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A Canadian Needs Assessment of Endocrinologist's use of Mealtime Insulin in Type 2 Diabetes
Abstracts / Can J Diabetes 40 (2016) S27–S74
of events. A high proportion of patients (n=60, 37%) had not been seen at our diabetes clinic in the year prior to the event and 77 events (48%) were preceded by at least 1 other hyperglycemic event within the last year. No outpatient follow up occurred following discharge in 36 events (22%). Conclusion: Patients with T1DM presenting with hyperglycemic emergencies may not be accessing appropriate diabetes resources despite having diabetes for many years. The lack of allied health visits suggests possible gaps in self-management, diabetes education and support. The high rate of recurrence highlights the need for preventive strategies to inform the development of riskreducing strategies.
138 A Canadian Needs Assessment of Endocrinologist’s use of Mealtime Insulin in Type 2 Diabetes JEAN-FRANÇOIS YALE*,†, LORI BERARD†, RONALD GOLDENBERG†, VINCENT WOO†, JEFFREY WINTERSTEIN† Montreal, QC Objective: To identify current practice and learning needs of Canadian endocrinologists with respect to the use of mealtime insulin for their patients with type 2 diabetes. Methods: Between December 2015 and February 2016, Canadian endocrinologists were invited to complete an online questionnaire to assess their level of knowledge, perceptions and use of mealtime insulin in clinical practice. A total of 21 endocrinologists completed the personal practice assessment, which included 172 profiles of patients with type 2 diabetes currently taking mealtime insulin. Results: Endocrinologists from across Canada and a range of clinical settings provided a representative sample of respondents. Gaps between current and desired knowledge were identified for the following topics: Co-management of patients within care team and other specialists, management of complex patients (e.g., neuropathy, foot ulcers, insulin resistance), new drugs and devices and areas of patient communication. In the 172 patient profiles of type 2 diabetes patients taking mealtime insulin, 48% were taking 1 or more other non-insulin antihyperglycemic agents (15% one other agent; 25% two other agents). For the patients on 1 or more other antihyperglycemic agent(s), the top 3 commonly prescribed were metformin (85%), DPP-4 inhibitors (41%) (alone or fixeddose combination with metformin) and SGLT2 inhibitors (33%). With regards to the use of mealtime insulin, 38% of patients were asked to self-adjust and to titrate based on pre-meal SMBG (67%). The main factors for considering concentrated mealtime insulin were identified as high insulin dose and/or high insulin volume. The mean total daily dose of mealtime insulin was 50 U (median 36 U) and mean dose per meal was 17 U before breakfast, 14 U before lunch and 19 U before supper. Most physicians recommended splitting basal (90%) and mealtime (65%) insulin injections above a particular dose (62 U and 55 U, respectively). Based on the patient profiles included, physicians estimated that concentrated insulin would be a good option for 55% of patients on mealtime insulin. Conclusions: This assessment suggests perceived knowledge gaps in management of complex cases, areas of patient communication, and new drugs and devices including the optimal use of mealtime insulin. Dose splitting, the concurrent use of other antihyperglycemic agents and the appropriate use of concentrated insulin seem to be areas in need of clarification. Disclosures: Eli Lilly and Company
S51
139 Use of Corneal Nerve Fibre Length for Diabetic Neuropathy Identification in Older Patients with Longstanding Type 1 Diabetes MOHAMMED A. FAROOQI, LEIF E. LOVBLOM*, DANIEL SCARR, JULIE LOVSHIN†, YULIYA LYTVYN, GENEVIEVE BOULET, ALANNA WEISMAN, HILLARY A. KEENAN, MICHAEL H. BRENT†, NARINDER PAUL, VERA BRIL, DAVID Z. CHERNEY†, BRUCE A. PERKINS† Toronto, ON Aim: Corneal nerve fibre length (CNFL) is a valid screening tool for diabetic neuropathy, but has not been systematically evaluated in older adults with longstanding diabetes. We aimed to explore the diagnostic performance of CNFL in a cohort with ≥50 years of type 1 diabetes (T1D). Methods: As part of the Canadian Study of Longevity in Diabetes where 150 subjects will undergo deep-phenotyping procedures, to date 48 T1D and 46 age- and gender-matched non-diabetic controls underwent evaluation of symptoms, signs and electrophysiology to define neuropathy. CNFL was determined by corneal confocal microscopy, and diagnostic performance was determined by receiver operating characteristic curves. Results: T1D participants were mean age 66±7 years, had median diabetes duration 54 (IQR 52 to 59) years, 28 (58%) female; nondiabetic controls were age 65±8 years and 32 (70%) female. Fortyone (85%) of T1D participants met neuropathy criteria. Mean sural nerve amplitude for non-diabetic controls (9.5±5.5 μV) was similar to T1D without neuropathy (8.4±2.8 μV, p=0.83) and was lowest for T1D with neuropathy (3.4±1.6 μV, p<0.001 for both comparisons). Mean CNFL for non-diabetic controls (20.0±5.7 mm/mm2) was similar to T1D without neuropathy (18.8±8.9 mm/mm2; p=0.74) and was lower for T1D with neuropathy (9.5±5.4 mm/mm2; p<0.001 for both comparisons). In T1D, area under the curve was 0.81, optimal threshold 13.7 mm/mm2, sensitivity 78%, specificity 86%. Conclusion: The diagnostic performance—even the optimal threshold value—for CNFL in older adults with longstanding T1D appears to parallel that observed in younger patients with shorter duration. As agerelated changes in CNFL do not appear to impair diagnostic validity, CNFL screening protocols may be applied to broad T1D populations. 140 Change is Afoot: Lower Extremity Amputation in Nova Scotia, 1996/97 to 2012/13 PAM TALBOT*, JENNIFER PAYNE, MARGARET DUNBAR Halifax, NS Purpose: Lower extremity amputations (LEAs) are a devastating complication of diabetes. Since 1991, Nova Scotia (NS) has fostered intensive prevention efforts for high-risk patients while promoting population-based prevention messages to the broader diabetes population. This work examined the burden of LEAs among NS adults (≥20 years) with and without diabetes between 1996/97 and 2012/13. Methods: Records from the NS health insurance registry, LEA hospital admissions and the Canadian Chronic Disease Surveillance System were linked at the individual level for 1996/97 to 2012/13. Results: Nearly 3500 individuals had ≥1 LEA admissions over the period. On average, there were 281 LEA admissions annually (DM=194, no DM=87). Over time, the annual number of LEA admissions among those with DM was relatively stable despite increasing DM prevalence (3% in 1996/97 to 11% in 2012/13). The LEA admission rate among those with DM decreased >55% from 47/10,000 to 21/10,000. Those with DM (vs. those without) were far more likely to have an LEA admission: 51x, 16x, 10x and 5x for individuals 20 to 59 years, 60 to 69 years, 70 to 79 years and ≥80 years, respectively. LEAs among
of events. A high proportion of patients (n=60, 37%) had not been seen at our diabetes clinic in the year prior to the event and 77 events (48%) were preceded by at least 1 other hyperglycemic event within the last year. No outpatient follow up occurred following discharge in 36 events (22%). Conclusion: Patients with T1DM presenting with hyperglycemic emergencies may not be accessing appropriate diabetes resources despite having diabetes for many years. The lack of allied health visits suggests possible gaps in self-management, diabetes education and support. The high rate of recurrence highlights the need for preventive strategies to inform the development of riskreducing strategies.
138 A Canadian Needs Assessment of Endocrinologist’s use of Mealtime Insulin in Type 2 Diabetes JEAN-FRANÇOIS YALE*,†, LORI BERARD†, RONALD GOLDENBERG†, VINCENT WOO†, JEFFREY WINTERSTEIN† Montreal, QC Objective: To identify current practice and learning needs of Canadian endocrinologists with respect to the use of mealtime insulin for their patients with type 2 diabetes. Methods: Between December 2015 and February 2016, Canadian endocrinologists were invited to complete an online questionnaire to assess their level of knowledge, perceptions and use of mealtime insulin in clinical practice. A total of 21 endocrinologists completed the personal practice assessment, which included 172 profiles of patients with type 2 diabetes currently taking mealtime insulin. Results: Endocrinologists from across Canada and a range of clinical settings provided a representative sample of respondents. Gaps between current and desired knowledge were identified for the following topics: Co-management of patients within care team and other specialists, management of complex patients (e.g., neuropathy, foot ulcers, insulin resistance), new drugs and devices and areas of patient communication. In the 172 patient profiles of type 2 diabetes patients taking mealtime insulin, 48% were taking 1 or more other non-insulin antihyperglycemic agents (15% one other agent; 25% two other agents). For the patients on 1 or more other antihyperglycemic agent(s), the top 3 commonly prescribed were metformin (85%), DPP-4 inhibitors (41%) (alone or fixeddose combination with metformin) and SGLT2 inhibitors (33%). With regards to the use of mealtime insulin, 38% of patients were asked to self-adjust and to titrate based on pre-meal SMBG (67%). The main factors for considering concentrated mealtime insulin were identified as high insulin dose and/or high insulin volume. The mean total daily dose of mealtime insulin was 50 U (median 36 U) and mean dose per meal was 17 U before breakfast, 14 U before lunch and 19 U before supper. Most physicians recommended splitting basal (90%) and mealtime (65%) insulin injections above a particular dose (62 U and 55 U, respectively). Based on the patient profiles included, physicians estimated that concentrated insulin would be a good option for 55% of patients on mealtime insulin. Conclusions: This assessment suggests perceived knowledge gaps in management of complex cases, areas of patient communication, and new drugs and devices including the optimal use of mealtime insulin. Dose splitting, the concurrent use of other antihyperglycemic agents and the appropriate use of concentrated insulin seem to be areas in need of clarification. Disclosures: Eli Lilly and Company
S51
139 Use of Corneal Nerve Fibre Length for Diabetic Neuropathy Identification in Older Patients with Longstanding Type 1 Diabetes MOHAMMED A. FAROOQI, LEIF E. LOVBLOM*, DANIEL SCARR, JULIE LOVSHIN†, YULIYA LYTVYN, GENEVIEVE BOULET, ALANNA WEISMAN, HILLARY A. KEENAN, MICHAEL H. BRENT†, NARINDER PAUL, VERA BRIL, DAVID Z. CHERNEY†, BRUCE A. PERKINS† Toronto, ON Aim: Corneal nerve fibre length (CNFL) is a valid screening tool for diabetic neuropathy, but has not been systematically evaluated in older adults with longstanding diabetes. We aimed to explore the diagnostic performance of CNFL in a cohort with ≥50 years of type 1 diabetes (T1D). Methods: As part of the Canadian Study of Longevity in Diabetes where 150 subjects will undergo deep-phenotyping procedures, to date 48 T1D and 46 age- and gender-matched non-diabetic controls underwent evaluation of symptoms, signs and electrophysiology to define neuropathy. CNFL was determined by corneal confocal microscopy, and diagnostic performance was determined by receiver operating characteristic curves. Results: T1D participants were mean age 66±7 years, had median diabetes duration 54 (IQR 52 to 59) years, 28 (58%) female; nondiabetic controls were age 65±8 years and 32 (70%) female. Fortyone (85%) of T1D participants met neuropathy criteria. Mean sural nerve amplitude for non-diabetic controls (9.5±5.5 μV) was similar to T1D without neuropathy (8.4±2.8 μV, p=0.83) and was lowest for T1D with neuropathy (3.4±1.6 μV, p<0.001 for both comparisons). Mean CNFL for non-diabetic controls (20.0±5.7 mm/mm2) was similar to T1D without neuropathy (18.8±8.9 mm/mm2; p=0.74) and was lower for T1D with neuropathy (9.5±5.4 mm/mm2; p<0.001 for both comparisons). In T1D, area under the curve was 0.81, optimal threshold 13.7 mm/mm2, sensitivity 78%, specificity 86%. Conclusion: The diagnostic performance—even the optimal threshold value—for CNFL in older adults with longstanding T1D appears to parallel that observed in younger patients with shorter duration. As agerelated changes in CNFL do not appear to impair diagnostic validity, CNFL screening protocols may be applied to broad T1D populations. 140 Change is Afoot: Lower Extremity Amputation in Nova Scotia, 1996/97 to 2012/13 PAM TALBOT*, JENNIFER PAYNE, MARGARET DUNBAR Halifax, NS Purpose: Lower extremity amputations (LEAs) are a devastating complication of diabetes. Since 1991, Nova Scotia (NS) has fostered intensive prevention efforts for high-risk patients while promoting population-based prevention messages to the broader diabetes population. This work examined the burden of LEAs among NS adults (≥20 years) with and without diabetes between 1996/97 and 2012/13. Methods: Records from the NS health insurance registry, LEA hospital admissions and the Canadian Chronic Disease Surveillance System were linked at the individual level for 1996/97 to 2012/13. Results: Nearly 3500 individuals had ≥1 LEA admissions over the period. On average, there were 281 LEA admissions annually (DM=194, no DM=87). Over time, the annual number of LEA admissions among those with DM was relatively stable despite increasing DM prevalence (3% in 1996/97 to 11% in 2012/13). The LEA admission rate among those with DM decreased >55% from 47/10,000 to 21/10,000. Those with DM (vs. those without) were far more likely to have an LEA admission: 51x, 16x, 10x and 5x for individuals 20 to 59 years, 60 to 69 years, 70 to 79 years and ≥80 years, respectively. LEAs among