2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S48 compared with subcutaneous short-acting or rapid-acting insulins (33-36). The short-term safety data demonstrate no clinically significant pulmonary dysfunction (33,34,37). It is recommended, however, that inhaled insulin not be used in those with abnormal baseline spirometry (i.e. forced expiratory volume in 1 second [FEV1] 3.0 mmol/L), exercise should not be performed, as metabolic deterioration will occur (57). Hypoglycemia unawareness and nocturnal hypoglycemia Asymptomatic hypoglycemia is the presence of a biochemically documented low BG level without any symptoms. Hypoglycemia unawareness occurs when the threshold for the development of autonomic warning symptoms is close to or lower than the threshold for the neuroglycopenic symptoms, such that the first signs of hypoglycemia will often be confusion or loss of consciousness. Severe hypoglycemic reactions are the primary barrier to achieving glycemic targets in people with type 1 diabetes (58). Severe hypoglycemic episodes occur frequently during sleep or in the absence of hypoglycemia awareness that alerts patients to take actions to correct their BG levels (59,60). The sympathoadrenal response to hypoglycemia is reduced during sleep (61). Asymptomatic nocturnal hypoglycemia is common and often lasts >4 hours (59,62-65). Severe hypoglycemia, resulting in seizures, is more likely to occur at night than during the day (66). To reduce the risk of asymptomatic nocturnal hypoglycemia, individuals using intensive insulin therapy should periodically monitor overnight BG levels at a time that corresponds with the peak action time of their overnight insulin. In people with type 1 diabetes, hypoglycemia was reported to occur at a mean rate of approximately 2 episodes per week. Increasing frequency of hypoglycemia can lead to a decrease in the normal responses to hypoglycemia (67), which, in turn, can lead to decreased awareness of hypoglycemia and defective glucose counterregulation. Hypoglycemia unawareness and defective glucose counterregulation are potentially reversible. Strict avoidance of hypoglycemia for a period of 2 days to 3 months has been
associated with improvement in the recognition of severe hypoglycemia, in the counterregulatory hormone responses, or both (42,67-73). Structured educational and psychobehavioural programs (e.g. blood glucose awareness training) may help improve detection of hypoglycemia and reduce frequency of severe hypoglycemia (74,75). RECOMMENDATIONS Insulin regimens for type 1 diabetes 1.To achieve glycemic targets in adults with type 1 diabetes, multiple daily insulin injections (prandial [bolus] and basal insulin) or the use of CSII as part of an intensive diabetes management regimen is the treatment of choice [Grade A, Level 1A (6)]. 2. Rapid-acting insulin analogues (aspart or lispro), in combination with adequate basal insulin, should be considered over regular insulin to improve A1C while minimizing the occurrence of hypoglycemia [Grade B, Level 2 (9,11)] and to achieve postprandial glucose targets [Grade B, Level 2 (76)]. 3. Insulin aspart or insulin lispro should be used when CSII is used in adults with type 1 diabetes [Grade B, Level 2 (29,30)]. 4.A long-acting insulin analogue (detemir, glargine) may be considered as an alternative to NPH as the basal insulin [Grade B, Level 2 (17-20)] to reduce the risk of hypoglycemia [Grade B, Level 2 (50), for detemir; Grade C, Level 3 (51), for glargine], including nocturnal hypoglycemia [Grade B, Level 2 (50), for detemir; Grade D, Consensus, for glargine]. Hypoglycemia 5.All individuals with type 1 diabetes should be counselled about the risk and prevention of insulin-induced hypoglycemia, and risk factors for severe hypoglycemia should be identified and addressed [Grade D, Consensus]. 6. In individuals with hypoglycemia unawareness, the following strategies should be implemented to reduce the risk of hypoglycemia and to attempt to regain hypoglycemia awareness: • Increased frequency of SMBG, including periodic assessment during sleeping hours [Grade D, Consensus]. • Less stringent glycemic targets with avoidance of hypoglycemia [Grade C, Level 3 (72,73)]. • Consideration of a psychobehavioural intervention program (blood glucose awareness training), if available [Grade B, Level 2 (75)]. OTHER RELEVANT GUIDELINES Targets for Glycemic Control, p. S29 Monitoring Glycemic Control, p. S32 Pharmacologic Management of Type 2 Diabetes, p. S53 Hypoglycemia, p. S62 In-hospital Management of Diabetes, p. S71 Management of Acute Coronary Syndromes, p. S119 Type 1 Diabetes in Children and Adolescents, p. S150 Type 2 Diabetes in Children and Adolescents, p. S162 Diabetes and Pregnancy, p. S168 Diabetes in the Elderly, p. S181 RELATED WEBSITE Health Canada information about animal insulin: http://hc-sc.gc.ca/dhp-mps/brgtherap/activit/fs-fi/qa_qr_ insulin_02_2006_e.html Accessed September 1, 2008. REFERENCES 1. Pickup J, Mattock M, Kerry S. Glycaemic control with continuous subcutaneous insulin infusion compared with intensive insulin injections in patients with type 1 diabetes: meta-analysis of randomised controlled trials. BMJ. 2002;324:705. 2. Tsui E, Barnie A, Ross S, et al. Intensive insulin therapy with insulin lispro: a randomized trial of continuous subcutaneous insulin infusion versus multiple daily insulin injection. Diabetes Care. 2001;24:1722-1727. 3. DeVries JH, Snoek FJ, Kostense PJ, et al; Dutch Insulin Pump Study Group. A randomized trial of continuous subcutaneous insulin infusion and intensive injection therapy in type 1 diabetes for patients with long-standing poor glycemic control. Diabetes Care. 2002;25:2074-2080. 4. Hirsch IB, Bode BW, Garg S, et al; Insulin Aspart CSII/MDI Comparison Study Group. Continuous subcutaneous insulin infusion (CSII) of insulin aspart versus multiple daily injection of insulin aspart/insulin glargine in type 1 diabetic patients previously treated with CSII. Diabetes Care. 2005;28:533-538. 5. Retnakaran R, Hochman J, DeVries JH, et al. Continuous subcutaneous insulin infusion versus multiple daily injections: the impact of baseline A1c. Diabetes Care. 2004;27:2590-2596. 6. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulindependent diabetes mellitus. N Engl J Med. 1993;329:977-986. 7. Nathan DM, Cleary PA, Backlund JY, et al; Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005;353:2643-2653. 8. DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. JAMA. 2003; 289:2254-2264. 9. Siebenhofer A, Plank J, Berghold A, et al. Short acting insulin analogues versus regular human insulin in patients with diabetes mellitus. Cochrane Database Syst Rev. 2006;(2):CD003287. 10. Heller SR, Colagiuri S, Vaaler S, et al. Hypoglycaemia with insulin aspart: a double-blind, randomised, crossover trial in subjects with type1 diabetes. Diabet Med. 2004;21:769-775. 11. Plank J, Siebenhofer A, Berghold A, et al. Systematic review and meta-analysis of short-acting insulin analogues in patients with diabetes mellitus. Arch Intern Med. 2005;165:1337-1344. 12. Schernthaner G,Wein W, Shnawa N, et al. Preprandial vs. post- S49 MANAGEMENT
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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