This page contains a Flash digital edition of a book.
CLINICAL: DIABETES Mags Bannister


MSc BSc (Hons) RGN RM Diabetes Nurse Consultant


Bradford Teaching Hospitals Foundation Trust and Bradford University


Insulin-requiring type 2 diabetes:


addressing the challenge The initiation of insulin therapy presents challenges to both the healthcare professional and the individual with type 2 diabetes


T


ype 2 diabetes has reached epidemic proportions worldwide a nd has doubled in prevalence with the UK in the last 15 years. Currently 2.9 million people are diagnosed with diabetes in the UK, of which 90% will have type 2 diabetes.1


The


diagnosis and initial management of the vast majority of these individuals will be the responsibil-


ity of the practice diabetes team up, until the need for injectable therapy - in particular insulin - is identified. National guidance actively encourages the prompt introduction of insulin as third-line therapy when glycaemic control cannot be achieved with maximum dual oral therapy.2 Type 2 diabetes develops as a result of two underlying


problems; insulin resistance and beta-cell failure. For the fast majority of patients diagnosed with type 2 diabetes, especially if overweight, the primary presenting problem is insulin resistance.


‘For the fast majority of patients diagnosed with type 2 diabetes, especially if overweight, the primary presenting problem is insulin resistance’


Therefore the initial focus will be to improve an individual’s insulin sensitivity by focusing on lifestyle changes, such as increased physical activity and healthy eating, which have a positive impact on insulin resistance, especially if they result in some degree of weight loss. Unfortunately type 2 diabetes is a progressive condition and with time the high demand for insulin caused by the underlying insulin resistance results in beta-cell failure and a decline in the body’s ability to produce insulin. The resulting fall in circulating insulin means that many oral therapies especially those that require the presence of insulin to be effective struggle to maintain the level of glycaemic control previously achieved.


WHEN SHOULD INSULIN THERAPY BE CONSIDERED IN TYPE 2 DIABETES? Whether an individual’s glycaemic control is being successfully managed, or their current treatment is assessed, by reviewing their HbA1c (glycosolated haemoglobin) against an agreed individual- ised target. For the vast majority of individuals with type 2 diabetes treated with oral therapy, the target will be 48-59 mmol/mol (6.5-7.5%). If an individual’s HbA1c is above 59 mmol/mol and they are on the maximum tolerated dose of two or more oral therapies, then the need for insulin therapy should be explored. This however should not be the first time the potential need for insulin therapy is mentioned to the patient. The possible need for insulin therapy in the management of type 2 diabetes should be included in the education delivered at the time of diagnosis, when the progressive nature of the condition is explored, and each time treatment options or changes are discussed.


WHAT DIFFERENCE WILL INSULIN MAKE? In the management of type 2 diabetes, insulin is commenced to supplement the individual’s own circulating insulin and to support the action of the oral medications it will be used in combination with. The addition of insulin to a treatment package should result in an improved feeling of wellbeing, improved self blood glucose monitoring (SBGM) results and lower HbA1c readings. This may take some time to achieve and will be dependent on active insulin dose titration and potential alteration of the insulin regime initially introduced.


BOX 1. DIABETES IN ADULTS - CLINICAL QUALITY STANDARD 6 - INSULIN THERAPY


Trained healthcare professionals initiate and manage therapy with insulin within a structured programme that includes dose titrations by the person with diabetes.


40 Nursing in Practice March/April 2012


www.nursinginpractice.com


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84