Insulin therapy in the management of diabetes

Insulin: Initiation, optimization, maintenance

Dr. Mashfiqul HasanPhase B Resident

Department of EndocrinologyBSMMU

2Dr. Mashfiq - Endocrine - BSMMU


Milestones of insulin therapy


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


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


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

6


• 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


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


Dr. Mashfiq - Endocrine - BSMMU 10

BASAL, BASAL-PLUS, BASAL-BOLUS


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







PREMIX INSULIN



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


• 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


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


PRINCIPLES OF INITIATION






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


THANK YOU


Health & Medicine

Insulin therapy in the management of diabetes