Dafne bi scenarios

Implementing the most clinically
effective background insulin regimen
Stephanie A Amiel & Anita Beckwith  IN BLUE the main points raised in Comparisons with once‐daily or twice‐daily basal insulin regimen:
† indicates p value = non significant; * differences are adjusted for baseline variable
Variable
Once Daily
P value
Twice daily 
P value
Pre‐DAFNE   Post‐DAFNE
Pre‐DAFNE   Post‐DAFNE
Patients n(%), on basal insulin regimes (for whom data available @ 1 year)
Severe hypogycaemia
Severe hypogycaemia P 
Pre‐DAFNE
Post‐DAFNE  ‐ 1yr
value†
value‡
 BD Isophane works well - DAFNE Evening isophane best given at bedtime (late) - Fanelli et al., Ann Intern Med. 2002;136:504-14 Logically rules for Isophane should work for Levemir Levemir probably most reproducible absorption day to day and this is very appreciated by patients. May be useful if fasting glucoses very variable with full DAFNE regimen on PRE-DAFNE Most practices are using analogues 19/20 using Lantus, of which 1 uses bd dose routinely and 6 use od and bd and one converts od to bd pre course. Only 6 routinely reduce doses that  18/20 do use Levemir also, of which 6 use it od at  3/20 routinely use Lantus pre breakfast; 1/20 pre-  With bd Levemir, 8 prescribe “12 hourly”; 9 “pre- Consensus that bd is preferable and most agree initially 50@50 split. Pre-course: Many do support move to bd Lantus or Levemir Should do this especially if patient is exerciser or shift worker During or Post-course: often convert remaining od users to bd because Changing in the course allows the patient to learn from own data BUT reduces opportunity for patient to learn about dose adjustment Changing pre-course requires educator to trust DAFNE and be able to convince patient to trust DAFNE and then allows full exploitation of the daily dose adjustments for all 5 days Changes from Lantus need to happen Friday night before the course All other changes Sunday night before the course Calculate BI referring to Berger regimen Some like to introduce large change more slowly and incrementally over 2 weeks prior to course, but this may need significant extra time from the educator and should not usually be necessary if we assume DAFNE  Patient forget second dose after years of one only Suggested solutions: set up mobile ‘phone alarm; keep BI pen in the toothglass with the toothbrush (or paste!)  Overlap from previous insulin affecting dose decision Which insulin to use? Argument for splitting the insulin the patient is using BUT no logic/evidence for splitting a 24 hr insulin and lantus not licenced for bd use.  Worries about Lantus and cancer in that setting Many therefore use isophane or, if there is evidence for nocturnal hypoglycaemia pre-analogue use, bd  Consensus that Levemir is weaker than Lantus and Isophane and may need to increase to 28 – 34 Changing from a ‘conventional’ basal/bolus regime:
Option 1 (isophane or Levemir):
‘Berger regime’: 12u at bedtime and 12u in the morning, as above.
Starting from Sunday bed-time, with a suggested QA dose for Adapt starting doses according to insulin sensitivity.
Option 2 (Lantus):
Consider leaving dose of Lantus unchanged, or approx 24u/24hrs (adapt
according to sensitivity). Main benefits from Lantus (ie reduced fasting
BG) may be achieved from taking it at bedtime, rather than in the morning.
If planning to convert from Lantus to isophane or Levemir, consider the ‘washout’ period for Lantus and plan to change 2-3 days prior to the course.
Pre- and post-course changes
It is important to realise that these
scenarios are designed for discussion
of dose adjustment and all solutions
would need to be adjusted for the
individual patient
The team’s solution: do nothing. Long duration of diabetes, let patient discover problems of regimen during week The group’s discussion. Total daily dose, divide 50/50 into BI and QA. Result Levemir 8 units bd and 1:1 QA for meals from Sunday night Discussion: should probably reduce total dose by ~20% if distributing more physiologically BUT need more levemir than Lantus WHAT HAD BEEN DONE REALLY: Converted to Lantus 16 units bedtime DISCUSSION: Group very anxious about doubling BI BUT: 1. The start QA:BI ratio is 75/25 not 50/50 2. The low breakfast dose and high evening meal dose strongly suggests too much basal in the morning and not enough at night 3. With bd 8 units you are just giving the same background replacement during the day as during the night 4. With 16 units of Lantus you are both trusting DAFNE (need for background insulin throughout the 24 hours) AND Lantus (active dose will be absorbed steadily through the 24 hours, so patient will NOT suddenly get a much bigger active dose at night 5. Probably reasonable to have checked a 3am glucose before making Team suggested no change and group agreed. All rather surprised after vigour of previous discussion Re-arrange Humulin I to 12 units bd if patient not obviously insulin resistant or 16 units bd if he is; and 1:1 or 1.5:1 QA. From MONDAY AM because he will have taken 30 units Sunday morning and may hypo overnight if 12 units then taken later that day Team solution : convert to 24 units of Lantus, 48 hours before Group: We agreed, although some preferred gradual reduction over 2 weeks prior to course. NB this does mean more work and Team discussion: convert to Insulatard 12 am and bedtime and 1:1 QA night before course starts  The action taken is given in the 2nd Scenario 1(a)
Scenario 1(b)
The conversion to split levemir from Lantus Would normally require an increase in total dose But not initially because Lantus effect will still be Present on day one. Eventual dose 9 units bd Scenario 2 (a)
Scenario 2 (b)
Run out of once daily basal and effects of exercise and alcohol. Needs bd to allow Flexibility. Prof Amiel suggested this patient must have been a man! Scenario 3
This patient has not yet been managed Group agreed there was clear evidence for a dawn And that converting to bd BI would not address this. Insulatard would likely make it worse Suggested that patient be asked to wake early (initially 6 am as this would be fairly convenient but may need to be earlier if already high by then, test and take QA (initially 2 units but increase as required to achieve fasting target glucose) and go back to sleep until usual morning alarm. If this works it would prove dawn phenomenon and a pump would be required unless patient preferred to continue to wake to take extra QA 1. A lot of teams still using daily Lantus but agree advantages of bd BI regimen, especially flexibility 2. IN discussion about which BI, there was felt to be an evidence base for isophane, no licence (or logic?) for Lantus and we should advise either isophane or levemir (if evidence of nocturnal hypo or high fasting glucoses on bd isophane in past; or if fasting glucoses very variable on isophane) as first line, using Lantus if patient very attached to 3. This is because DAFNE provides the evidence base

Source: http://www.dafne.uk.com/uploads/135/documents/BI_Replacement_Workshop.pdf