Kendala dan Kesalahan Penggunaan Insulin

Dalam Praktek Klinik

Nanang Miftah Fajari

Divisi Endokronilogi Metabolik dan Diabetes
FK ULM/RS Ulin Banjarmasin
 Case discussion
Milestone of being seriously ill

According Guideline, Does The Patient

PATIENT PROFILE Need Insulin?

Male
Age 58
Finance Director
DM since 7 yrs

Clinical values HbA1c: 10.5%

Tx : Glimepirid 1x4mg,
metformin 3x500,
acarbose 3x100
 The Challenges of Insulin Therapy

www.diabetes.org.uk/professionals/resources/shared-practice/psychological-care/emotional-health-
professionals-guide/chapter-5-fear-insulin
Clinical inertia to insulin initiation and intensification

Jennifer Okemah, John Peng, Manuel Quiñones. Addressing Clinical Inertia in Type 2 Diabetes Mellitus: A Review. Advances in Therapy,
2018, Volume 35, Number 11, Page 1735
 Case discussion
Milestone of being seriously ill

According Guideline, Does The Patient

PATIENT PROFILE Need Insulin?

Male
Age 58
What are the obstacles ?
Finance Director
DM since 7 yrs

Clinical values HbA1c: 10.5%

Tx : Glimepirid 1x4mg,
metformin 3x500,
acarbose 3x100
Identification Obstacles
Clinical Inertia – Barriers to Use Insulin

50%

30%

20%

O'Connor, Patricia J. et al. “Clinical Inertia and Outpatient Medical Errors.” (2005).
Clinical Inertia – Barriers to Use Insulin

O'Connor, Patricia J. et al. “Clinical Inertia and Outpatient Medical Errors.” (2005).
Clinical Inertia – Barriers to Use Insulin

O'Connor, Patricia J. et al. “Clinical Inertia and Outpatient Medical Errors.” (2005).
Clinical Inertia – Barriers to Use Insulin

O'Connor, Patricia J. et al. “Clinical Inertia and Outpatient Medical Errors.” (2005).
 Case discussion
Milestone of being seriously ill

According Guideline, Does The Patient

PATIENT PROFILE Need Insulin?

Male
Age 58 What are the obstacles ?
Finance Director
DM since 7 yrs

Clinical values HbA1c: 10.5%

How Can you promote Patient
to Use Insulin as needed?
Tx : Glimepirid 1x4mg,
metformin 3x500,
acarbose 3x100
• So what about the injection?

Techniques on how to identify

and overcome barriers
 Managing Fears and Barrier Related to
injection Therapy
<10% pts of perceive a
benefit of insulin
40-50% pts
difficult to use
insulin

50% pts fearful 50% pts associate insulin with

of needles personal failure

SOLUTION

• Identify and address a patient’s

• Focus on glycemic outcomes
personal obstacles
• Explain the progressive nature of DM
• Introduce Insulin as a brief
• Do not refer to insulin as a threat
experiment
• Introduce the possible need for insulin
• Educate patients on Hypo’s
therapy early in treatmen
• Consider the use of insulin pens

Polonsky WH, Jackson RA. Clin Diabetes 2004, 22 147,150

How to Overcome the Barriers
 Case Scenario
64-year-old woman with type 2 diabetes mellitus for 7 years

Vital Signs and Current

Laboratory Results Notes
Management

Weight: 56 kg • Lifestyle management • Has experienced several

BMI: 24,5 kg/m2 episodes of symptomatic
• Metformin 500 mg hypoglycemia over past
BP: 136/82 mm Hg BID few months.
A1c: 7,5%
• Insulin detemir 30 • Episode early yesterday
FPG: 258 mg/dL morning required
units (0.6 units/kg) at
PPG: 189 mg/dL treatment in emergency
bedtime
eGFR: 70 mL/min/1.73 department
m2 (blood glucose 52
mg/dL)

What are The Problems of this patient ?

Fasting Hyperglycemia
Somogi Effect
Uptitrating Basal Insulin May Not Achieve A1c
Target and May Increase Risk of Hypoglycemia

Reid T, et al. Int J Clin Pract. 2016;70:56–65.

Solusi = Structured Glucose Monitoring
 Case Scenario
47-year-old man with type 2 diabetes mellitus for 4 years

Vital Signs and Current

Laboratory Results Notes
Management

Weight: 78 kg • Lifestyle management • He said that he did

BMI: 29 kg/m2 exercise and diit verry
• Insulin detemir 30 well
BP: 136/82 mm Hg units at bedtime
A1c: 10,5% • He noted that his body
• Insulin aspart 24 u weight increase 7 kg in 1
FPG: 258 mg/dL year
before meals
PPG: 389 mg/dL
• He got knee arthritis
eGFR: 70 mL/min/1.73 • Aspilet 1x80 mg
m2

What are The Problems of this patient ?

What Should Evaluate ?
Factors Contribute Unmeet Glucose Target
What Physicians do when Glucose unmeet target

Dalal, M.R et al.diabetes research and clinical practice 121 ( 2016 ) 17 –26
How to Optimize Glucose Control
 Kesalahan Pengelolaan DM dalam
Praktek Klinik sehari hari
1. Jarang melakukan evaluasi hypoglikemi pada pasien
2. Pada pemeriksaan gula darah 2 jam, pasien tdk diedukasi
untuk tetap menyuntik insulin prandrial atau minum obat
oral
3. Tidak pernah mengevaluasi dosis optimal basal insulin
4. Monitor kadar gula tiap bulan, tidak pakai monitoring
glukosa harian
5. Dosis titrasi insulin dilakukan tiap bulan ( tidak sesuai
guideline)
6. Jarang melakukan evaluasi diit dan exercise
7. Jarang mengevaluasi penggunaan steroid pada pasien
yang tidak terkontrol
 Summary
Many patient barriers are based on myths and insulin
therapy

HCP and patient perceptions not always aligned

Once on injectable therapy – patients’ fear drops

Evaluate correcty :
Risk of hypo’s

Injection technique

Diit and other medication