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The presentation consists of practical issues as well as background theory regarding insulin therapy.
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Insulin: Initiation, optimization, maintenance
Dr. Mashfiqul HasanPhase B Resident
Department of EndocrinologyBSMMU
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Milestones of insulin therapy
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INDICATION FOR INSULIN THERAPY IN TYPE 2 DIABETES
Acute metabolic complications
Acute illness
Severe infection
Pregnancy and lactation
Fasting plasma glucose >300 mg/dl
Failure of oral anti-diabetic agent
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Types Examples
Bolus (Meal) InsulinRapid-acting Insulin lispro,
Insulin aspartShort-acting Regular
Basal (Background) InsulinIntermediate-acting NPH, Lente
Long-acting Glargine, Detemir
Pre-Mixed InsulinNPH/Regular 70/30, 50/50NPL/Lispro Mix 75/25NPA/Aspart Mix 70/30
Insulin
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0 2 4 8 10 12 14 16 18 20 22 24
Plas
ma
Insu
lin
Leve
ls
Hours
NPH (12–16 hr)
Regular (6–8 hr)
Glargine (~22 hr)
ASAspart, Lispro (4–5 hr)
Ultralente (~16–20 hr )
Insulin Profiles – schematic (duration)
Detemir (~20 hr)
INSULIN THERAPY in Diabetes Mellitus
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• Combination of Oral Agent-Insulin
– Single bedtime injection Glargine or NPH
• Conventional Insulin Stages 2 and 3
• Physiologic Insulin Stage 4
– Basal/Bolus Regimen
– 4 or more injections/day
Insulin Regimens
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0
10
20
30
40
50
0 2 4 6 8 10 12 14 16 18 20 22 24
Normal Insulin SecretionS
eru
m in
su
lin
(m
U/L
)
Time (Hours)
Meal Meal Meal
Basal Insulin Needs
Bolus insulin needs
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BASAL, BASAL-PLUS, BASAL-BOLUS
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Guidelines for commencing insulin
● Continue oral hypoglycaemic agents
● intermediate-acting/long-acting insulin at bedtime
● Initial dose 0.2 units/kg
● Monitor FP
● Aim for FPG 4-8 mmol/L (72-244mg/dl) (individualise)
● Adjust insulin by 2-4 units every 3-4 days until FPG target is met
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PREMIX INSULIN
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Start with once daily 6-10 units•In the morning : if the pre-dinner blood glucose is high•In the evening : if the pre-breakfast blood glucose is high
Titrate according to following schedule
Pre-breakfast or Pre-dinner BG Chang in insulin dose (U)
<6 -2
6-7 0
>7 +2
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• For human premix when dose >20 U split the dose: 2/3 in morning and 1/3 in evening• For premix analogue split the dose when dose is >30 units, consider splitting dose equally between breakfast and dinner.
Adjust breakfast dose necessary based on
post-lunch to pre dinner glucose levels
Adjust pre-dinner dose necessary based on post-dinner to pre-
breakfast glucose levels
SPLIT-MIX INSULIN
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Split Mix Regimen
Intermediate acting + short-acting
Before Breakfast
Time of day
60
0
20
40
Intermediate acting + short-acting
Before Dinner
Others
• Regular insulin
• Sliding scale
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PRINCIPLES OF INITIATION
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References
• Text book of diabetes
• Bangladesh Insulin guideline for type 2 diabetes
• ADA guideline 2014
• UpToDate 19.3
• Lecture of Prof. Md. Fariduddin & Prof. M A Hasanat
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THANK YOU
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