1) Welcome to a tweetorial on #insulinhesitancy in contemporary #T2D management. This serialized program is accredited for 0.5h by @academiccme: #physicians, #nurses, #pharmacists! I am @AliceYYCheng . . . pic.twitter.com/yKicEMoR4W
— cardio-met (@cardiomet_CE) June 29, 2021
2) Let's start with a case. Meet Masika: 66 year old non-frail woman with #T2D x 15 yrs , MI 2 yrs ago, hypertension, no heart failure, otherwise well. On metformin, #GLP1-RA, #SGLT2i, sulfonylurea. BMI 30 kg/m2, A1c 7.9%, eGFR 66, normal ACR, LDL at target.
— cardio-met (@cardiomet_CE) June 29, 2021
4) Consistent with guidelines from around the world, it would be appropriate to target A1c ≤7% (choice b), given that she is non-frail. @DiabetesCanada pic.twitter.com/pNkGXUM6YF
— cardio-met (@cardiomet_CE) June 29, 2021
— cardio-met (@cardiomet_CE) June 29, 2021
7) Mark your answer and return tomorrow for more on insulin initiation in T2D! Come back, #FOAMed @PharmacyUpdates @CardioNerds @Sglt2inhibitorL @mvaduganathan @DaveDixonPharmD @kamleshkhunti @hvanspall @mirvatalasnag @djc795 @EiranGorodeski @AndrewJSauer @JohnRMontford
— cardio-met (@cardiomet_CE) June 29, 2021
9) After #GLP-1RA, add basal insulin or transition to fixed ratio combo of GLP-1RA + basal insulin. Consistent with consensus algorithm from @AmDiabetesAssn @EASDnews. 4T study (DOI: 10.1056/NEJMoa075392) . . .
— cardio-met (@cardiomet_CE) June 30, 2021
11) Despite advances in insulin, initiation still is often delayed by many yrs. Why?
— cardio-met (@cardiomet_CE) June 30, 2021
a) System-related factors (low access, lack of time)
b) Provider factors (lack of time/experience, inertia)
c) Patient factors (fear of insulin, stigma, fear of wgt gain)
d) All of the above
13) Delaying advancement of therapy by 1 yr is associated with the loss of ~13,390 life-yrs and increased cost of USD 7.3 billion (1-yr time horizon, see DOI: 10.1007/s12325-019-01199-8). What can we do to address this inertia?
— cardio-met (@cardiomet_CE) June 30, 2021
15) Here’s the “what”. All available insulins can be classified as Bolus (mealtime), Basal or Premixed. Here is a VERY handy insulin prescription tool from @DiabetesCanada . . .
— cardio-met (@cardiomet_CE) June 30, 2021
17) For the “How”, we need to self-reflect. The negative perception of insulin often comes from us. Insulin = “replacement” therapy. It is not punishment or threat. It is not the end of the road.
— cardio-met (@cardiomet_CE) June 30, 2021
19) Do not get hung up on the starting dose of insulin. It will be wrong! It is ALL ABOUT THE TITRATION. If you are not going to titrate, do not bother starting. Usual basal starting dose is 10 units or 0.2 units/kg. #Titration is the key!
— cardio-met (@cardiomet_CE) June 30, 2021
21) Mark your answer and return tomorrow for a wrap-up and a link to your FREE CE/#CME ! Poke @DavidLBrownMD @DanielJDrucker @DrRamiMFikri @parthaskar @sotonDSN @DiabetesNNF @DianaSherifali @AlannaWeisman @doreen_rabi @SLubchansky @profmjdavies @ilanajhalperin @GoDiabetesMD
— cardio-met (@cardiomet_CE) June 30, 2021
23) Self-titration by person w/#diabetes is as effective (or more) than HCP-led. If glucose testing is available, teach self-titration of basal insulin using simple algorithm. In Canada, we increase by 1 unit daily until fasting glucose target reached https://t.co/jzvfOjHe3g pic.twitter.com/WeqiiAZ91d
— cardio-met (@cardiomet_CE) July 1, 2021
25) Successful titration requires ongoing support from interprofessional providers – always involve #diabetes education team (nurse, #dietitian, pharmacist etc)
— cardio-met (@cardiomet_CE) July 1, 2021
25) Successful titration requires ongoing support from interprofessional providers – always involve #diabetes education team (nurse, #dietitian, pharmacist etc)
— cardio-met (@cardiomet_CE) July 1, 2021
28) That's it! You made it! Free CE/#CME! #Physicians, #nurses, #pharmacists: go to https://t.co/E1iTOVK3U9 and claim your credit! I am @AliceYYCheng. Follow us for more tweetorials! #Medtwitter #MedEd @MedTweetorials @CardioNerds
— cardio-met (@cardiomet_CE) July 1, 2021