compliance to the treatment regimen. 56 references.
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Understanding Insulin And Amylin. 3rd ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).
This DVD program reviews how insulin works in the body and how it can be used to help people with diabetes keep their blood glucose levels in a healthy range. The program introduces amylin, another pancreatic hormone, and explains how taking the drug pramlintide (Symlin) can help people who use insulin maintain greater control of their blood glucose levels. Other topics include insulin and amylin safety, storage, recordkeeping, hypoglycemia, and how to handle sick days. Viewers are reminded of the importance of a comprehensive self-management plan for keeping diabetes under control. The video depicts a variety of people who share their experiences with diabetes management, insulin use, and pramlintide use. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.
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Understanding Insulin. 3rd ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).
This DVD program describes insulin and how it is used by people with diabetes to help keep their blood glucose levels in a healthy range. The program discusses insulin’s mechanism of action and the onset, peak, and duration of different types of insulin. Other topics include insulin safety, storage recommendations, hypoglycemia, and coping with sick days. Viewers are reminded of the importance of a comprehensive self-management plan for keeping diabetes under control. The video depicts a variety of people who share their experiences with diabetes management and insulin use. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.
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