Insulin Treatment 2

8/8/2019 Insulin Treatment 2

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ObjectivesObjectives

To know indications for insulin therapy To know indications for insulin therapy To know types and pharmaco-dynamics of insulin To know types and pharmaco-dynamics of insulin

To know different types of insulin regimens To know different types of insulin regimens To know how to initiate and titrate insulin dosage To know how to initiate and titrate insulin dosage


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Current indications for insulinCurrent indications for insulintherapytherapy

Patients with type 1 DMPatients with type 1 DM Type 2 DM Type 2 DM

Initial stabilization of patients with severeInitial stabilization of patients with severehyperglycemiahyperglycemiaHyperglycemic crisesHyperglycemic crisesPregnancyPregnancySignificant liver or kidney diseaseSignificant liver or kidney diseaseStressful situations ( ACS, ICU, major surgery, severeStressful situations ( ACS, ICU, major surgery, severe

infection, corticosteroid therapy.etcinfection, corticosteroid therapy.etcPatients in whom oral glucose-lowering therapy hasPatients in whom oral glucose-lowering therapy hasfailedfailed


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Onset of action

(h or min)

.

Peak actio

n

(h)

Maximalduration

(h)

Insulin types and durationInsulin types and durationof actionof action

Insulin PreparationInsulin Preparation

Short-acting 30 min 1-3 6-8Intermediate-acting 1-2 h 5-10 18-24Premixed insulin 30/70 0.5-1 h 5-9 18-24Rapid-acting insulin analogue 10-20 min 1-2 h 3-5 hLong-acting insulin analogue

(glargine,Detemir) Peakless 24 h


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Storage of insulinStorage of insulin

Stable at room temperature for 4 weeksStable at room temperature for 4 weeksShould not be exposed to temperaturesShould not be exposed to temperatures> 25C or under freezing point> 25C or under freezing pointUnused vials and cartridges should beUnused vials and cartridges should bestored in the refrigeratorstored in the refrigerator

Should never be exposed to sunlightShould never be exposed to sunlightShould never be frozenShould never be frozen


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Insulin RegimenInsulin Regimen

Combination therapyCombination therapy (for T2DM only)(for T2DM only)- bed-time insulin + OHA- bed-time insulin + OHA

Total insulin replacement Total insulin replacement (Type(Type1&2 DM)1&2 DM)

- Twice daily insulin mixture Twice daily insulin mixture-

Basal-bolus regimenBasal-bolus regimen


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Combination therapyCombination therapy- bed-time insulin + OHA- bed-time insulin + OHA

Total insulin replacement Total insulin replacement- Twice daily insulin mixture Twice daily insulin mixture- Basal-bolus regimenBasal-bolus regimen


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Insulin Therapy for Type 2 DMInsulin Therapy for Type 2 DMCombination therapyCombination therapy

Continue Maximal dose of OHAContinue Maximal dose of OHA

Add either NPH or insulin Glargine at bed timeAdd either NPH or insulin Glargine at bed time (both(bothare effective but the incidence of noctural hypoglycemia isare effective but the incidence of noctural hypoglycemia is

lower with insulin Glargine)lower with insulin Glargine)Start by 10 units and adjust insulin dose guided byStart by 10 units and adjust insulin dose guided byFBG to achieve FBG between 80 and 120 mg/dlFBG to achieve FBG between 80 and 120 mg/dl

If PPG


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Initiation and Titration of BasalInitiation and Titration of Basal

Insulin in DM2 patients on OHAInsulin in DM2 patients on OHAAdd 10 units Basal insulin at bedtimeAdd 10 units Basal insulin at bedtime

(NPH , Detemir, or Glargine)(NPH , Detemir, or Glargine)

Continue current oral agentsContinue current oral agents Titrate insulin weekly to fasting BG < Titrate insulin weekly to fasting BG 180 mg/dL, increase 8 units- if >180 mg/dL, increase 8 units


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Biphasic insulin treatment guidelines Twice-daily regimen

IndicationsIndications

Type 2 diabetic patients not controlled Type 2 diabetic patients not controlledon once-daily regimenon once-daily regimen

Type 1 diabetic patients Type 1 diabetic patients

GiudelinesGiudelines

For Type 2 diabetic patients stop OAD except MetforminFor Type 2 diabetic patients stop OAD except MetforminStarting daily dose = 0.3-0.5 U/Kg body weightStarting daily dose = 0.3-0.5 U/Kg body weightGive 2/3 of the total daily dose before breakfast and 1/3 before dinnGive 2/3 of the total daily dose before breakfast and 1/3 before dinnTitrate the dose according to FBG and PPG Titrate the dose according to FBG and PPG


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Twice-daily injections, mixture short and intermediate, Twice-daily injections, mixture short and intermediate,before breakfast and the evening mealbefore breakfast and the evening meal

8 am 12 4 pm 8 pm 12 4 am 8am8 am 12 4 pm 8 pm 12 4 am 8am

B S L S D SB S L S D S

InsulinInsulinRegimenRegimen

HypoglycemiaHypoglycemia


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SnackSnack




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hyperglycemiahyperglycemia




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HypoglycemiaHypoglycemia




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4:004:00

2525

5050

7575

8:008:00 12:0012:00 16:0016:00 20:0020:00 24:0024:00 4:004:00

BreakfastBreakfast LunchLunch Dinner Dinner

Plasma Insulin

Plasma InsulinU/ml)

U/ml)

TimeTime

Physiological Insulin SecretionPhysiological Insulin SecretionProfileProfile


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00.0000.00 08.0008.00 12.0012.00 18.0018.00 24.0024.00

Basal insulinBasal insulin

Prandial insulinPrandial insuline.g. Aspart, Lispro,e.g. Aspart, Lispro,GlulisineGlulisine

Basal Bolus TherapyBasal Bolus Therapy

I n s u

l i n

I n s u

l i n

l e v e

l s

l e v e

l s e.g.e.g. GlargineGlargine


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00.00 08.00 12.00 18.00 24.00

Basal insulin

Prandial insulin

Basal Bolus Therapy

I n s u

l i n

l e v e

l s eg: Glargine


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00.00 08.00 12.00 18.00 24.00

Basal insulin

Prandial insulin

Basal Bolus Therapy

I n s u

l i n

l e v e

l s eg: Glargine

S i B l B l


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Starting a Basal-BolusRegimen

TDD = Weight (kg) x 0.5 U/kg TDD = Weight (kg) x 0.5 U/kg

TDD TDD

Basal Insulin DoseBasal Insulin Dose TDD TDD

Bolus Insulin DoseBolus Insulin Dose TDD TDD

Breakfast DoseBreakfast Dose1/6 TDD1/6 TDD

Lunch DoseLunch Dose1/6 TDD1/6 TDD

Dinner DoseDinner Dose1/6 TDD1/6 TDD

S i B l B l


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TDD = Weight (kg) x 0.5 U/kg TDD = Weight (kg) x 0.5 U/kg

TDD TDD






S i B l B l


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TDD = 110 (kg) x 0.5 U/kg TDD = 110 (kg) x 0.5 U/kg

TDD TDD






S i B l B l


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55 U55 U






S i B l B l


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55 U55 U

Basal Insulin DoseBasal Insulin Dose

27 U27 U

Bolus Insulin DoseBolus Insulin Dose

27 U27 U




St ti B l B l


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55 U55 U

Basal Insulin DoseBasal Insulin Dose

27 U27 U

Bolus Insulin DoseBolus Insulin Dose

27 U27 U

Breakfast DoseBreakfast Dose9 U9 U

Lunch DoseLunch Dose9 U9 U

Dinner DoseDinner Dose9 U9 U


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Adjustment of insulinAdjustment of insulindosagedosage

Basal-bolus regimenBasal-bolus regimenBasal insulin is adjusted according toBasal insulin is adjusted according toFPG levelsFPG levels

Prandial insulin is adjusted accordingPrandial insulin is adjusted accordingto the PPG level after each meal byto the PPG level after each meal byincreasing the corresponding insulinincreasing the corresponding insulin

dose by 2-4 unitsdose by 2-4 units

Titrate insulin weekly to fasting BG Titrate insulin weekly to fasting BG< 100 mg/dL< 100 mg/dL

- if 120-140 mg/dL, increase 2- if 120-140 mg/dL, increase 2

unitsunits- if 140-160 mg/dL, increase 4- if 140-160 mg/dL, increase 4

unitsunits- if 160-180 mg/dL, increase 6- if 160-180 mg/dL, increase 6

unitsunits- if >180 mg/dL, increase 8 units- if >180 mg/dL, increase 8 units


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Insulin Treatment 2