07 Insulin Therapy

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Clinical Practice Guidelines:Management of

Type 2 Diabetes Mellitus

(4thEdition 2!!"

Topic 7:

#nsulin Therapy


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Targets for Control

LevelsGlycaemic Control $

%asting 4&4 ' &) mmol*l

+on,fasting 4&4 ' -&! mmol*l

.b/)c


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Diagnosis of Type 2 DiabetesAll patients advised LIFESTLE !odification

F"$ %bA&cat Diagnosis and Follo' (p

%bA&c

)+,- ./

F" ) 00ol1L

LIFESTYLE

APPROACH*

Follow-up with HbA1c

after

3 months.

If HbA1c6.5%,continuewith ifest!le Approach.

If HbA1c

"6.5% on follow-

up, consi#er OAD

MONOTHERAPY.

%bA&c

+, )3+4-

./

F" )&4 00ol1LOAD MONOTHERAPY

$etformin

&'

A(I ) *++- Inhibitor )

(lini#es ) ) /0*s.

&ptimise #ose of &A* aent

in the subse2uent 3-6

months.


after 3-6

months.

If HbA1c

6.5%, continue

therap!.

If HbA1c"6.5%, consi#erCOMBINATION OAD

THERAPY.

%bA&c

5&4+4- ./

F" 5&6 00ol1LCOMBINATION

THERAPY + BASAL /

PREMIXED INSULIN

THERAPY.

&'

INTENSIVE INSULINTHERAPY, contin!

M!t"o#$in.

%bA&c

3+4&4+4- ./

F" &4&6 00ol1L

COMBINATION THERAPY***

$etformin with other &A*

aents A(I ) *++-

Inhibitor ) (lini#es ) Incretin

$imetic ) ) /0*s4 or withinsulin.

&ptimise #ose of &A* aents

in the subse2uent 3-6

months.


after 3-6

months.

If HbA1c

6.5%, continue

therap!.If HbA

1c"6.5%, consi#er

a##ition of INSULIN

THERAPY.

Teat0ent Algoit80 fo t8e !anage0ent of T2D!

Footnote:

If symptomatic (weight loss, polyuria, etc) at any HbA1cand FPG level, consider insulin therapy

! "onsider metformin#AGI#other insulin sensitiser in appropriate patients!! $etformin is preferred %st line agent, and &' should preferably not be used as %stline

!!! Although oral agents can be used, initiation and intensification of insulin therapy is preferred based oneffectiveness and epense


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Combination of @ral /gents A

#nsulin Therapy

B Combining insulin and the follo6ing @/Dagents has been sho6n to be effecti


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hort Term se of #nsulin

S8otte0 ins(lin t8eapy s8o(ld be

consideed in t8e follo'ing conditions:

B /cute illness> surgery> stress and emergencies

B Pregnancy

B 8reast,feeding

B #nsulin may be used as initial therapy in T2DM

particularly in mar7ed hyperglycaemiaB e

.@+


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ong Term se of #nsulin

B Persistent hyperglycaemia in spite of optimal@/D agents 6ith stable or loss of 6eightsuggests beta cell failure& .o6e it isimportant to e5clude chronic infections>

malignancies or medications as cause of 6eightloss&

B The basal intermediate acting insulin should beadministered pre,bed because of the ris7 of

hypoglycaemia in the early hours of the morningif gi


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ong Term se of #nsulin(cont&

B 9eFuirements of high dose of insulin ()&0 unit*7g perday should prompt a search for an underlyingcause*secondary problems such as non,compliance>incorrect dosing and administration timing> hypertrophy

of inHection area> inter meal hypoglycaemia 6ith reboundhyperglycaemia pre,meal> e5pired insulin or e5piredstrips and occult infections&

B There is no limitation of insulin dose&

B The rate of absorption from the inHections depend on thesite and Ie5ercise acti


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#nsulin #nitiation

B #f targets ha consider adding:

' Pre,bed intermediate,acting> or

' Pre,bed long,acting insulin> or' Pre,dinner premi5ed insulin


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#nsulin @ptimisation

B Dose of insulin can be increased e


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#nsulin #ntensification

B 8edtime basal insulin premi5ed insulin daily *

t6ice daily

B 8edtime basal insulin seFuential addition of

bolus insulin premeals (8// PB 8edtime basal insulin addition of three bolus

insulin (8// 8@

B ingle premi5ed dose T6ice then maybethrice daily )2 (premi5ed analogue


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Types of #nsulin 9egimes

B @/D agents K basal insulin or premi5ed insulin

once a day

B Metformin K premi5ed insulin more than once a

dayB Metformin K basal insulin K prandial insulin


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elf 8lood Glucose Monitoring

B Method of choice in monitoring glycaemic control& 8GMshould be carried out for patients on insulin and isdesirable for those on @/D agents&

B %reFuency of blood glucose testing depends on the

glucose status> glucose goals and mode of treatment&B /lthough 8GM has not been sho6n to ha it is recommended as part of a 6idereducational strategy to promote self,care&

B 8GM should be carried out or 4 times daily forpatients using multiple insulin inHections or insulin pumptherapy


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Monitoring , 8GM

!ode ofTeat0ent

9eafast L(nc8 Dinne

"e "ost "e "ost "e"ost 1

"ebed

Diet @nly

@ral anti,diabeticagent

#nsulin

9ecommended timing of 8GM

@ptional timing of 8GM


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9eaching Glycaemic Targets

To contol Ad;(st

"ebeafastgl(cose

Pre bed intermediate acting insulin or long acting analogueor pre,dinner premi5ed

28o( post

beafast

8rea7fast inta7e or pre brea7fast rapid acting or morning

premi5ed insulin analogue

"el(nc8gl(cose

Morning tea or pre brea7fast short acting insulin or morningpremi5ed insulin

28o( postl(nc8

unch inta7e or pre lunch rapid acting or morning premi5edinsulin

"edinne /fternoon tea inta7e or pre lunch short acting insulin ormorning premi5ed insulin

"ostdinne 1pebed

Dinner inta7e or pre dinner rapid acting or pre dinnerpremi5ed analogue or pre dinner premi5ed insulin


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Glucose Monitoring in 9elation to

#nsulin Therapy

B Those on replacement insulin therapy need tochec7 glucose le


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@ral /gents K 8edtime #nsulin

%igure )a: @ral /gent(s K 8edtime #nsulin ' #ntermediate /cting #nsulin



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@ral /gents K 8edtime #nsulin (cont&


%igure )b: @ral /gent(s K @nce Daily 8asal ong /cting #nsulin

B=alues before brea7fast gi


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8asal 8olus #nsulin 9egimen

%igure 2: 8asal 8olus #nsulin 9egimen


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8asal 8olus #nsulin 9egimen (cont&

B =alues before brea7fast gi


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T6ice Daily Premi5ed or

Combination #ntermediate /cting

6ith hort /cting #nsulin

%igure : #ntermediate /cting 6ith hort /cting #nsulin


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T6ice Daily Premi5ed or

Combination #ntermediate /cting

6ith hort /cting #nsulin (cont&B =alues before brea7fast gi


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eys to success 6ith insulin

B tart early

B tart simply ' easy regimen

B 8GM ' monitor regularly

B /


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Thank you

Documents

07 Insulin Therapy