Insulin initiation and adjustment

Supervisor by : Dr. Mostafa Baker

Consultant FM
Prepared by : Dr. Mousa Hulal R4
 Case 1
year-old male with type 2 DM 10 years ago, DLP He is already-56
on Current medications are metformin 1000 mg BID, gliclazide 160
mg BID daily, sitagliptin 100 mg and simvastatin 40 mg OD
Initially he was controlled on the same medications with HbA1c 6.9.
mg/dl however since 1 year his FBG always in the range of 260-300
and HbA1c 10.8%
.he says that he compliant to diet
: On examination
Wt: 80 kg Ht:150 cm BMI :35
Rest examination : unremarkable
?What you will recommend for this patient
 Case 1
year-old male with type 2 DM 10 years ago, DLP He is already on-56
Current medications are metformin 1000 mg BID, gliclazide 160 mg
BID daily, sitagliptin 100 mg and simvastatin 40 mg OD
Initially he was controlled on the same medications with HbA1c
6.9.however since 1 year his FBG always in the range of 260-300
mg/dl and HbA1c 10.8%
.he says that he compliant to diet
: On examination
Wt: 80 kg Ht:150 cm BMI : 35
Rest examination : unremarkable
?What you will recommend for this patient
 Next steps
Make a decision to start insulin
Offer patient encouragement, not blame
.you decided to go with Basal insulin
Starting with 10 u/day at bedtime
Indications of Insulin Therapy
 Indications of Insulin Therapy
?When is Insulin Appropriate
When OHAs are not enough to achieve target glycemic status-1
% A1C > 10 -2
Random glucose levels >300 mg/dL-3
Fasting blood sugar > 250 mg/dl-4
Type 1 DM is suspected-5
hyperglycmic For patients presenting with symptomatic of severe-6
with ketonuria or weight loss ,DKA , during surgery
Pregnancy-7
 Insulin Regimens
There are 3 primary insulin regimens for type 2 DM
Glargine, Detemir)) 1. Basal insulin once daily
Basal + bolus insulin .2
Rapid-acting (mealtime): lispro, aspart, glulisine
Short-acting (mealtime): regular insulin
Premixed insulin(Insulin mixtures) twice daily .3
NPH/short - NPH/rapid
 Insulin Regimens
Pre-Mixed Insulin
70/30, 50/50 NPH/Regular •
Mix 75/25 NPH/Lispro •
Mix 70/30 NPH/Aspart •
 Glycemic Targets
o HBA1c Less than 7%.
o Pre-prandial : 80-130 mg/dl
o Peak postprandial : < 180 mg/dl
 Step One: Initiating Insulin
Start with either…
Bedtime long-acting/intermediate acting insulin
Starting Basal Only Insulin (Augmentation) and
Advancing to Basal/Bolus Insulin (Replacement)
 Calculation Basal Dose
:STARTING DOSE
Start dose: 10 units
Consider using a lower starting dose (such as 0.1
units/kg/day) especially if patient is thin or has a
.fasting glucose only minimally above goal
.Start insulin at night
When starting basal insulin: Continue
.secretagogues and Continue metformin
 :TITRATE
Teach patient to self titrate ↑ by 2 units every
2-3 days until average fasting glucose < 130
Inform patient to hold titration until further)
(evaluation if develops any hypoglycemia
If hypoglycemia occurs or if fasting glucose less
than 70 mg/dl Reduce bedtime dose by ≥4 units
or 10% if dose >60 units
 General Considerations
Consider the following goals when Starting basal insulin:
A1C Goals: A1C < 7.0 for most patients
A1C > 7.0 (consider 7.0-7.9) for higher risk patients
History of severe hypoglycemia -1
Multiple co-morbid conditions .2
Long standing diabetes .3
Limited life expectancy .4
Advanced complications .5
Difficult to control despite use of insulin .6
 General Considerations
Basal insulin not causing hypoglycemia
NPH Note: NPH insulin has elevated risk of
.hypoglycemia so use with caution
Note: if NPH causes nocturnal hypoglycemia,
consider switching NPH to long-acting insulin
 General Considerations
…After 2-3 Months
If HbA1c is <7%
Continue regimen and check HbA every 3months
: If HbA1c is ≥7%
adding a GLP-1 receptor agonist -1
) Add prandial insulin) 2- Move to Step Two
Initiation and adjustment of insulin
regimens in type 2 DM

step one
 Case 2
A 62-year-old female with type 2 diabetes mellitus routinely has fasting
blood glucose levels in the 80–100 mg/dL range and her hemoglobin A1c
level is 7.8%. She has been diligently monitoring her blood glucose levels
.and all are acceptable with the exception of She elevated bedtime readings
glargine (Lantus), 18 U at night She currently on
Which one of the following changes would be most appropriate for this
?patient
A) Adding rapid-acting insulin at breakfast
B) Adding rapid-acting insulin at lunch
C) Adding rapid-acting insulin at dinner
D) Increasing the nightly insulin glargine dose
This patient continues to have an elevated hemoglobin
A1c and bedtime hyperglycemia. The addition of a
rapid-acting insulin at dinner would be the next step in
.management
For patients exhibiting blood glucose elevations before
dinner, the addition of rapid-acting insulin at lunch is
.preferred
For patients with elevations before lunch, rapid-acting
insulin with breakfast would most likely improve glucose
.control
Increasing or splitting the insulin glargine would be
.unlikely to improve management
 Step Two: Intensifying Insulin
If fasting blood glucose levels are in target range
but HbA1c ≥7%, check blood glucose before
lunch, dinner, and bed and add a second
injection
Add prandial insulin to basal insulin if
.post-meal blood glucose levels are above goal
Initiation and adjustment of insulin regimens
in type 2 DM

step two
If pre-lunch blood glucose is out of range, add
rapid-acting insulin at breakfast
If pre-dinner blood glucose is out of range, add
NPH insulin at breakfast or rapid- acting insulin
at lunch
If pre-bed blood glucose is out of range, add
rapid-acting insulin at dinner
 BASAL BOLUS REGIMEN replacement
There is the option of only adding bolus insulin to the meal with
the highest postprandial BG as a starting point for the patient
.who is not ready for more injections

Starting dose 4 unit and titrate 1-2 unit every 2- 3 days until post
meal glucose < 180

For current basal insulin users, maintain the basal dose and add
bolus insulin with each meal at a dose equivalent to 10% of the
.basal dose

For example, if the patient is on 50 units of basal insulin, add 5

units of bolus insulin with each meal
 BASAL BOLUS REGIMEN replacement

Calculate total daily insulin dose (TDI) as 0.6 to 1 units / kg

Basal + Bolus Insulins
of TDI dose as basal insulin at bedtime % 50
of TDI dose as bolus insulin prior to each meal % 50

Adjust the dose of the basal insulin to achieve the target fasting
BG level (usually 4-7 mmol/L)

Adjust the dose of the bolus insulin to achieve postprandial BG

levels (usually 5-10 mmol/L)

Consider stopping the secretagogue when bolus insulin is

added, and continue metformin
Metformin (Glucophage) combined with insulin
,is associated with decreased weight gain
lower insulin dose, increased insulin sensitivity
and less hypoglycemia compared with insulin
.alone
Adjustment prandial insulin dosing
depends upon

1-Pre-meal plasma glucose levels .

2- meal size (carbohydrate content).
 Adjustment prandial insulin dosing
A usual starting dosage for patients with type 2
diabetes is 1 U of rapid-acting insulin for every 10 g
of carbohydrate eaten plus an additional 1 U for
every 30 mg/dL above the target self-monitoring
.blood glucose
For example, a patient who had a premeal self-
monitoring blood glucose level of 160 mg/dL, and
was planning to eat a meal containing 30 g of
4 carbohydrate, would take a prandial insulin dose of
.U
 Adjustment prandial insulin dosing
If the patient is uncomfortable counting
carbohydrates, the physician can recommend a
range of insulin dosages empirically based on
.the size of the meal
U of a rapid-acting analog for a small meal and 5
.U for a large meal 8-10
plus additional units of insulin, if needed, based
on the pre -meal self-monitoring blood glucose
.level reading
 After 2-3 Months
If HbA1c is <7%...
Continue regimen and check HbA1c every 3 months
...If HbA1c is ≥7%
…Move to Step Three
step three
Step Three: Further Intensifying Insulin
Recheck pre-meal blood glucose and if out of
range, may need to add a third injection:
If HbA1c is still ≥ 7%
Check 2-hr postprandial levels
Adjust preprandial rapid-acting insulin
Hypoglycemia
Tell patient to carry rapidly absorbed carbohydrate
source at all times and teach friends and family about
how to treat low glucose. Treat low glucose (<70) as per
Rule of 15’s: Give 15 gm of rapidly absorbed
carbohydrate (ie: 1/2 cup juice or 4 glucose tabs).
Recheck glucose level in 15 minutes. Give another 15 gm
of carbohydrate if glucose still < 70. Repeat until the
glucose level is > 70. Once glucose level returns to
normal administer insulin and meal as usual
Prescribe glucagon kit for high risk patient to have at
home
Exercise
Low glucose levels may occur during or after exercise.
Carry glucose source when exercising. Check glucose
before and during exercise. If patient has low glucose
levels associated with exercise: consider decreasing
preceding prandial insulin dose (if within several hours
before exercise) and/or taking extra carbohydrates
.before or during exercise
Education
All patients should receive Diabetes Self Management
Training (DSMT) and Medical Nutrition Therapy (MNT) by
.diabetes educator if possible
Note: If patient unable to do multiple daily
injections with ( basal- bolus regimens) consider
switching to MIXED INSULIN
Mixed insulin is more likely to cause
hypoglycemia and generally requires a fixed
.
meal schedule
 Case 3
years old engineer, diagnosed with diabetes 8 years 63
ago ,commenced 6 months ago on basal-bolus regimen
Currently on 27 unit basal and 9 unit rapid insulin with
each meals and metformin
% Glycemic control improved from 8.9 % to 7.6
Patient eats mainly breakfast and dinner due to his work
himself Today presented to you with inability to injected
multiple injections
?Which insulin should be used
 Mixed Regimens
If patient unable to do multiple daily injections with
( basal- bolus regimens)
and generally requires a fixed meal schedul
consider switching to MIXED INSULIN regimen
Example Pre-Mixed Insulin
70/30, 50/50 NPH/Regular •
Mix 75/25 NPH/Lispro •
Mix 70/30 NPH/Aspart •
 Premixed Insulin dose
Continue the metformin and consider stopping the
.secretagogues

The easiest way to initiate this regimen is to start at

a dose between 5 and 10 units before breakfast and
.dinner then titrate

more effective in reducing postprandial blood

glucose levels but less effective in reducing fasting
.blood glucose
 Premixed Insulin dose
Step1:First calculate the total daily starting requirement of insulin
Body Weight / 2
For a 60 kg patient
total daily dose =30 units
Step 2: Then divide this dose into 3 equal parts
10+10+10
Step 3:Give 2 parts in the morning and 1 part in the evening
Morning=20U + Evening=10 U

Another approach is 50% of the dose In the morning and 50% at bedtime
 Dose Titration of premixed
You can increase or decrease the dose of pre-mixed
% insulin by 10
If the patients is using
units………….….+/- 1 unit 1-10
units……………+/- 2 units 11-20
units……………+/- 3 units 21-30
units……………+/- 4 units 31-40
 Glycemic Targets
o HBA1c Less than 7% (6.5, 8)
o Pre-prandial : 80-130 mg/dl
o Peak postprandial : < 180 mg/dl
 Advantages of premixed insulin
Easy to administer for the physician
Easy to fill and inject by the patient
Provides both basal and bolus coverage with
fewer number of injections
SUMMERY
Oral medications should not be abruptly
discontinued when starting insulin therapy
.because of the risk of rebound hyperglycemia
Patients should measure blood glucose two to
four times daily during insulin dose adjustment
and when changes in daily activities (traveling,
changes in diet or exercise pattern) or acute
.illness makes insulin adjustments necessary
 Pearls for practice
Never try to control diabetes with oral drugs or
insulin without first ensuring strict diet control.
Always bring fasting sugar to normal before trying
.to control random blood sugar
Control any underlying infection/stressful
.condition
 Pearls for practice
Keep meal timings regular with 6 hrs between
.the three meals
Keep number of calories during the meals same
.from day to day
The quantity and quality of diet should be same
.at same timings
.Use proper technique to inject s/c insulin
Ensure proper storage of insulin
 Sites of Injection
Arms
Legs
Abdomen
buttocks
 Injection Technique

Injection technique :
Tight skin fold
Appropriate needle size
degree angle 90
lipodystrophy Change site to avoid

:Storage
injections:refrigerate
Pens: don’t refrigerate
shelf life :One month
once opened
 References
ADA -
AAFP -
MEDSCAPE -
UPTODATE -
Thanks To All