1. SDM: Focus on Insulin Therapy

2. Major microvascular and macrovascular
complications of diabetes
Microvascular1,2 Macrovascular1,2
Cognitive impairment3 Cerebrovascular disease
Diabetic retinopathy Coronary disease
Coronary heart disease
Diabetic nephropathy
Diabetic neuropathy
Cardiac autonomic Atherosclerosis
neuropathy
Skin infection
Gastro-intestinal and Peripheral vascular
bladder dysfunction disease
Sexual dysfunction
Peripheral sensory
dysfunction
Diabetic foot
Adapted from: 1. International Diabetes Foundation. Time to Act: Type 2 diabetes, the metabolic
syndrome and cardiovascular disease in Europe. 2006. 2. International Diabetes Federation. Time to Act.
2001. 3. Seaguist ER. Diabetes. 2010;59:4-6.

3. UKPDS: Tight Glycaemic Control Reduces
Complications
Epidemiological extrapolation showing benefit of a 1% reduction in mean HbA1c
Deaths related
21%
to diabetes *
Microvascular
37% complications e.g.
HbA1c kidney disease and
blindness *
1% 14% Heart attack *
Amputation or fatal
43% peripheral blood
* p<0.0001 vessel disease *
** p=0.035
Stroke **
12%
Stratton IM et al. UKPDS 35. BMJ 2000; 321: 405–412

4. Scientific Foundation for Insulin
Therapy in Type 2 Diabetes
 Why is insulin needed?
 When is insulin needed?
 Is insulin therapy effective?
 Is insulin therapy safe?

5. Achieving Glycemic Control
The first step is to set a glycemic target
(agreed to by the patient)
HbA1c target (%)
ADA/EASD <7
IDF ≤6.5
NICE <6.5
AACE ≤6.5
France <6.5*
Canada ≤7
Australia ≤7
Latin America <6.5
Are these HbA1c targets still appropriate in light of recent clinical trials?

6. Scientific Foundation for Insulin
Therapy in Type 2 Diabetes
 Why is insulin needed? To achieve glycemic targets
 When is insulin needed?
 Is insulin therapy effective?
 Is insulin therapy safe?

7. Clinical Inertia:
“Failure to Advance
Therapy When Recommended”
Mean A1C at Last Visit* (%)
10 9.6%
8.9%
8.6% Combination
9
oral agents
SU or
Diet and metformin
8 Exercise
7
ADA Goal 2.5 Years 2.9 Years 2.8 Years
Initiation
8.2 Years of
insulin therapy
Years Elapsed Since Initial Diagnosis
*Adapted from: Brown JB et al. Diabetes Care. 2004;27:1535-1540.

8. Staged Diabetes
Management
*
* Liraglutide approved in EU
Mazze, Strock, Simonson, Kendall, Cuddihy, Bergenstal. SDM Quick Guide 5th Edition, International Diabetes Center, 2009

9. ADA/EASD Revised Algorithm for T2DM
Nathan DM, et al. Diabetes Care & Diabetologia January 2009.
Tier 1: well-validated therapies
Lifestyle + Metformin Lifestyle + Metformin
+ Basal insulin + Intensive insulin
At diagnosis:
Lifestyle +
Insulin
Metformin Lifestyle + Metformin
+ Sulfonylureas
STEP 1 STEP 2 STEP 3
Tier 2: Less well validated therapies
Lifestyle + Metformin
+ Pioglitazone Lifestyle + metformin
No hypoglycaemia + Pioglitazone
Oedema/CHF
Bone loss + Sulfonylurea
Lifestyle + metformin Lifestyle + metformin
+ GLP-1 agonist + Pioglitazone
No hypoglycaemia
Weight loss + Basal insulin
Nausea/vomiting

10. ADA/EASD Revised Algorithm for T2DM
Nathan DM, et al. Diabetes Care & Diabetologia January 2009.
Tier 1: well-validated therapies
Lifestyle + Metformin Lifestyle + Metformin
At diagnosis: Insulin
+ Basal insulin + Intensive insulin
Lifestyle +
Metformin Lifestyle + Metformin
+ Sulfonylureas
STEP 1 STEP 2 STEP 3
Tier 2: Less well validated therapies
Lifestyle + Metformin
+ Pioglitazone Lifestyle + metformin
No hypoglycaemia + Pioglitazone
Oedema/CHF
Bone loss + Sulfonylurea
Lifestyle + metformin Lifestyle + metformin
+ GLP-1 agonist + Pioglitazone
No hypoglycaemia
Weight loss + Basal insulin
Nausea/vomiting

11. *
* Liraglutide approved in EU
Mazze, Strock, Simonson, Kendall, Cuddihy, Bergenstal. SDM Quick Guide 5th Edition, International Diabetes Center, 2009

12. Scientific Foundation for Insulin
Therapy in Type 2 Diabetes
 Why is insulin needed? To achieve glycemic targets
 When is insulin needed? Earlier in the treatment plan
 Is insulin therapy effective?
 Is insulin therapy safe?

13. Type 2 Diabetes Master DecisionPath
METFORMIN
Titrate to clinically effective dose Advance if not at target in 3 months
TWO DRUG THERAPY
Add SU Add DPP4-I Add GLP-1 Agonist Add TZD
THREE DRUG THERAPY
Add Background Insulin Add Background Insulin
or Add Background Insulin or
TZD, DPP-4, GLP1 Or TZD, SU
SU, DPP-4, GLP1
A1C >11%
FPG >300 mg/dL Titrate to clinically effective dose Advance if not at target in 3 months
RPG >350 mg/dL
Start Insulin
(Multi-Dose
MULTI-DOSE INSULIN THERAPY
Insulin therapy
preferred)
Background & Mealtime Premixed Insulin
(main meal) + Oral Agent(s)* + Sensitizers*
2 meals
Background & Mealtime
(all meals) + Sensitizers* * Limited published data for use of insulin
plus either DPP-4 inhibitor or GLP-1
agonist
Mazze, Strock, Simonson, Kendall, Cuddihy, Bergenstal. SDM Quick Guide 5th Edition, International Diabetes Center, 2009

14. Relative contributions of postprandial glucose and FPG to
A1C
100
80
60
Contribution
(%)
40
20
0
<7.3 7.3–8.4 8.5–9.2 9.3–10.2 >10.2
A1C quintiles (%)
Fasting plasma glucose Postprandial plasma glucose
Monnier L et al. Diabetes Care. 2003;26:881-5.

15. Plasma Glucose Normally Maintained
in Narrow Range
Diabetes
400
No diabetes
Plasma Glucose (mg/dL)
control
300
200
Fix fasting first
100
0
6 AM 10 AM 2 PM 6 PM 10 PM 2 AM
Time of Day
Adapted from Polonsky KS, et al. N Engl J Med. 1988;318:1231-1239.

16. Plasma Glucose Normally Maintained
in Narrow Range
Diabetes
400
No diabetes
Plasma Glucose (mg/dL)
control
300
200
Fix fasting first
100
0
6 AM 10 AM 2 PM 6 PM 10 PM 2 AM
Time of Day
Adapted from Polonsky KS, et al. N Engl J Med. 1988;318:1231-1239.

17. Insulin Glargine vs. NPH in Treat-to-
Target Trial: HbA1c and Hypoglycemia
Randomized to NPH or Glargine +
OAD with target HbA1c <7%
16 21% risk reduction
Events per patient per year
p <0.02
9.0 14
NPH + OAD
Insulin glargine + OAD 12
8.5
10
HbA1c (%)
8.0
42% risk
8 reduction p <0.01
7.5
6
7.0
4
6.5 2
0
0 4 8 12 16 20 24 Overall Nocturnal
Weeks Hypoglycemia
Riddle et al. Diabetes Care 2003;26:3080-6.

18. Insulin Detemir vs. NPH in Treat-to-Target
Trial: HbA1c and Hypoglycemia
18
9.0 16
Events per patient per year
NPH + OAD
Insulin detemir + OAD 14 47% risk reduction
8.5 p < 0.001
12
HbA1c (%)
8.0
10
7.5
8
7.0 6 55% risk
reduction
6.5 4 p < 0.001
2
-2 0 12 24
0
Weeks
Overall Nocturnal
Hermansen et al. Diabetes Care 29:1269, 2006
Hypoglycaemia

19. Using Insulin Effectively
Physiologic Insulin Replacement
Sensitizers
Sulfonylurea / GLP-1 A / DPP-4 I
50 Long-Acting
Insulin Levels
40
30
20
10 Long-acting
0
0 2 4 6 8 10 12 14 16 18 20 22 24
Time of Day
Adapted from Polonsky. N Engl J Med. 1996;334:777-783.
Kendall DM. N Engl J Med 322: 898-903, 1990.

20. Using Insulin Effectively
Physiologic Insulin Replacement
Sensitizers
Sulfonylurea / GLP-1 A / DPP-4 I
50
Long-Acting
Insulin Levels
40
30
20
10 Long-acting
0
0 2 4 6 8 10 12 14 16 18 20 22 24
Time of Day
Adapted from Polonsky. N Engl J Med. 1996;334:777-783.
Kendall DM. N Engl J Med 322: 898-903, 1990.

21. 24-Hour Plasma Glucose Curve
Normal and People with Type 2 Diabetes
Fix Fasting First
400
300
Glucose
(mg/dL) 200
100
Meal Meal Meal
Normal
0
0600 1000 1400 1800 2200 0200 0600
Time of Day
Adapted from Polonsky et al, N Engl J Med 1988.

22. 24-Hour Plasma Glucose Curve
Normal and People with Type 2 Diabetes
Fix Fasting First
400
300
Glucose
(mg/dL) 200
100
Meal Meal Meal
Normal
0
0600 1000 1400 1800 2200 0200 0600
Time of Day
Adapted from Polonsky et al, N Engl J Med 1988.

23. Premixed Regimen with Rapid-acting
Insulin
Premixed: 75/25 with lispro, 70/30 with aspart,
50/50 with lispro

24. Background / Mealtime (Basal / Bolus)
Insulin Regimen
Rapid-acting insulin at meals Long-acting
insulin at bed

25. Improvement in HbA1c with Basal – Bolus Insulin
Regimen (Glargine / Glulisine) in Type 2 Diabetes
Simple algorithm
CHO counting
The majority of patients achieved HbA1c <7.0%
• Simple algorithm: 73.0%
p = NS
• CHO counting: 69.2%
Bergenstal RM, Johnson M, Powers M et al. Diabetes Care 2008;31:1305–10.

26. Scientific Foundation for Insulin
Therapy in Type 2 Diabetes
 Why is insulin needed? To achieve glycemic targets
 When is insulin needed? Earlier in the treatment plan
Yes – if regimen is
 Is insulin therapy effective? matched to patient’s
glucose profile and
lifestyle
 Is insulin therapy safe?

27. Scientific Foundation for Insulin
Therapy in Type 2 Diabetes
 Why is insulin needed? To achieve glycemic targets
 When is insulin needed? Earlier in the treatment plan
 Is insulin therapy effective? Yes – if regimen matched to patient’s
glucose profile and lifestyle
 Is insulin therapy safe? Used effectively – the benefits of
glycemic control out weight risks
Weight Gain Minimize by lifestyle advice & matching glycemic
profile
Hypoglycemia Minimize by lifestyle advice & matching glycemic profile
Cancer Not clear risk of exogenous insulin and cancer
established – likely some increased risk of
cancer with diabetes

28. Starting and Adjusting Insulin in
Type 2 Diabetes

29. Steps for Starting Insulin Therapy
in Type 2 Diabetes
1. Set a target or goal for glucose control
• HbA1c and self-monitored blood glucose
2. Use an algorithm to advance therapy
Apply a consistent approach with
timelines to reach goal
3. Determine the appropriate insulin
regimen
4. Calculate the starting insulin dose
5. Educate patient and family

30. Steps for Starting Insulin Therapy
in Type 2 Diabetes
1. Set a target or goal for glucose control
• HbA1c and self-monitored blood glucose
2. Use an algorithm to advance therapy
Apply a consistent approach with
timelines to reach goal
3. Determine the appropriate insulin
regimen
4. Calculate the starting insulin dose
5. Educate patient and family

31. Glycemic Targets for Type 2 Diabetes*
IDF ADA IDC/SDM
HbA1c <6.5% <7% <7%
Fasting <100 mg/dL 90 -130 mg/dL 70-120 mg/dL
and 5.5 mmol/l 6.0-7.2 mmol/l 3.9-6.7 mmol/l
Premeal
2 hour <140 mg/dL <180 mg/dL <160 mg/dL
Postmeal 7.8 mmol/l <10 mmol/l 8.9 mmol/l
* non-pregnant adults
Diabetes Care 33 Supp1, Jan 2010
Insulin BASICS 2nd ed 2008:p25, © International Diabetes Center

32. Steps for Starting Insulin Therapy
in Type 2 Diabetes
1. Set a target or goal for glucose control
• HbA1c and self-monitored blood glucose
2. Use an algorithm to advance therapy
Apply a consistent approach with
timelines to reach goal
3. Determine the appropriate insulin
regimen
4. Calculate the starting insulin dose
5. Educate patient and family

33. Staged Diabetes
Management at IDC
*
Mazze, Strock, Simonson, Kendall, Cuddihy, Bergenstal. SDM Quick Guide 5th Edition, International Diabetes Center, 2009

34. Steps for Starting Insulin Therapy
in Type 2 Diabetes
1. Set a target or goal for glucose control
• HbA1c and self-monitored blood glucose
2. Use an algorithm to advance therapy
Apply a consistent approach with
timelines to reach goal
 Determine the appropriate insulin
regimen
 Calculate the starting insulin dose
 Educate patient and family

35. Preparing for Insulin in Type 2 Diabetes
Clinical Indicators
Initiate insulin if:
 HbA1c above target for >3 months and on
maximum effective dose of 2 or more glucose-
lowering agents
 HbA1c >11% and/or symptomatic and blood
glucose >300 mg/dL
– If clinically stable and high intake of sweetened
beverages (>36 oz or 3 cans/day), eliminate sweetened
beverages and re-evaluate need for insulin in 1-2
weeks
SDM Quick Guide 5th Edition, 2009
International Diabetes Center, Park Nicollet Institute

36. Using Insulin Effectively
Physiologic Insulin Replacement
Meal Meal Meal
50 Mealtime (bolus)
40 insulin needs = 50%
Insulin Levels
30
20
10 Basal (background) insulin needs = 50%
0
0 2 4 6 8 10 12 14 16 18 20 22 24
Time of Day
Adapted from Polonsky. N Engl J Med. 1996;334:777-783.
Kendall DM. N Engl J Med 322: 898-903, 1990.

37. Insulin Time Action Curves
Rapid-Acting: Lispro (Humalog®), Aspart (NovoLog®),
Glulisine (Apidra®)
Relative Insulin Effect
Short-Acting: Regular (Humulin® R, Novolin® R)
Intermediate: NPH (Humulin® N, Novolin® N)
Long-Acting: Glargine (Lantus®)
Detemir (Levemir®)
0 2 4 6 8 10 12 14 16 18 20
Time (Hours)
Bergenstal, “Effective insulin therapy,” International Textbook of Diabetes Mellitus
vol 1. 3rd ed, Chichester NY, John Wiley and Sons, Inc., 2004:995-1015.

38. Selecting an Insulin Regimen
Background Background and
Premixed Insulin
(Basal) Insulin Mealtime Insulin ± Sensitizer(s)
+ 2 Drugs ± Sensitizer(s)
Glycemic  Elevated FPG  Elevated fasting  Elevated PPG
Factors and/or post-meal  Increasing daytime BG
 Stable daytime BG
 HbA1c >11%  HbA1c >11%
 Intensive control
Patient  Overwhelmed
 More flexibility  Decreased dexterity
Factors  Desire single injection
 Erratic schedule or visual acuity
 Regular schedule

39. Case Study: Khalida
 73 year-old woman
 Glycemic factors
Diabetes for 7 years
Taking metformin 1000 BID; and 10 mg glyburide
BID
Current HbA1c 7.9%
SMBG in morning and evening are high
 Patient factors
Very Fearful of injections

40. Background (Basal) Insulin Options
 Glargine (Lantus®) and Detemir (Levemir®)
– No significant peak; lasts up to 24 hours
– Twice daily dosing may be required
– Decreases risk of nocturnal hypoglycemia
 NPH (Humulin® N and Novolin® N)
– Less expensive
– Twice daily dosing required
Riddle et al. Diabetes Care. 26:3080-3086; 2003
Raskin et al Diabetes Care. 28:260-265; 2005

41. Starting Background (Basal) Insulin
HbA1c <9% HbA1c
≥9%
Background
Insulin 0.1 units/kg 0.2 units/kg
Dose
 Start with single dose of long-acting insulin (glargine or
detemir) or intermediate-acting insulin (NPH) at
bedtime if cost is a concern.
 Maintain oral agents: 1-2 of them - SU, Metformin,
(maybe TZD), NOTE: DPP-4 Inhibitors and/or GLP-1
mimetic with insulin is “off-label”

42. Starting Background (Basal) Insulin
Example: Khalida with HbA1c of 7.9%
Determine weight in kg
222 100
Weight in lbs _____ ÷ 2.2 = _____ kg
Calculate initial dose of background insulin
100 0.1 10
Weight in kg ______ x units/kg _____ = _____units
AM Noon PM Bed
Plan LA - 10

43. Selecting an Insulin Regimen
Background Background and
Premixed Insulin
(Basal) Insulin Mealtime Insulin
+ 2 Drugs ± Sensitizer(s)
± Sensitizer(s)
Glycemic  Elevated FPG  Elevated fasting  Elevated PPG
Factors  Stable daytime BG and/or post-meal  Increasing daytime BG
HbA1c >11%  HbA1c >11%
 Intensive control
Patient  Overwhelmed  More flexibility  Decreased dexterity
 Desire single injection  Erratic schedule or visual acuity
Factors
 Regular schedule

44. Premixed Insulin
Human Insulin Begins to Works Stops
Work Hardest Working
75/25 with Lispro
Humalog Mix 75/25
50/50 with Lispro 5-15 min 1-2 hrs 10-16 hrs
Humalog Mix 50/50
70/30 with Aspart
NovoLog Mix 70/30
70/30 with Reg
Humulin 70/30 30-45 min 4-8 / 2-3 hrs 10-16 hrs
Novolin 70/30
Based on package insert data

45. Case Study: Saleem Ahmad
 63-year-old
 Glycemic factors
Came to the Emergency Room with a foot
infection
HbA1c 11.8%
 Patient factors
Fatigued, thirsty, dehydrated, +family history of
diabetes but surprised he got diabetes and he is
scared

46. Starting Premixed Insulin
HbA1c < 9% HbA1c ≥ 9%
Premixed 0.1 units/kg 0.2 units/kg
Insulin Dose (2 times/day) (2 times/day)
0.2 units/kg 0.4 units/kg
total total
 Start with two doses; before breakfast and dinner
 Consider adding insulin sensitizer (metformin)
Guide to Starting and Adjusting Insulin for Types 2 Diabetes
© 2008 International Diabetes Center, Park Nicollet

47. Premixed regimen with rapid-acting
insulin
Premixed: 75/25 with lispro, 70/30 with aspart,
50/50 with lispro
© 2007 International Diabetes Center, Minneapolis, MN All rights reserved.
.

48. Selecting an Insulin Regimen
Background Background and
Premixed Insulin
(Basal) Insulin Mealtime Insulin
± Sensitizer(s)
+ 2 Drugs ± Sensitizer(s)
Glycemic  Elevated FPG  Elevated fasting  Elevated PPG
Factors  Stable daytime BG and/or post-meal  Increasing daytime BG
 HbA1c >11%  HbA1c >11%
 Intensive control
Patient  Overwhelmed  More flexibility  Decreased dexterity
 Desire single injection  Erratic schedule or visual acuity
Factors
 Regular schedule

49. Case Study: A Qudoos
 58 year old male
 Glycemic factors
Diabetes for 14 years
Sitagliptin/metformin (Janumet™) 50/1000 BID and 30 mg
pioglitazone (Actos®)
Current HbA1c 9.4%, elevated fasting and post-meal
glucose
 Patient factors
Eats healthy diet, exercises regularly
Desire flexible schedule for work

50. Starting Background (Basal) and Mealtime
(Bolus) Insulin
HbA1c <9% HbA1c ≥9%
Background 0.1 units/kg 0.2 units/kg
Insulin Dose (once daily) (once daily)
Mealtime 0.1 units/kg 0.2 units/kg
Insulin Dose (divided evenly (divided evenly
between meals) between meals)
Total Insulin 0.2 units/kg 0.4 units/kg
Dose
 Stop meal related therapy (Janumet™) and begin metformin
1000 mg BID.
 Consider pros and cons of maintaining pioglitazone (Actos®).

51. Background (Basal) and Mealtime (Bolus)
Insulin Regimen
RA = rapid-acting insulin: Lispro, aspart, glulisine
Rapid-acting insulin at meals Long-acting
insulin at bed

52. Steps for Starting Insulin Therapy
in Type 2 Diabetes
1. Set a target or goal for glucose control
• HbA1c and self-monitored blood glucose
2. Use an algorithm to advance therapy
Apply a consistent approach with
timelines to reach goal
 Determine the appropriate insulin
regimen
 Calculate the starting insulin dose
 Educate patient and family

53. Team Approach to Starting Insulin

54. What Gets in the Way of Starting Insulin?
Patient Concerns
1. Injections (Shots) 4. Inconvenient
2. Diabetes more 5. Sense of failure
serious 6. Hypoglycemia
3. Complicated
Bergenstal Chapter 53, International Textbook of Diabetes Mellitus 3rd
Edition, 2004 John Wiley & Sons and International Diabetes Center,
unpublished survey data

55. How does diabetes change over the
years?
Insulin Resistance
Insulin Level
Pre Diabetes
Metabolic Syndrome Impaired Incretin Action
-15 -10 -5 0 5 10 15 20 25 30
Years
© From Let’ s Talk About Insulin 2008, © International Diabetes Center

56. What Gets in the Way of Starting Insulin?
Doctor Concerns
1. Complexity of starting and
adjusting insulin
2. Not sure what it is like to
take an insulin injection
3. Weight gain
4. Hypoglycemia
5. Other concerns?
Bergenstal Chapter 53, International Textbook of Diabetes Mellitus 3rd
Edition, 2004 John Wiley & Sons; Jeavons D et al. Postgrad Med J
2006; 82:347-350.

57. Begin with a practice injection (saline)
 Can help to allay apprehension about injections
 Information that follows may be better heard
You try it!

58. Saline Injection Demonstration
1. Remove cap from the end 2. Remove the needle cap 3. Pull back on plunger 4. Insert needle and
of the syringe to the amount calculated push air into the vial
(e.g. 10 units)
5. Pull back on the 6. To remove air bubbles, 7. Pull back on the plunger to
plunger to measure the push plunger back in. measure the correct amount
correct amount (e.g. 10 (e.g. 10 units). Remove needle
units) from vial
You are ready to give the injection

59. Saline Injection Demonstration
8. Hold the syringe 9. Administer the injection into 10. Throw away the
in your hand as the abdomen. Remove needle used syringe in
shown (like holding and cover area with your a sharps container
a pen) finger for a few seconds. (do not re-cap)

60. Important Education Topics for Starting
Insulin Therapy
 Diabetes overview
 Insulin administration
 Glucose monitoring
 Simple eating guidelines
 Hypoglycemia

61. Examples of Insulin Pens
Pre-filled (Disposable)
FlexPen ®
SoloStar (sanofi aventis)
®
Re-usable (uses insulin cartridges)
HumaPen ®
NovoPen® 4

62. Sites for Insulin Administration
Abdomen preferred
Insulin BASICS 2 nd ed 2008:p19, © International Diabetes Center

63. Insulin storage
Check package insert for specific instructions
 Keep unopened insulin in refrigerator or cool
temperature
 Insulin in use can be stored at room temperature
Range is from 10 days to 42 days depending
on insulin
Check package insert for specific instructions
 Keep above freezing and below 86°F ( 30°C)
Insulin BASICS 2 nd ed 2008:p110, © International Diabetes Center

64. Important Education Topics for Starting
Insulin Therapy
 Diabetes overview
 Insulin administration
 Glucose monitoring
 Simple eating guidelines
 Hypoglycemia

65. Blood Glucose Monitoring
 To improve clinical decision-making
 To evaluate efficacy of the therapy
 To pin point problems
 To support adherence to regimen
 Feedback for the patient

66. Glycemic Targets for Type 2 Diabetes*
IDF ADA IDC
HbA1c <6.5% <7% <7.0%
Fasting <100 mg/dL 70 -130 mg/dL 70-120 mg/dL
and 5.5 mmol/l 3.9-7.2 mmol/l 3.9-6.7 mmol/l
Premeal
2 hour <140 mg/dL <180 mg/dL <160 mg/dL
Postmeal 7.8 mmol/l <10 mmol/l 8.9 mmol/l
* non-pregnant adults
Diabetes Care 29(8), Aug 2006
Diabetes Care 32 Supp1, Jan 2009
Insulin BASICS 2 nd ed 2008:p25, © International Diabetes Center

67. Ideal Testing Frequency
Patients Taking Insulin
 Minimum four times/day recommended
 Glucose testing:
– Before each meal and before bedtime
– Consider pre-meal and 30-90 minutes post meal to
evaluate effect of insulin on post-meal glucose
 Modify frequency of monitoring if necessary
 Encourage patients to record values in a record book
 Use meter with a memory for verified data
 Modify based on individual patient circumstances; vary the
times of testing to build a profile

68. Important Education Topics for Starting
Insulin Therapy
 Diabetes overview
 Insulin administration
 Glucose monitoring
 Simple eating guidelines
 Hypoglycemia
2009 International Diabetes Center

69. Quick Start: Healthy Eating Guidelines
1. Eat 3 meals per day 2. Choose a variety of foods
 Small to moderately sized  Eat fewer or smaller portions of
portions sweetened foods or beverages
 Similar portions from day to (soft drinks, juices,
day at a given meal time desserts, candy)
 Consistent meal times  Include carbohydrate at each
(initially for all insulin meal
regimens)  Avoid alcohol for now
 Include small snacks, if  Choose healthy foods when
desired possible
 Replace, reduce, restrict
Insulin BASICS 2 nd ed 2008:p34, © International Diabetes Center

70. Important Education Topics for Starting
Insulin Therapy
 Diabetes overview
 Insulin administration
 Glucose monitoring
 Simple eating guidelines
 Hypoglycemia

71. Hypoglycemia
Common Symptoms
 Weak, shaky, lightheaded
BG
 Sweaty, clammy
 Irritability
 Tingling or numb lips
Below  Confusion
 Hungry
70 mg/dL
(3.9 mmol/L)
Insulin BASICS 2 nd ed 2008:p30, © International Diabetes Center

72. Treatment of Hypoglycemia
(Routine 15)
Test blood glucose if possible
Treat with 15 gm carbohydrate if <70 mg/dL (3.8 mol/L)
– 3-4 glucose tablets or 1/2 cup
juice or soda pop
– ↑ BG ~50-60 mg/dL (3 mmol/L)
– Have carbohydrate readily available
– Avoid high-fat carbohydrates
(slower absorption)
Wait 15 minutes
Test and treat again if glucose below target
Insulin BASICS 2 nd edition 2008: p 31, © International Diabetes Center

73. Treatment of Severe Hypoglycemia
Requires assistance to treat
Note: Severe hypoglycemia is rare in type 2 diabetes
Unable to swallow safely
Needs injection of glucagon
– Hormone that releases stored
glycogen (glucose)
– Given intramuscular or subcutaneous
– Standard dose: 1.0 mg adults; 0.5 mg for children
Precautions
– May cause nausea/vomiting/headache
– Increase fluids following injection
Call for emergency assistance
Insulin BASICS 2 nd edition 2008: p 77, © International Diabetes Center

74. Hypoglycemia Prevention
 Follow food/insulin plan
 Test BG daily
 Be prepared and carry carbohydrate
 Keep records
 Wear medical ID
 Inform family, friends, co-workers
how to recognize and treat lows
 Inform doctor of low
glucose patterns
 Check BG before driving
Insulin BASICS 2 nd edition 2008, © International Diabetes Center

75. Steps for Starting Insulin Therapy in
Type 2 Diabetes
1. Set a target or goal for glucose control
HbA1c and self-monitored blood
glucose
2. Use an algorithm to advance therapy
Apply a consistent approach with
timelines to reach goal
3. Determine the appropriate insulin
regimen
4. Calculate the starting insulin dose
5. Educate patient and family

76. Fine-Tuning Glycemic Control

77. Overview
 Nutrition Messages
 Insulin Adjustments
 Glucose Data
 Treating Hypoglycemia

78. Nutrition Messages
Insulin Meals Snacks
Regimen
Background Control carbohydrate Not needed
3-4 carb choice*/meal
Pre-Mixed Eat at consistent times May be needed
with consistent carb depending on
schedule & insulin
Background Start with consistent Not needed
and Mealtime carb if snack is eaten, add
RA insulin to cover
*One carb choice = 15 grams of carbohydrate

79. Titrating Insulin for Background Regimen
If most AM fasting BG Titrate until fasting glucose at
>120 mg/dL target BG
If most AM fasting BG Test pre dinner and bedtime (or 2-
<120 mg/dL and HbA1c hour post dinner) and consider
remains above target need for mealtime insulin
Guide to Starting and Adjusting Insulin for Types 2 Diabetes
© 2008 International Diabetes Center, Park Nicollet

80. Titration Guide (Table 6)
If most BG <200 mg/dL
<70 mg/dL Decrease by 1-3 units
70-120 mg/dL No change
121-200 mg/dL Increase by 1-3 units
>200 mg/dL Increase by 3-5 units or 10%
SDM Quick Guide, 2009, IDC
Guide to Starting and Adjusting Insulin for Types 2 Diabetes
© 2008 International Diabetes Center, Park Nicollet

81. What adjustments would you
make for Khalida?
Pre- Ins- Post Pre Ins- Pt Pre- Ins Post HS
Bkfst Med Med Din
Mon 155 Met. 121 Met. 148 10
1000 1000
LA
Glyb. Glyb.
10 10
Tue 163 142 199 10
LA
Wed 143 112 143 10
LA
Thur 133 96 116 12
LA
Started at 0.1 units/kg x 100 kg (220#) =10 units

82. After Insulin Adjustment
Pre- Ins- Post Pre Ins- Pt Pre- Ins Post HS
Bkfst Med Med Din
Mon 137 Met. 111 Met. 147 12
1000 1000
LA
Glyb. Glyb.
10 10
Tue 140 125 165 12
LA
Wed 122 102 137 12
LA
Thur 148 114 156
?

83. Titrating Insulin for Background Regimen
If most AM fasting BG Titrate until fasting glucose at
>120 mg/dL target BG
If dose reaches 0.5-0.7 units/kg
body weight, consider adding
mealtime insulin
If most AM fasting BG Test pre dinner and bedtime (or 2-
<120 mg/dL and HbA1c hour post dinner) and consider
remains above target need for mealtime insulin
Guide to Starting and Adjusting Insulin for Types 2 Diabetes
© 2008 International Diabetes Center, Park Nicollet

84. Step-wise Transition from Background
to Background & Mealtime Regimen
 Start with single injection rapid-acting insulin before largest meal
(most carb. choices)
– 0.1 units/kg rapid-acting (RA) insulin
 Subtract 0.1 units/kg from background insulin dose
 Consider maintaining oral agents
 Example 100 kg patient on 60 units background insulin
New dose: 100 kg x 0.1 units/kg = 10 units RA before largest meal
60 units – (0.1 units/kg) = 50 units background insulin
Staged Diabetes Management Quick Guide
© 2007 International Diabetes Center, Park Nicollet

85. Titrating Insulin for Premixed Regimen
If most BG >200 mg/dL Increase total insulin by 0.1
units/kg
Distribute equally between doses
If most BG <200 mg/dL Use titration guide to adjust
AM FBG: adjust pre-dinner insulin
dose
Pre-dinner: adjust pre-breakfast
insulin

86. How would you adjust
Saleem Ahmad dose of Mix 75/25?
Pre- Ins Post Pre Ins Post Pre- Ins Post HS
Bkfst Din
Mon 265 19 201 19 236
Tue 244 19 198 19 254
Wed 254 19 205 19 215
Thur 195 24 206 227
24
Started at 0.2 units/kg x 95 kg (209#) = 19 units AM and PM
0.1 units/kg x 95 kg (209#) = 9.5 units

87. After Insulin Adjustment
Pre- Ins Post Pre Ins Post Pre- Ins Post HS
Bkfst Din
Mon 184 24 162 24 210
Tue 193 24 182 24 219
Wed 174 24 158 24 183
Thur 160 26 155 26 194
Use titration guide to adjust

88. Titrating Insulin for Background &
Mealtime Regimen
If most BG >200 mg/dL Increase total insulin by 0.1 units/kg
Add half to background
Distribute remaining half between
mealtime doses
If most BG <200 mg/dL Use titration guide to adjust
AM FBG: adjust background
Pre-lunch/dinner: adjust previous
mealtime insulin
If more than 40 mg/dL pre- to 2 hr.
postmeal rise, increase RA 1-3 units

89. What adjustment would you
make to A. Qudoos insulin doses?
Pre- Ins Post Pre Ins Post Pre- Ins Post HS
Bkfst Din
Mon 133 5 244 5 115 6 156 16
RA RA RA LA
Tue 125 5 201 5 124 6 170 16
RA RA RA LA
Wed 114 5 199 5 117 6 187 16
RA LA
RA RA
Thur 139 7 5 8 16
RA RA RA LA
Started at 0.2 units/kg x 80 kg (176#) = 16 units LA
and 16 units RA divided between 3 meals

90. After Insulin Adjustment
3 carbs for breakfast - 2 carbs for lunch 4 carbs for dinner
Pre- Ins Post Pre Ins Post Pre- Ins Post HS
Bkfst Din
Mon 105 7 142 5 RA 78 72 8 RA 139 16
RA LA
Tue 112 7 151 5 RA 85 70 8 RA 125 16 LA
RA
Wed 98 7 125 5 66 69 8 RA 98 16 LA
RA RA
Thur 110 132 74 65 112
7 5 8 16
RA RA RA LA

91. Starting vs. Final Insulin Dose
Typical Regimen Starting Dose Common
Patient (units) Final Dose
(Type 2 DM) (units)
Background 0.2 units/kg 0.5-0.7 units/kg
Insulin (20 units) (50-70 units)
Premixed 0.2 units/kg BID 1.0-1.2 units/kg
Insulin (40 units total) (100-120 units)
220 lbs
(100 kg)
Background & 0.2 units/kg background 1.0-1.2 units/kg
HbA1c 9% Mealtime 0.2 units/kg mealtime (100-120 units)
Insulin (40 units total)
Average dose for type 1 diabetes is 0.7 units/kg

92. Follow-up and Summary
 Recommended follow-up
– Every 1-2 weeks while adjusting dose
– Every 3 months once dose established
 Have patient monitor BG more extensively 1-2
weeks prior to visit to have recent data for
adjusting
 Use a team approach when starting insulin
 Consider enabling patients to make adjustments
to their insulin regimen

93. Case Studies