Newer Insulins under pressure from QIPP

June 16, 2011 15:00

chrisinbrum DAFNE Graduate
University Hospitals Birmingham NHS Foundation Trust 41 posts

Carolin said:
1. is there research evidence of an improved safety record for analogues compared with old NPH/soluble insulins, from the DAFNE database? [one for DAFNE top brass!]

I can tell you that an audit of the DAFNE database around 4yrs ago asked just that question. And the reuslts?.......

Traditional NPH (Humulin I or Insulatard) used twice daily as per DAFNE regimen resulted in better HbA1c than the modern analogue Background Insulins, however ANY type of BI taken twice daily was better than analogue taken just once daily.

There was no difference in terms of severe hypos (needing 3rd party assistance), however analogue BI showed a trend towards slightly lower rates of minor, symptomatic hypos.

The DAFNE stance therefore is still to default to NPH twice daily as it is still a very effective and proven insulin and this has nothing to do with cost! If people have problems with night-time hypos and/or uncontrollable Dawn Phenomenon on NPH, twice daily Levemir or Lantus is an option.

In addition, much of the work done by Dr Ian Gallen's team at Wycombe has shown an increased risks of prolonged hypos during/following exercise with analogue BIs and they recommend switching back to NPH or using a pump if you're a serious exerciser.

Hope this info helps?

Carolin

Thanks Carolin - that's really interesting and helpful! I'd not heard anything like that before about hypos and exercise. On my DAFNE course, and i think in the course manual, it just says that hypos might be a problem after exercise, but doesn't link that to any particular insulin so i assumed they were all the same. The manual also says that Lantus users might manage better with twice daily Isophane or Levemir.

June 16, 2011 15:22

Welshmapleleaf DAFNE Graduate
Betsi Cadwaladr University Health Board 19 posts

Yes, on my DAFNE course last week, they explained Lantus was less suitable to those who exercise regularly, and indeed one of the other delegates had changed to levimir for that very reason. It was also deemed to be better for those who found that the effectiveness of Lantus was running out too early every day.

June 16, 2011 15:46

JayBee DAFNE Graduate
James Paget University Hospitals NHS Foundation Trust 587 posts

Why is Lantus not suitable for Type1s who exercise regularly? Is it because it responds stronger to exercise compared to the other two?

That might explain the trouble I had possibly... it's weird how a very busy working environment can affect your body without you realising. Sad

June 16, 2011 15:53

Carolin
Sheffield Teaching Hospitals 83 posts

Hi JWo

It's a bit complicated, but in simple terms when you exercise your liver needs to release glucose into your bloodstream from the glycogen stores. It's thought that the analogue BIs suppress this to a greater extent / for longer than NPH.

There may be more detail on the www.runsweet.com website

Or you could try to Google E Perry/I Gallen as they're the docs who have done the studies.

Carolin

June 17, 2011 08:13

Brum_Taffy 13 posts

I heard from some colleagues who were at the recent DAFNE collaborative that twice daily Levemir was suggested as the favoured BI. They didn't mention NPH being a favoured option. Do you think, Carolin, that they got only half the message?

I'll look into what you said about Ian Gallen's approach, very interesting! I'm always concerned that failure to adequately resuspend cloudy NPH will be an issue for many people, maybe I shouldn't be so worried if the 4 yr old DAFNE data is to believed.

I believe that exercise and safe enjoyment of alcohol don't get as much attention in our local DAFNE courses as they should.

June 17, 2011 09:19

JayBee DAFNE Graduate
James Paget University Hospitals NHS Foundation Trust 587 posts

Thanks Carolin, I will look more into it. Smile

I agree with Brum_Taffy on things like exercise and alcohol not being covered enough on the DAFNE course (I'm more particularly interested in exercise considering I don't drink)... I mean it's quite common for people to speak up about the effects of exercise on this forum (at least 6 topics).

June 17, 2011 11:51

novorapidboi26 DAFNE Graduate
NHS Lanarkshire 1,819 posts

I though Lantus was not suitable as adjusting it for exercise wasn't very flexible as the effects are not noticed for days..........

Interesting points about the liver during exercise etc.....I didn't think it played a huge part during exercise, but after when trying to replenish the muscles stores.........

June 17, 2011 14:15

Carolin
Sheffield Teaching Hospitals 83 posts

Brum_Taffy said:
I heard from some colleagues who were at the recent DAFNE collaborative that twice daily Levemir was suggested as the favoured BI. They didn't mention NPH being a favoured option. Do you think, Carolin, that they got only half the message?

I'll look into what you said about Ian Gallen's approach, very interesting! I'm always concerned that failure to adequately resuspend cloudy NPH will be an issue for many people, maybe I shouldn't be so worried if the 4 yr old DAFNE data is to believed.

I believe that exercise and safe enjoyment of alcohol don't get as much attention in our local DAFNE courses as they should.

Hi,

Yes, I think your colleagues may have got hold of the wrong end of the stick regarding BI use. Analogue BIs are certainly used almost exclusively in some DAFNE centres, however the evidence still comes out very favourably for NPH and is what Michael Berger's algorithms were developed around (the ITTP programme in Dusseldorf on which DAFNE is based).

But the audit data show that the important thing is taking the BI twice daily, whichever it is. So many centres prefer to keep patients on analogue and just split the dose.

June 17, 2011 14:22

Carolin
Sheffield Teaching Hospitals 83 posts

JWo said:
Thanks Carolin, I will look more into it.

I agree with Brum_Taffy on things like exercise and alcohol not being covered enough on the DAFNE course (I'm more particularly interested in exercise considering I don't drink)... I mean it's quite common for people to speak up about the effects of exercise on this forum (at least 6 topics).

Hi,

This is a very important point and has been noted by DAFNE nationally. The consensus is that the vast majority of people need the basics during their DAFNE week so they can at least tackle exercise more safely & effectively.

The DAFNE Collaborative ran an 'exercise masterclass' for Educators and Doctors late last year, partly to help Educators to think about different ways of delivering that part of the 5-day course, but also to think about developing an 'advanced module' for DAFNE graduates.

It may be worth approaching your local Educators to find out if they're planning anything along these lines. In Sheffield we've provided 2 additional sessions this year in our 'RefresherClinics', aimed at people who do regular exercise and sports and incorporating more detail on exercise physiology and sports nutrition.

June 17, 2011 14:28

Welshmapleleaf DAFNE Graduate
Betsi Cadwaladr University Health Board 19 posts

Having only graduated last week, I am still grappling with normalising my BGs at a stable and consistent level. My own attitude whilst I was learning the DAFNE principles, and still is this week, is that at the moment, exercise is another complicating factor which would make it more difficult for me to 'get in tune' with how my body is reacting to CPs, ratios of QA etc etc.

I hope within the next few weeks, I'll get the confidence to build some exercise into my regime. I don't know whether any further information on this subject wouldn't have 'muddied the waters' on the course itself, but it would definately be welcome by the time of the six week reunion.

June 16, 2011 15:00 chrisinbrum DAFNE Graduate University Hospitals Birmingham NHS Foundation Trust 41 posts	Carolin said: 1. is there research evidence of an improved safety record for analogues compared with old NPH/soluble insulins, from the DAFNE database? [one for DAFNE top brass!] I can tell you that an audit of the DAFNE database around 4yrs ago asked just that question. And the reuslts?....... Traditional NPH (Humulin I or Insulatard) used twice daily as per DAFNE regimen resulted in better HbA1c than the modern analogue Background Insulins, however ANY type of BI taken twice daily was better than analogue taken just once daily. There was no difference in terms of severe hypos (needing 3rd party assistance), however analogue BI showed a trend towards slightly lower rates of minor, symptomatic hypos. The DAFNE stance therefore is still to default to NPH twice daily as it is still a very effective and proven insulin and this has nothing to do with cost! If people have problems with night-time hypos and/or uncontrollable Dawn Phenomenon on NPH, twice daily Levemir or Lantus is an option. In addition, much of the work done by Dr Ian Gallen's team at Wycombe has shown an increased risks of prolonged hypos during/following exercise with analogue BIs and they recommend switching back to NPH or using a pump if you're a serious exerciser. Hope this info helps? Carolin Thanks Carolin - that's really interesting and helpful! I'd not heard anything like that before about hypos and exercise. On my DAFNE course, and i think in the course manual, it just says that hypos might be a problem after exercise, but doesn't link that to any particular insulin so i assumed they were all the same. The manual also says that Lantus users might manage better with twice daily Isophane or Levemir.
June 16, 2011 15:22 Welshmapleleaf DAFNE Graduate Betsi Cadwaladr University Health Board 19 posts	Yes, on my DAFNE course last week, they explained Lantus was less suitable to those who exercise regularly, and indeed one of the other delegates had changed to levimir for that very reason. It was also deemed to be better for those who found that the effectiveness of Lantus was running out too early every day.
June 16, 2011 15:46 JayBee DAFNE Graduate James Paget University Hospitals NHS Foundation Trust 587 posts	Why is Lantus not suitable for Type1s who exercise regularly? Is it because it responds stronger to exercise compared to the other two? That might explain the trouble I had possibly... it's weird how a very busy working environment can affect your body without you realising.
June 16, 2011 15:53 Carolin Sheffield Teaching Hospitals 83 posts	Hi JWo It's a bit complicated, but in simple terms when you exercise your liver needs to release glucose into your bloodstream from the glycogen stores. It's thought that the analogue BIs suppress this to a greater extent / for longer than NPH. There may be more detail on the www.runsweet.com website Or you could try to Google E Perry/I Gallen as they're the docs who have done the studies. Carolin
June 17, 2011 08:13 Brum_Taffy 13 posts	I heard from some colleagues who were at the recent DAFNE collaborative that twice daily Levemir was suggested as the favoured BI. They didn't mention NPH being a favoured option. Do you think, Carolin, that they got only half the message? I'll look into what you said about Ian Gallen's approach, very interesting! I'm always concerned that failure to adequately resuspend cloudy NPH will be an issue for many people, maybe I shouldn't be so worried if the 4 yr old DAFNE data is to believed. I believe that exercise and safe enjoyment of alcohol don't get as much attention in our local DAFNE courses as they should.
June 17, 2011 09:19 JayBee DAFNE Graduate James Paget University Hospitals NHS Foundation Trust 587 posts	Thanks Carolin, I will look more into it. I agree with Brum_Taffy on things like exercise and alcohol not being covered enough on the DAFNE course (I'm more particularly interested in exercise considering I don't drink)... I mean it's quite common for people to speak up about the effects of exercise on this forum (at least 6 topics).
June 17, 2011 11:51 novorapidboi26 DAFNE Graduate NHS Lanarkshire 1,819 posts	I though Lantus was not suitable as adjusting it for exercise wasn't very flexible as the effects are not noticed for days.......... Interesting points about the liver during exercise etc.....I didn't think it played a huge part during exercise, but after when trying to replenish the muscles stores.........
June 17, 2011 14:15 Carolin Sheffield Teaching Hospitals 83 posts	Brum_Taffy said: I heard from some colleagues who were at the recent DAFNE collaborative that twice daily Levemir was suggested as the favoured BI. They didn't mention NPH being a favoured option. Do you think, Carolin, that they got only half the message? I'll look into what you said about Ian Gallen's approach, very interesting! I'm always concerned that failure to adequately resuspend cloudy NPH will be an issue for many people, maybe I shouldn't be so worried if the 4 yr old DAFNE data is to believed. I believe that exercise and safe enjoyment of alcohol don't get as much attention in our local DAFNE courses as they should. Hi, Yes, I think your colleagues may have got hold of the wrong end of the stick regarding BI use. Analogue BIs are certainly used almost exclusively in some DAFNE centres, however the evidence still comes out very favourably for NPH and is what Michael Berger's algorithms were developed around (the ITTP programme in Dusseldorf on which DAFNE is based). But the audit data show that the important thing is taking the BI twice daily, whichever it is. So many centres prefer to keep patients on analogue and just split the dose.
June 17, 2011 14:22 Carolin Sheffield Teaching Hospitals 83 posts	JWo said: Thanks Carolin, I will look more into it. I agree with Brum_Taffy on things like exercise and alcohol not being covered enough on the DAFNE course (I'm more particularly interested in exercise considering I don't drink)... I mean it's quite common for people to speak up about the effects of exercise on this forum (at least 6 topics). Hi, This is a very important point and has been noted by DAFNE nationally. The consensus is that the vast majority of people need the basics during their DAFNE week so they can at least tackle exercise more safely & effectively. The DAFNE Collaborative ran an 'exercise masterclass' for Educators and Doctors late last year, partly to help Educators to think about different ways of delivering that part of the 5-day course, but also to think about developing an 'advanced module' for DAFNE graduates. It may be worth approaching your local Educators to find out if they're planning anything along these lines. In Sheffield we've provided 2 additional sessions this year in our 'RefresherClinics', aimed at people who do regular exercise and sports and incorporating more detail on exercise physiology and sports nutrition.
June 17, 2011 14:28 Welshmapleleaf DAFNE Graduate Betsi Cadwaladr University Health Board 19 posts	Having only graduated last week, I am still grappling with normalising my BGs at a stable and consistent level. My own attitude whilst I was learning the DAFNE principles, and still is this week, is that at the moment, exercise is another complicating factor which would make it more difficult for me to 'get in tune' with how my body is reacting to CPs, ratios of QA etc etc. I hope within the next few weeks, I'll get the confidence to build some exercise into my regime. I don't know whether any further information on this subject wouldn't have 'muddied the waters' on the course itself, but it would definately be welcome by the time of the six week reunion.