Optimisation Of Glycaemic Control For Newly Insulin Initiation Patients – A Patient Partnership Approach

Yeung THM, Chik MY, Choy WY, Chan WS, Lee KY, Lau LW, Wong RYM, Loo KM, So TTY, Ozaki R, Cheung KKT
Diabetes and Endocrine Centre, Prince of Wales Hospital


Introduction
Type 2 diabetes mellitus is characterized by insulin resistance and progressive beta cell failure. Most patients will eventually require insulin therapy; which will need adjustment over time to maintain good glycemic control. However, with limited resources, physicians can only follow up these patients every 4-6 months, resulting in delay in insulin titration to achieve glycemic targets. 
The Diabetes and Endocrine Centre, Prince of Wales Hospital ran a pilot program on “Insulin Titration Program For Patient With Type 2 Diabetes’’ to empower patients in achieving and maintaining good glycemic control within a shorter period of time.

Objectives
To develop a structured insulin titration program to empower and engage patients to better understand and be more involved in their diabetes care
To educate and encourage patients to self-titrate their insulin dosage according to a structured insulin titration algorism 

Methodology
Patients (aged 18 to 75) newly initiated supplementary bedtime insulin were invited to join the program. In the program, patients learned the technique of self-injection, blood glucose monitoring, hypoglycemic management, healthy lifestyle modifications. Self-adjustment of insulin dose was encouraged, based on 3 consecutive home fasting blood glucose (FBG) readings, and a weekly fine-tuning titration of +/- 1-2 units. Patients were phone contacted on their progress at Week 1 and 2, and their insulin titration ability assessed using a standardized assessment form at Week 3. Patients who passed the evaluation would self-titrate their insulin dose with the support of diabetes nurses. If they failed the assessment, diabetes nurses would lead the insulin adjustment accordingly. Phone interviews continued until patients achieved their target FBGs. 

Result & Outcome
33 patients (male=22; female=11; mean age 60.5 ± 10.8 years) completed the program. At Week 0, mean baseline HbA1c was 9.5 ± 1.2%. At 5 months, HbA1c was lowered to 8.0 ± 0.7%. 19 patients (57.5%) had adjusted insulin dose according to the prescribed algorithm. There were a total of 119 insulin titration episodes with few episodes of mild hypoglycemic event during the study period: titration by nurse=56.3% (n=67); by patients = 33.6% (n=40); by doctor = 10.1%(n=12). 6 patients did not require insulin titration as home FBGs were optimized by the prescribed starting dose of insulin therapy. 

Conclusion 
Empowering patients to take greater control of their diabetes, through education and patient-oriented insulin titration algorithms, can achieve targeted FBGs at a faster and more effective manner.

Optimization of glycemic control for newly insulin initiation patients – a patient partnership approach