Clinical care and other categories posters: Insulin: actions, metabolism and therapy

A structured, systematic and safe novel insulin dose titration regime reducing clinical inertia and significantly improving glycaemic control in type 2 diabetes patients

H Jodeh, A Hameed, S Naqvi, A Ahmad

Diabetes and Endocrinology, Imperial College London Diabetes Centre Abu Dhabi, Abu Dhabi, UAE

Background and aims Clinical inertia is reported to delay insulin dose intensification in type 2 diabetes patients. Lack of a standardised insulin dose titration regime may be responsible and unstructured regimens may in turn lead to excessive basal insulin doses and between meal hypoglycaemia.

Materials and methods We evaluated our 1-insulin-at-a-time dose titration regime, that starts with pre-breakfast bolus insulin dose increment by 2 units every five days till target pre-lunch glucose is achieved followed by similar stepwise pre-lunch, pre-dinner and lastly basal insulin dose titration. All patients with type 2 diabetes who were started on basal bolus insulin regimen (BBIR), 6-units bolus with each meal and 12-units basal, and completed three months were included. All patients were on continuous glucose monitoring and were asked to contact diabetes specialist nurse via email every five days for titration. Data collected for HbA1c, age, gender, weight and oral hypoglycaemia agent (OHAs). Data represented as mean ± SD.

Results 40 patients (Age: 42.7 ± 12.1 years, men=19; women=21), mean bolus insulin dose at three months increased to 31.2 ± 5.6 and basal 21.1 ± 4.2 units. HbA1c decreased from 10.4 ± 0.31% to 8.8 ± 0.33%, p < 0.001, weight increased 76.1 ± 3.1 to 77.8 ± 3.4kg, p < 0.01 and only 2 patients had minor hypoglycaemia on continuous glucose monitoring. Similarly HbA1c decreased significantly in patients aged ≥50 vs <50 years (2% vs 1%, p < 0.05) and on ≤2 vs >2 OHAs (1.7% vs 0.5%, p < 0.05).

Conclusion Our 1 insulin dose titration regime provides a structured, systematic and safe method to achieve significant reductions in HbA1c with minimal risk of hypoglycaemia. We believe this could help reduce clinical inertia.

Acknowledgement ICLDC Abu Dhabi

SUPPORTING INFORMATION The conference poster for this abstract is available online in the Supporting Information section at the end of this page.

Is Fiasp an effective insulin in patients using insulin pump therapy?

FN Mohideen Bawa, R Sood, PJ Weston

Diabetes and Endocrinology, Royal Liverpool University Hospital, Liverpool, UK

Introduction Fiasp is a faster acting version of insulin aspart to which vitamin B3 (nicotinamide) was added to increase the speed of insulin absorption.

Aims Does Fiasp have advantages over insulin aspart when used in patients with type 1 diabetes using insulin pump therapy?

Methods A total of 16 patients with type 1 diabetes on insulin pump therapy were switched to Fiasp from their usual rapid acting insulin. The efficacy of Fiasp insulin was assessed by comparing the post meal blood glucose increment in one, two and four hours. In addition, we compared the HbA1cs, hypoglycaemic episodes, blood sugar time in target and standard deviation in blood sugars.

Results One hour post-meal increments were 0.08mmol with Fiasp, whereas it was 1.13mmol with rapid acting insulins (p value 0.0002). The two-hour increments were 0.35 with Fiasp, but 1.71mmol with rapid acting insulin (p value 0.0176). The four hour increments were 0.79mmol with Fiasp, but 1.24mmol with other rapid-acting insulins (p value 0.039). Time in target for blood sugar values were 50% pre-Fiasp and 63% post-Fiasp (p value 0.0003). Standard deviation of blood glucose was 3.4 pre-Fiasp and 3.1 post-Fiasp suggesting variability was less with Fiasp use. There was also reduction in self-reported mild to moderate hypoglycaemic episodes.

three months after starting Fiasp, HbA1c improved from 56.3mmol/mol to 53.8mmol/mol (p value 0.0004).

Conclusion Fiasp reduces post-prandial spikes in glucose in patients with type 1 diabetes using insulin pump therapy. It is associated with less glucose variability and a fall in HbA1c.

Characterisation of lipohypertrophy with ultrasound following a standard operating procedure for use by diabetes specialist nurses

H Mulnier¹, R Hashem¹, M Duaso¹, S Halson-Brown², R Rogers¹, K Karaliedde³, A Forbes¹

¹Department of Clinical Diabetes Research: Florence Nightingale Faculty of Nursing, Midwifery and Pallative Care, King's College London, London, UK, ²Medical Ultrasound: Women and Children's Health, King's College London, London, UK, ³Endocrinology and Medicine GSTfT: Vascular Biology and Inflammation, King's College London, London, UK

Aims Lipohypertrophy (LH) can be difficult to assess. We aimed to use ultrasound to characterise and grade LH using a standard operating procedure (SOP).

Methods Participants with type 1 diabetes for more than three years and suspected to have LH were recruited. A SonoSite X-Porte scanner with a high-frequency linear probe (6–13MHz) was used. The scanning was undertaken by a diabetes specialist nurse (DSN) under the supervision of an ultrasonographer and following the SOP.

Results A total of 74 participants were scanned: 59.5% male, mean age 40.6 ± 14.24 years, duration of diabetes 18.32 ± 10.89 years. Ultrasound revealed areas of increased echogenicity in all injection sites in comparison to normal surrounding tissue. There were diffuse patches of dense tissue and nodules of varying size. In 22 participants reduced echogenicity was observed within the centre of some nodules; suggestive of necrotic tissue. A grading strategy was developed: 1=diffuse LH, 2=nodules <6mm, 3=nodules >6mm and <8mm, 4=>8mm and <10mm and 5=nodules >10mm. In the 74 participants 32.4%(n=24) had stage 5; 25.7%(n=19) stage 4; 28.4%(n=21) stage 3; 9.5%(n=7) stage 2; and 4%(n=3) stage 1. Necrotic areas occurred across all grades with the majority (77%[n=12]) occurring in grades 4 and 5. The average depth of the LH was within 0.28mm (SD ± 1.17mm) of the needle length; correlation coefficient r=0.69(p < 0.001).

Conclusions The work adds to current LH ultrasound literature and shows that an ultrasound SOP can be used by a DSN to assess and grade LH.

Is Toujeo is safe in pregnancy? Comparison of Toujeo and Lantus for treatment of diabetes in pregnancy

A Zeeshan, T Khalid, CM McHugh

Department of Diabetes, Sligo University Hospital, Sligo, Ireland

Aims It is estimated that gestational diabetes effect 12% of pregnant women. One or two women in every 10 with gestational diabetes will require medication to control their blood glucose level.

Understanding the new insulin formulation and strength is important in accessing the risk of gestational diabetes on mother and baby. There are no clinical studies of use of Toujeo in pregnant women.

In Sligo University Hospital, we have completed a study in which we have looked at all pregnant women who are on Toujeo and compared them with Lantus group.

Results There are total 13 patients on Toujeo during pregnancy, 10 with diagnosis of gestational diabetes and 3 with known diabetes. Results shows mean maternal age was largely similar in both groups but mean gestational age of diagnosis and mean maternal BMI was high in Toujeo group (p=0.08), requirement of additional hypoglycaemics like metformin and short acting insulin was more in the Toujeo group than Lantus, 55% and 25% respectively. 2 patients required insulin infusion during delivery as none of Lantus group required this. Episodes of moderate hypoglycaemia(blood glucose level <4.5mmol) was 75% more in Lantus group, incidence of emergency delivery, caesarean section, baby average weight and baby Apgar score was largely similar in both groups.

Conclusion The use of Toujeo during pregnancy was non-inferior to Lantus but use of additional hypoglycaemic like metformin and short acting insulin was high in the Toujeo group and incidence of moderate hypoglycaemia was high in the Lantus group but we need another study with large number of patients.