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Insulin Therapy

Prof. Khalifa Abdallah


Diabetes, Metabolism and Lipidology Unit
Alexandria Faculty of Medicine
Objectives
 To know indications for insulin therapy
 To know types and pharmaco-dynamics of insulin
 To know different types of insulin regimens
 To know how to initiate and titrate insulin dosage
Current indications for insulin
therapy
 Patients with type 1 DM
Type 2 DM
 Initial stabilization of patients with severe

hyperglycemia
 Hyperglycemic crises

 Pregnancy

 Significant liver or kidney disease

 Stressful situations ( ACS, ICU, major surgery, severe

infection, corticosteroid therapy….etc


 Patients in whom oral glucose-lowering therapy has

failed
Insulin types and duration
of action
Insulin Preparation Onset of Peak Maximal
action actio duration
n
(h or min) (h)
 Short-acting 30 min 1-3 (h) 6-8
 Intermediate-acting 1-2 h 5-10 18-24
 Premixed insulin 30/70 0.5-1 h 5-9 18-24
 Rapid-acting insulin analogue
.
10-20 min 1-2 h 3-5 h
 Long-acting insulin analogue
(glargine,Detemir) Peakless 24 h
Storage of insulin

 Stable at room temperature for 4 weeks


 Should not be exposed to temperatures

> 25ºC or under freezing point


 Unused vials and cartridges should be

stored in the refrigerator


 Should never be exposed to sunlight

 Should never be frozen


Insulin Regimen

 Combination therapy (for T2DM only)


- bed-time insulin + OHA

 Total insulin replacement (Type


1&2 DM)
- Twice daily insulin mixture
- Basal-bolus regimen
Insulin Regimen

 Combination therapy
- bed-time insulin + OHA

 Total insulin replacement


- Twice daily insulin mixture
- Basal-bolus regimen
Insulin Therapy for Type 2 DM
Combination therapy
 Continue Maximal dose of OHA
 Add either NPH or insulin Glargine at bed time (both
are effective but the incidence of noctural hypoglycemia is
lower with insulin Glargine)
 Start by 10 units and adjust insulin dose guided by
FBG to achieve FBG between 80 and 120 mg/dl
 If PPG <180 mg/dl continue combination therapy
otherwise shift to total insulin replacement therapy
Initiation and Titration of Basal
Insulin in DM2 patients on OHA
 Add 10 units Basal insulin at bedtime
(NPH , Detemir, or Glargine)
 Continue current oral agents
 Titrate insulin weekly to fasting BG <
120 mg/dL
- if 120-140 mg/dL, increase 2 units
- if 140-160 mg/dL, increase 4 units
- if 160-180 mg/dL, increase 6 units
- if >180 mg/dL, increase 8 units
Insulin Regimen

 Combination therapy
- bed-time insulin + OHA

 Total insulin replacement


- Twice daily insulin mixture
- Basal-bolus regimen
Insulin Regimen

 Combination therapy
- bed-time insulin + OHA

 Total insulin replacement


- Twice daily insulin mixture
- Basal-bolus regimen
Biphasic insulin treatment guidelines
Twice-daily regimen

Indications

Type 2 diabetic patients not controlled


on once-daily regimen
Type 1 diabetic patients

Giudelines

 For Type 2 diabetic patients stop OAD except Metformin


 Starting daily dose = 0.3-0.5 U/Kg body weight
 Give 2/3 of the total daily dose before breakfast and 1/3 before dinne
 Titrate the dose according to FBG and PPG
Insulin
Regimen
Twice-daily injections, mixture short and intermediate,
before breakfast and the evening meal

8 am 12 4 pm 8 pm 12 4 am 8am
B S L S D S
Hypoglycemia
Insulin
Regimen
Twice-daily injections, mixture short and intermediate,
before breakfast and the evening meal

8 am 12 4 pm 8 pm 12 4 am 8am
B S L S D S
Snack
Insulin
Regimen
Twice-daily injections, mixture short and intermediate,
before breakfast and the evening meal

hyperglycemia

8 am 12 4 pm 8 pm 12 4 am 8am
B S L S D S
Insulin
Regimen
Twice-daily injections, mixture short and intermediate,
before breakfast and the evening meal

8 am 12 4 pm 8 pm 12 4 am 8am
B S L S D S

Hypoglycemia
Insulin
Regimen
Twice-daily injections, mixture short and intermediate,
before breakfast and the evening meal

8 am 12 4 pm 8 pm 12 4 am 8am
B S L S D S
Insulin
Regimen
Twice-daily injections, mixture short and intermediate,
before breakfast and the evening meal

8 am 12 4 pm 8 pm 12 4 am 8am
B S L S D S
Insulin Regimen

 Combination therapy
- bed-time insulin + OHA

 Total insulin replacement


- Twice daily insulin mixture
- Basal-bolus regimen
Insulin Regimen

 Combination therapy
- bed-time insulin + OHA

 Total insulin replacement


- Twice daily insulin mixture
- Basal-bolus regimen
Physiological Insulin Secretion
Profile
75
Breakfast Lunch Dinner
Plasma Insulin µU/ml)

50

25

4:00 8:00 12:00 16:00 20:00 24:00 4:00


Time
Basal Bolus Therapy

Prandial insulin
e.g. Aspart, Lispro,
Glulisine

Basal insulin
Insulin

e.g. Glargine
levels

00.00 08.00 12.00 18.00 24.00


Basal Bolus Therapy

Prandial insulin

Basal insulin
Insulin

eg: Glargine
levels

00.00 08.00 12.00 18.00 24.00


Basal Bolus Therapy

Prandial insulin

Basal insulin
Insulin

eg: Glargine
levels

00.00 08.00 12.00 18.00 24.00


Starting a Basal-Bolus
Regimen
TDD = Weight (kg) x 0.5 U/kg

TDD

Basal Insulin Dose Bolus Insulin Dose


½ TDD ½ TDD

Breakfast Dose Lunch Dose Dinner Dose


1/6 TDD 1/6 TDD 1/6 TDD
Starting a Basal-Bolus
Regimen
TDD = Weight (kg) x 0.5 U/kg

TDD

Basal Insulin Dose Bolus Insulin Dose


½ TDD ½ TDD

Breakfast Dose Lunch Dose Dinner Dose


1/6 TDD 1/6 TDD 1/6 TDD
Starting a Basal-Bolus
Regimen
TDD = 110 (kg) x 0.5 U/kg

TDD

Basal Insulin Dose Bolus Insulin Dose


½ TDD ½ TDD

Breakfast Dose Lunch Dose Dinner Dose


1/6 TDD 1/6 TDD 1/6 TDD
Starting a Basal-Bolus
Regimen
TDD = 110 (kg) x 0.5 U/kg

55 U

Basal Insulin Dose Bolus Insulin Dose


½ TDD ½ TDD

Breakfast Dose Lunch Dose Dinner Dose


1/6 TDD 1/6 TDD 1/6 TDD
Starting a Basal-Bolus
Regimen
TDD = 110 (kg) x 0.5 U/kg

55 U

Basal Insulin Dose Bolus Insulin Dose


27 U 27 U

Breakfast Dose Lunch Dose Dinner Dose


1/6 TDD 1/6 TDD 1/6 TDD
Starting a Basal-Bolus
Regimen
TDD = 110 (kg) x 0.5 U/kg

55 U

Basal Insulin Dose Bolus Insulin Dose


27 U 27 U

Breakfast Dose Lunch Dose Dinner Dose


9U 9U 9U
Adjustment of insulin
Titrate insulin weekly to fasting BG
dosage
< 100 mg/dL
- if 120-140 mg/dL, increase 2

Basal-bolus
units
regimen
- if 140-160 mg/dL, increase 4
units
 Basal insulin is adjusted according
- if 160-180 mg/dL, increase 6 to
FPG levels units
- if >180 mg/dL, increase 8 units
 Prandial insulin is adjusted according
to the PPG level after each meal by
increasing the corresponding insulin
dose by 2-4 units
Sliding scale
Insulin Insulin

300
Plasma glucose mg/dl

250

200

150

100

50

6AM 12MD 6PM 12MN


Time
Thank You