Insulin therapy in the management of diabetes
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This document discusses insulin therapy for Type 2 diabetes, covering its indications, types, regimens, and guidelines for initiation and optimization. It outlines different insulin profiles, including bolus and basal insulins, and emphasizes the need for personalized adjustments of insulin dosages based on blood glucose levels. The importance of continuing oral hypoglycemic agents alongside insulin and monitoring fasting plasma glucose is also highlighted.
Insulin therapy in the management of diabetes
- 1. Insulin: Initiation, optimization, maintenance Dr. Mashfiqul Hasan Phase B Resident Department of Endocrinology BSMMU
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- 4. Milestones of insulin therapy Dr. Mashfiq - Endocrine - BSMMU 4
- 5. 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 Dr. Mashfiq - Endocrine - BSMMU 5
- 6. Insulin Types Examples Bolus (Meal) Insulin Rapid-acting Insulin lispro, Insulin aspart Short-acting Regular Basal (Background) Insulin Intermediate-acting NPH, Lente Long-acting Glargine, Detemir Pre-Mixed Insulin NPH/Regular 70/30, 50/50 NPL/Lispro Mix 75/25 NPA/Aspart Mix 70/30 Dr. Mashfiq - Endocrine - BSMMU 6
- 7. INSULIN THERAPY in Diabetes Mellitus Insulin Profiles – schematic (duration) Regular (6–8 hr) NPH (12–16 hr) 0 2 4 8 10 12 14 16 18 20 22 24 Plasma Insulin Levels Hours Glargine (~22 hr) ASAspart, Lispro (4–5 hr) Ultralente (~16–20 hr ) Detemir (~20 hr) 6 Dr. Mashfiq - Endocrine - BSMMU 7
- 8. Insulin Regimens • 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 Dr. Mashfiq - Endocrine - BSMMU 8
- 9. 50 40 30 20 10 0 Normal Insulin Secretion Meal Meal Meal Basal Insulin Needs 0 2 4 6 8 10 12 14 16 18 20 22 24 Serum insulin (mU/L) Time (Hours) Bolus insulin needs Dr. Mashfiq - Endocrine - BSMMU 9
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- 11. BASAL, BASAL-PLUS, BASAL-BOLUS Dr. Mashfiq - Endocrine - BSMMU 11
- 12. 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 meDtr. Mashfiq - Endocrine - BSMMU 12
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- 18. PREMIX INSULIN Dr. Mashfiq - Endocrine - BSMMU 18
- 19. 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 Dr. Mashfiq - Endocrine - BSMMU 19
- 20. • 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 Dr. Mashfiq - Endocrine - BSMMU 20
- 21. SPLIT-MIX INSULIN Dr. Mashfiq - Endocrine - BSMMU 21
- 22. Split Mix Regimen 40 20 Intermediate acting + short-acting Before Breakfast Time of day 60 0 Intermediate acting + short-acting Before Dinner
- 23. Others • Regular insulin • Sliding scale Dr. Mashfiq - Endocrine - BSMMU 23
- 24. PRINCIPLES OF INITIATION Dr. Mashfiq - Endocrine - BSMMU 24
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- 29. 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 Dr. Mashfiq - Endocrine - BSMMU 29
- 30. THANK YOU Dr. Mashfiq - Endocrine - BSMMU 30