Insulin therapy in primary health care DrMajdi

Practical guide to insulin therapy in primary health care.
Types of insulin (basal-bolus, pre-mixed)
Insulin regimens (augmentation, total replacement)
How to convert from one insulin type to another.
Some challenging cases.

1. 1
Practical Guide to
INSULIN THERAPY
In Primary Health Care
Dr. Majdi N. Al-Jasim
Consultant Family Medicine
Research Field Coordinator

3. OBJECTIVES
1.To gain knowledge about the main types of insulin therapy:
▪Basal-bolus
▪Pre-mixed
2.To understand the main regimen ways (approaches) to initiate insulin
therapy:
▪Augmentation regimen (only for DM-2):
✓How to initiate
✓How to build up
✓How to monitor using HBGM
▪Total replacement regimen:
✓How to calculate total daily insulin requirement (TDI)
✓How to distribute the insulin doses based on TDI
requirement
✓How to monitor using HBGM
3.To understand how to convert from basal-bolus type to pre-mixed type
and vise versa
Dr. Majdi
AlJasim

4. SCENARIO #1
UmTahseenis56year-oldwomanwhohasDM-2forthe
past10years,cametodayforfollow-up.Sheisonthe
followingmedicationsforDM:
▪Glibenclamidetab10mgPOBID
▪MetforminXRtab1500mgPOOD
▪Linagliptintab5mgPOOD
HerFBStodayis250mg/dl,HbA1Cis12%,weightis60Kg,
andsheisvitallystable.
How will you manage the case?
Dr. Majdi
AlJasim

5. 1.Failure of oral treatment.
2.High A1C at time of diagnosis (> 10%).
3.Significant symptomatic hyperglycemia (> 250 mg/dl).
4.Pregnancy.
5.Hospitalization.
WHY Insulin?
Dr. Majdi
AlJasim

6. POWER of oral drugs on A1C
Dr. Majdi
AlJasim
0.8% to
1.5%
▪Sulfonylureas
▪Biguanides
▪Thiazolidinediones
▪GLP-1 agonist
0.5% to
0.9%
▪DPP4 inhibitors
▪SGLT2 inhibitors
0.7% to
1.0%
▪α-glucose inhibitors

7. Case analysis:
A1C is 12%
On Glibenclamide10mg BID, Metformin XR 1500mg OD, Linagliptin 5mg OD
OPTIONS…
①Add Empagliflozin (SGLT2i)→Max lowering A1C by about 1%
❷Add Dulaglutide (GLP1a)→Max lower to A1C by about 1.5%
▪Adding both may reduce A1C by 2.5% total, and so A1C will be 9.5%
which is still not on target.
Back to our case…
Dr. Majdi
AlJasim
So the patient needs insulin

8. Insulin Types

9. ▪NPH (Humulin N®)
▪Glargine (Lantus®, Basaglar®, Toujeo®)
▪Detemir(Levemir®)
▪Degludec(Tresiba®)
Insulin Types
1 Basal-Bolus Type
Dr. Majdi
AlJasim
Basal Bolus (Meal)
▪Regular (HumilinR® )
▪Lispro(Humalog®)
▪Aspart(Novorapid®)
▪Glulisine(Apidra®)

10. Insulin Types
1 Basal-Bolus Type
Dr. Majdi
AlJasim
Basal
Bolus
About 4 hrs

11. Insulin Types
1 Basal-Bolus Type
Dr. Majdi
AlJasim
Hirsch IB. Insulin analogues. N EnglJ Med. 2005;352(2):177

12. Insulin Types
Dr. Majdi
AlJasim
Resemble the natural way !!
Diabetes Education Online. University of California, San Francisco. http://www.deo.ucsf.edu

13. Insulin Types
1 Basal-Bolus Type
Dr. Majdi
AlJasim
Basal

14. Insulin Types
1 Basal-Bolus Type
Dr. Majdi
AlJasim
Bolus

15. It is a mixture of short acting insulin with intermediate acting insulin.
Examples:
▪Mixtard30® →Regular 30% + NPH 70%
▪NovoMix30® →Aspart30% + Aspartprotamine 70%
▪Humalog Mix25® →Lispro 25% + Lispro protamine 75%
▪Humalog Mix50® →Lispro 50% + Lispro protamine 50%
The number in the trade name represent the short acting insulin percentage.
Insulin Types
2 Pre-Mixed Type
Dr. Majdi
AlJasim

16. Insulin Types
2 Pre-Mixed Type
Dr. Majdi
AlJasim

17. Insulin Types
2 Pre-Mixed Type
Dr. Majdi
AlJasim
Endotext.org. insulin pharmacology, types of regimens and adjustment

18. Insulin Types
2 Pre-Mixed Type
Dr. Majdi
AlJasim

19. Which insulin type to start with?
It is better for these cases to start with
AUGMENTATION approach, starting with basal
insulin alone at first (to break insulin fear).
Back to our case…
Dr. Majdi
AlJasim
Basal insulin may work alone if A1C < 9.5%

20. Augmentation
Regimen
Insulin Regimens

21. What is pre-prandial fasting state?
It means no calories intake for at least 8 hours except for water.
How to start basal insulin?
Either you start with 10U or 0.1U/Kg
How to adjust basal insulin?
The target pre-prandial FBS is 70 -130mg/dl. Increase the dose by 2U every 3 days until you reach
the goal. If pre-prandial FBS is < 70mg/dl, decrease the dose by 2U.
Augmentation Regimen
Step 1.
Add basal insulin to current medications. No need to modify or discontinue any medication.
Basal insulin will take care of pre-prandial blood sugar on fasting state.
Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen

22. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasim

23. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasim

24. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasim
▪The best time to monitor the effect of basal insulin is before breakfast.
▪If you use before launch and before dinner time, make sure it is in fasting
state (8 hours with no calories intake)

25. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasim
Basal insulin curse!
The upper limit to increase the dose of basal
insulin SHOULD NOT exceed 0.7of patient
weight (Max dose benefit).
Our patient is 60Kg, so the upper limit of basal
insulin increment is (60 x 0.7 = 42 units)

26. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasim
Basal
insulin dose
Anabolic
effect
(Hunger)
Food intake
(weight)
Insulin
resistance
Blood
sugar
Basal insulin cursed cycle!

27. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasim
Patient instructions
▪Your basal insulin starting dose is 10U (or 0.1U/Kg,
patient weight is 60Kg so 6U).
▪Check your fasting blood sugar daily before breakfast.
▪Your target sugaris 70mg/dl -130mg/dl
✓insulinby 2 units every3daystill fasting< 130
✓Ifsugargoes < 70, thedoseby 2units
▪Whatever happened, do not exceed 42U
▪When sugar at target, stay on same dose until your
next appointment with your family physician.

28. On3monthsfollow-up,patientbroughther
bloodglucosemonitoringchart:
HernewHbA1Cis9.8%
What are you going to do?
Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen
110
115
90
118
She is currently on:
▪Glibenclamide10mg BID.
▪Metformin XR 1500mg OD
▪Linagliptin 5mg OD
▪Glargine insulin 16U OD HS

29. Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen
Case analysis:
▪A1C gets to 9.8%.
▪Thepre-prandialblood sugar is at target
Next step is to check post-prandialglucose

30. Do we need to modify patient medications?
Stop any sulfonylurea that its action time duration (about 14 hrs) overlap with
bolus insulin.
Augmentation Regimen
Step 2.
Add bolus insulin to current medications at the time of patient biggest meal.
Bolus insulin will take care of post-prandial blood sugar of that meal.
Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen
How to start bolus insulin?
Start with 4U
How to adjust bolus insulin?
The target 2 hrspost-prandial is 70 -180mg/dl. Increase the dose by 2U every 3 days until you
reach the goal. If 2 hrspost-prandial is < 70mg/dl, decrease the dose by 2U.

31. Patientsaidherbiggestmealisonlaunch.Soyourcurrent
prescriptionis:
▪Glibenclamidetab5mgPOatdinneronly
▪MetforminXRtab1500mgPOOD
▪Linagliptintab5mgPOOD
▪GlargineinsulinS/C16UODHS
▪AspartinsulinS/C4Ubeforelaunch
Why have you kept Glibenclamideat dinner?
Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen
Aspartwill be given
at noon.
Glibenclamide
morning dose
duration will overlap
with aspart, unlike
night dose

32. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasim

33. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasim
▪To monitor basal insulin, use before breakfastreadings.
▪To monitor launch bolus insulin, use 2 hours after launch readings.

34. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasimPatient instructions
▪Your bolus insulin before launch time by 5min is 4U.
▪Check your blood sugar 2 hours after launch daily
▪Your target sugaris 70mg/dl -180mg/dl
✓insulinby 2 units every3daystill fasting< 180
✓Ifsugargoes < 70, thedoseby 2units
▪When sugar at target, stay on same dose until your
next appointment with your family physician.

35. Patient3monthsfollow-upchart:
HbA1Cis9.0%.
What are you going to do next?
Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen
100
115
125
108
150
175
155
145
She is currently on:
▪Glibenclamide10mg at dinner.
▪Metformin XR 1500mg OD
▪Linagliptin 5mg OD
▪Glargine insulin 16U OD HS
▪Aspartinsulin 10U before launch

36. Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen
Case analysis:
▪A1C gets to 9.0%.
▪Thepre-prandialblood sugar is at target
▪The 2-hrs post launch blood sugar is at target
Next step is to check post-prandialglucose of other meals

37. Do we need to modify patient medications?
Stop any sulfonylurea that its action time duration (about 10 hrs) overlap with
bolus insulin.
Augmentation Regimen
Step 3.
Add bolus insulin to current medications at the time of patient second biggest meal.
Bolus insulin will take care of post-prandial blood sugar of that meal.
Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen
How to start bolus insulin?
Start with 4U
How to adjust bolus insulin?
The target 2 hrspost-prandial is 70 -180mg/dl. Increase the dose by 2U every 3 days until you
reach the goal. If 2 hrspost-prandial is < 70mg/dl, decrease the dose by 2U.

38. Patientsaidhersecondbiggestmealisatdinner.Soyour
currentprescriptionis:
▪MetforminXRtab1500mgPOOD
▪Linagliptintab5mgPOOD
▪GlargineinsulinS/C16UODHS
▪AspartinsulinS/C10Ubeforelaunch
▪AspartinsulinS/C4Ubeforedinner
Why did you stop Glibenclamideat dinner?
Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen

39. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasim
▪To monitor basal insulin, use before breakfastreadings.
▪To monitor launch bolus insulin, use 2 hours after launch readings.
▪To monitor dinner bolus insulin, use 2 hours after dinner readings.

40. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasimPatient instructions
▪Your bolus insulin before dinner time by 5min is 4U.
▪Check your blood sugar 2 hours after dinner daily
▪Your target sugaris 70mg/dl -180mg/dl
✓insulinby 2 units every3daystill fasting< 180
✓Ifsugargoes < 70, thedoseby 2units
▪When sugar at target, stay on same dose until your
appointment

41. Patient3monthsfollow-upchart:
HbA1Cis8.0%.
What are you going to do next?
Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen
105
120
115
118
170
158
164
157
155
149
175
140
She is currently on:
▪Metformin XR 1500mg OD
▪Linagliptin 5mg OD
▪Glargine insulin 16U OD HS
▪Aspartinsulin 10U before launch
▪Aspartinsulin 8U before dinner

42. Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen
Case analysis:
▪A1C gets to 8.0%.
▪Thepre-prandialblood sugar is at target
▪The 2-hrs post launch blood sugar is at target
▪The 2-hrs post dinner blood sugar is at target
Next step is to check post-prandialglucose of other meals

43. Augmentation Regimen
Step 4.
Add bolus insulin to current medications at the time of patient third meal.
Bolus insulin will take care of post-prandial blood sugar of that meal.
Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen

44. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasim
Basal insulin effect
Breakfast time
Bolus insulin effect Launch time Bolus
insulin effect
Dinner time Bolus
insulin effect
▪To monitor basal insulin, use before breakfastreadings.
▪To monitor launch bolus insulin, use 2 hours after launch readings.
▪To monitor dinner bolus insulin, use 2 hours after dinner readings.
▪To monitor breakfast bolus insulin, use 2 hours after breakfast readings.

45. Case Approach: Augmentation Regimen
Dr. Majdi
AlJasim
Home message
▪Basal insulinacts on pre-meal blood sugar on fasting state.
▪Bolus insulin acts on post-meal blood sugar.
Golden Rule

46. Whydon’twestartpatientwithbolusinsulinatthebeginninginsteadofbasalinsulin
withaugmentationregimen?Whyitshouldbebasalinsulinfirst..!!
Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen
■Pre-prandial
Post-prandial
AsA1Cgetsabove8.5%,
theeffectofpre-prandial
hyperglycemiaovercomes
thepost-prandialone.
MonnierL,etal.DiabetesCare
2003;26(3):881-85.

47. Whydon’tdoctorsdotheinsulindoseadjustmentwithaugmentationregimen?Whyit
shouldbedonebypatientathome..!!
Dr. Majdi
AlJasim
Case Approach: Augmentation Regimen
■Patientalgorithm
Doctoralgorithm
-Patientalgorithm:A1Cby
1.22%.
-Doctoralgorithm:A1Cby
1.08%.
p<0.001
DaviesM,etal.DiabetesCare
2005;28(6):1282-8.AT.LANTUSSTUDY

48. Replacement
Regimen
Insulin Regimens

49. Dr. Majdi
AlJasimAbuAhmedis49year-oldmanwhohasDM-2and
stage3bCKD,hisdoctortoldhimhemustshiftto
insulintherapyinsteadoforalhypoglycemicagents
otherwisehewillprogresstoend-stageCKD.
HisFBStodayis240mg/dl,HbA1Cis12.5%,weight
is80Kg,andheisvitallystable.
How will you approach the case?
SCENARIO #2

50. Case analysis:
▪A1C is 12.5%
▪Stage-3b CKD, weight is 80Kg
OPTIONS…
Shift him to insulin
Dr. Majdi
AlJasim
The patient needs insulin (total replacement)
Case Approach: Replacement Regimen

51. Do we need to modify patient medications?
It is better to stop all medications especially sulfonylurea and those with
contraindications.
Replacement Regimen
Step 1.
Calculate Total Daily Insulin (TDI) requirement:
TDI index is a wide range from 0.1 –1 unit/Kg. As a general rule, start with 0.2 unit/Kg for
DM-1 (insulin sensitive) and 0.5 unit/Kg for DM-2 (insulin resistant).
Dr. Majdi
AlJasim
Case Approach: Replacement Regimen
How to adjust replacement insulin?
The target pre-prandial is 70 –130mg/dl and 2 hrspost-prandial is 70 -180mg/dl.
Increase the dose by 2U every 3 days until you reach the goal. If blood sugar is < 70mg/dl,
decrease the dose by 2U.

52. Calculating TDI requirement:
▪Patient is DM-2.
▪Patient weight is 80Kg.
▪Since he is DM-2, we will use 0.5 unit/Kg TDI index.
▪So TDI requirement = weight ×TDI index
= 80 ×0.5
= 40 units per day
Dr. Majdi
AlJasim
Case Approach: Replacement Regimen

53. Replacement Regimen
Step 2.
ReplacementusingBasal-Bolusinsulintype:
▪Use60%ofTDIrequirementasBasalinsulin.
▪Use40%ofTDIrequirementastotalBolusinsulin→distributethirdthetotalforeach
meal,thentakesomeunitsfromthelightestmealandaddittothebiggestmeal.
▪Sameasbeforebutuse50%ofTDIforBasalinsulinand50%ofTDIfortotalBolusinsulin.
Dr. Majdi
AlJasim
Case Approach: Replacement Regimen
OPTION A:
60% to 40% method
50% to 50% method

54. Replacement Regimen
Step 2.
Dr. Majdi
AlJasim
Case Approach: Replacement Regimen
ReplacementusingPre-mixedinsulintype:
▪Distribute½ofTDIrequirementatAMand½ofTDIrequirementatPM.
▪Put⅔ofTDIrequirementatthepartoftimewhenthepatientismostlikelyawake,and
⅓ofTDIrequirementattheotherpartoftime.
N.B: Always start with Mix25 or Mix30
OPTION B:
½ to ½ method
⅔to ⅓method

55. Using Basal Bolus insulin type as replacement (60% : 40%)
▪TDI requirement is 40 units per day.
▪Use60% of that as basal insulin, and 40% as bolus insulin.
▪So calculated basal insulin = TDI requirement ×60% = 40 ×60% = 24 units
▪Socalculated total bolus insulin = TDI requirement ×40% = 40 ×40% = 16 units
▪Sobolus dose at each meal = total bolus insulin ÷3 meals = 16 ÷3 = 6 units in
each meal
➢Before breakfast 6 units (the lightest meal)
➢Before launch 6 units (the biggest meal)
➢Before dinner 6 units
Dr. Majdi
AlJasim
Case Approach: Replacement Regimen
Basal insulin dose = 24 units
Bolus insulin doses:
Before breakfast 4 units
Before launch 8 units
Before dinner 6 units
OPTION A:

56. Using Basal Bolus insulin type as replacement (50% : 50%)
▪TDI requirement is 40 units per day.
▪Use50% of that as basal insulin, and 50% as bolus insulin.
▪So calculated basal insulin = TDI requirement ×50% = 40 ×50% = 20 units
▪Socalculated total bolus insulin = TDI requirement ×50% = 40 ×50% = 20 units
▪Sobolus dose at each meal = total bolus insulin ÷3 meals = 20 ÷3 = about 7
units in each meal
➢Before breakfast 7 units (the lightest meal)
➢Before launch 7 units (the biggest meal)
➢Before dinner 7 units
Dr. Majdi
AlJasim
Case Approach: Replacement Regimen
Basal insulin dose = 20 units
Bolus insulin doses:
Before breakfast 5 units
Before launch 9 units
Before dinner 7 units
OPTION A:

57. Case Approach: Replacement Regimen
Dr. Majdi
AlJasim
Basal insulin curse!
The upper limit to increase the dose of basal
insulin SHOULD NOT exceed 0.7of patient
weight (Max dose benefit).
Our patient is 80Kg, so the upper limit of basal
insulin increment is (80 x 0.7 = 56 units)
Have you
missed
me!!

58. Case Approach: Replacement Regimen
Dr. Majdi
AlJasim
▪Pre-prandial goal of blood sugar is 70 –130 mg/dl.
▪2 hours post-prandial goal of blood sugar is 70 –180 mg/dl.
Basal insulin effect
Breakfast time
Bolus insulin effect Launch time Bolus
insulin effect
Dinner time Bolus
insulin effect

59. Using Pre-mixed insulin type as replacement
Dr. Majdi
AlJasim
Case Approach: Replacement Regimen
OPTION B:
Method #1 (½ to ½)
Since TDI requirement is 30 units/day, so the dose will be:
▪AM Pre-mixed 25% insulin = TDI ×½ = 30 ×½ = 15 units
▪PM Pre-mixed 25% insulin = TDI ×½ = 30 ×½ = 15 units
Method #2 (⅔ to ⅓)
Since TDI requirement is 30 units/day, so the dose will be:
▪AM Pre-mixed 25% = TDI ×⅔ = 30 ×⅔ = 20 units (assuming
patient is awaked at this time)
▪PM Pre-mixed 25% insulin = TDI ×⅓ = 30 ×⅓ = 10 units

60. Case Approach: Replacement Regimen
Dr. Majdi
AlJasim
AM Pre
-
mixed
insulin rapid part
effect
AM Pre-mixed insulin
intermediate part
effect
PM Pre
-
mixed
insulin rapid part
effect
▪Pre-prandial goal of blood sugar is 70 –130 mg/dl.
▪2 hours post-prandial goal of blood sugar is 70 –180 mg/dl.
PM Pre
-
mixed insulin
intermediate part
effect
PM Pre
-
mixed insulin
intermediate part
effect

61. Case Approach: Replacement Regimen
Dr. Majdi
AlJasim
Home message
Basal-bolusinsulinreplacementcanbetitratedbypatientat
homeuntilitreachesitsgoal.
Onanotherhand,Pre-mixedinsulinreplacementismore
difficulttopatienttotitratethedoseathomeandmustbe
followedbyphysician.
Important…

62. Insulin
Conversion

63. After1year,UmTahseenbacktotheclinicafterhearingfromher
friendsthatshewasdeceivedbyherphysicianandthereis
anotherregimenthatrequiresfewerinjectionsinsteadof4
injectionsaday.Sheinsistedtochangeherinsulinregimen.Her
currentinsulinregimenconsistsof:
▪GlargineinsulinS/C20UODHS
▪AspartinsulinS/C8Ubeforebreakfast
▪AspartinsulinS/C14Ubeforelaunch
▪AspartinsulinS/C12Ubeforedinner
How will change her regimen from basal-bolus insulin type to
pre-mixed insulin type?
Dr. Majdi
AlJasim
SCENARIO #4

64. Calculate TDI
▪In already established patient on insulin, TDI is just a summation of insulin
doses the patient is taking daily.
▪In our case, the patient is taking:
▪GlargineinsulinS/C20UODHS
▪AspartinsulinS/C8Ubeforebreakfast
▪AspartinsulinS/C14Ubeforelaunch
▪AspartinsulinS/C12Ubeforedinner
Dr. Majdi
AlJasim
Insulin Conversion (basal-bolus to pre-mixed)
Step: 1
Calculate Total Daily Insulin (TDI) requirement:
Glargine dose + Aspartdose before breakfast + Aspartdose before launch + Aspartdose
before dinner
TDI = 20 + 8 + 14+ 12 = 54 units/day

65. Basal-bolus TO Pre-mixed TDI conversion ratio
Dr. Majdi
AlJasim
Step: 2
Basal-bolus TDI = Pre-mixed TDI
Basal-bolus TDI = 20 + 8 + 14+ 12 = 54 units/day
So Pre-mixed TDI = 54 units/day
1:1
CONVERSION
Insulin Conversion (basal-bolus to pre-mixed)

66. Distribution of new doses
▪ALWAYS, ALWAYS start with Mix25% or Mix30%.
▪Either you distribute with ½ to ½ OR ⅔ to ⅓ :
Dr. Majdi
AlJasim
Step: 3
TDI = 54 units/day
▪So Pre-mixed 25% AM dose = 54 ×½ = 27 units before breakfast
▪Also Pre-mixed 25% PM dose = 54 ×½ = 27 units before dinner
½ to ½ method
TDI = 54 units/day
▪So Pre-mixed 25% AM dose = 54 ×⅔= 36 units before breakfast
assuming this is the time the patient will still awake.
▪Also Pre-mixed 25% PM dose = 54 ×⅓= 18 units before dinner⅔to ⅓method
Insulin Conversion (basal-bolus to pre-mixed)

67. Dr. Majdi
AlJasim
SCENARIO #4
AbuAhmedpickedthepre-mixedinsulintypesinceitis
fewerinjections.Youtriedtoexplaintohimthatbasal-
bolusisbetterbecausehecouldtitratethedoseby
himself,butheinsistedonpre-mixedtype.
After1year,hisCKDdeterioratedandcametoyouin
ordertochangehisinsulinregimen
Heiscurrentlyon:
▪Pre-mixed25%insulinS/C40unitsAM
▪Pre-mixed25%insulinS/C20unitsPM
How will change his regimen from pre-mixed insulin
type to basal-bolus insulin type?

68. Calculate TDI
▪In already established patient on insulin, TDI is just a summation of insulin
doses the patient is taking daily.
▪In our case, the patient is taking:
▪Pre-mixed25%insulinS/C40unitsbeforebreakfast
▪Pre-mixed25%insulinS/C20unitsbeforedinner
Dr. Majdi
AlJasim
Insulin Conversion (pre-mixed to basal-bolus)
Step: 1
Calculate Total Daily Insulin (TDI) requirement:
Pre-mixed 25% dose before breakfast + Pre-mixed 25% dose before dinner
TDI = 40 + 20 = 60 units/day

69. Pre-mixed TO Basal-bolus TDI conversion ratio
Dr. Majdi
AlJasim
Step: 2
Pre-mixed TDI = Basal-bolus TDI
Pre-mixed TDI = 40 + 20 = 60 units/day
So Basal-bolus TDI = 60 units/day
1:1
CONVERSION
Insulin Conversion (pre-mixed to basal-bolus)

70. Distribution of new doses
▪Either you distribute with 60% basal to 40% bolus, OR50% basal to 50% bolus, ORold school way
Dr. Majdi
AlJasim
Step: 3
TDI = 60 units/day
▪So Basal dose = 60 ×60% = 36 units
▪Also total Bolus dose = 60 ×40% = 24 units
▪Each meal bolus dose = total bolus dose ÷3 meals = 24 ÷3 = 8
8 units before breakfast 6 units before breakfast
8 units before launch 10 units before launch
8 units before dinner 8 units before dinner
60% to 40% method
Insulin Conversion (pre-mixed to basal-bolus)
Adjustment

71. Distribution of new doses
Dr. Majdi
AlJasim
Step: 3
TDI = 60 units/day
▪So Basal dose = 60 ×50% = 30 units
▪Also total Bolus dose = 60 ×50% = 30 units
▪Each meal bolus dose = total bolus dose ÷3 meals = 30 ÷3 = 10
10 units before breakfast 8 units before breakfast
10 units before launch 12 units before launch
10 units before dinner 10 units before dinner
50% to 50% method
Insulin Conversion (pre-mixed to basal-bolus)
Adjustment

72. Distribution of new doses
Dr. Majdi
AlJasim
Step: 3
TDI = 60 units/day
▪Since the patient was using Mix25%, it means 25% of the dose is
rapid insulin and 75% of the dose is intermediate insulin.
▪So total rapid insulin = TDI ×25% = 60 ×25% = 15 units per day
▪And total intermediate insulin = TDI ×75% = 60 ×75% = 45 units per
day
▪Total Bolus dose = Total calculated rapid dose = 15 units
▪Each meal bolus dose = total bolus dose ÷3 meals
= 15 ÷3 = 5 units in each meal
▪Total Basal dose = 80% of total calculated intermediate dose
= 45 ×80% = 36 units
Old school way
Insulin Conversion (pre-mixed to basal-bolus)

74. Thisishomebloodsugarmonitoringchartof41year-oldman,weight
is80Kg.
What are you going to do?
Dr. Majdi
AlJasim
105
120
115
118
110
100
105
115
155
149
175
140
He is using:
▪Pre-mixed 25% insulin 35 units
before breakfast
▪Pre-mixed 25% insulin 20 units
before dinner
SCENARIO #5
250
230
240
260
85
75
78
88

75. Case analysis:
▪The patient has ↑ 2hrs after breakfast readings.
▪The patient has ↓ before launch readings.
▪The pre-mixed insulin dose responsible for these readings is AM dose.
Dr. Majdi
AlJasim
Case Approach: Scenario #5
Thinking…
▪If we ↑ the AM dose, the 2hrs after breakfast readings will be corrected
(rapid part), but the patient will suffer from hypoglycemia before launch
(intermediate part)..!!!
▪If we ↓ the AM dose, the before launch readings will be fine (intermediate
part), but the patient will suffer from more hyperglycemia 2hrs after
breakfast (rapid part)..!!!

76. Dr. Majdi
AlJasim
Case Approach: Scenario #5
Is there a way just to ↑ the rapid
part and to ↓ the intermediate
part of AM pre-mixed 25%
insulin?
Did anybody ask for
help?!!

77. Case Approach: Scenario #5
▪Pre-mixed 50% insulin 35 units before breakfast
▪Pre-mixed 25% insulin 20 units before dinner
Dr. Majdi
AlJasim

78. Thisishomebloodsugarmonitoringchartof45year-oldman,weight
is100Kg.
What are you going to do?
Dr. Majdi
AlJasim
200
171
162
189
155
146
169
147
240
234
244
227
He is using:
▪Pre-mixed 25% insulin 46 units
before breakfast
▪Pre-mixed 25% insulin 30 units
before dinner
SCENARIO #6
150
130
140
160
72
75
71
72

79. Case analysis:
▪The patient has ↑ before breakfast readings.
▪The patient has ↑ after dinner readings.
▪The patient has ↓ mid-night (3 AM) readings.
▪The pre-mixed insulin dose responsible for these readings is PM dose.
Dr. Majdi
AlJasim
Case Approach: Scenario #6
Thinking…
▪SOMOGYIEFFECT,Ifthebloodsugarleveldropstoolowintheearly
morninghours,hormones(suchasgrowthhormone,cortisol,and
catecholamines)arereleased.Thesehelpreversethelowbloodsugarlevel
butmayleadtobloodsugarlevelsthatarehigherthannormalinthe
morning.
▪The cause:high PM intermediate part insulin dose.

80. Dr. Majdi
AlJasim
Case Approach: Scenario #6
Igotit,let’schange
PMpre-mixed25%to
pre-mixed50%
What a little champ
we have here ☺

81. Case Approach: Scenario #6
▪Pre-mixed 25% insulin 46 units before breakfast
▪Pre-mixed 50% insulin 30 units before dinner
Dr. Majdi
AlJasim

82. Thisishomebloodsugarmonitoringchartof46year-oldman,weight
is96Kg.
What are you going to do?
Dr. Majdi
AlJasim
120
115
100
108
155
140
142
136
130
141
152
142
He is using:
▪Aspart12 units before breakfast
▪Aspart18 units before launch
▪Aspart14 units before dinner
▪Glargine 24 units OD HS
SCENARIO #7
300
270
223
280
145
136
134
130
240
260
256
238

83. Case analysis:
▪The patient has ↑ before launch readings.
▪The patient has ↑ before dinner readings.
▪The basal insulin is responsible for pre-prandial readings.
Dr. Majdi
AlJasim
Case Approach: Scenario #7
Thinking…
▪Glargineeffectdurationmayvaryforeachindividualwithadurationof
actionasshortas11hours,causingnotenoughbasalinsulinlevelto
controlallpre-prandialbloodsugar.
▪The fix:Add second dose of glargine in AM (start with 8-10 units), or
change basal insulin to more extended-duration analogue like degludec.
(Eldrisietal, Twice-daily insulin glargine for patients with uncontrolled type 2 diabetes mellitus. J Clin TranslEndocrinol. 2018 Dec 11;15:35-36)

84. Case Approach: Scenario #7
▪Aspart12 units before breakfast
▪Aspart18 units before launch
▪Aspart14 units before dinner
▪Glargine 24 units at 10:00 PM and 10 units at
10:00 AM
Dr. Majdi
AlJasim
Option #1

85. Case Approach: Scenario #7
▪Aspart12 units before breakfast
▪Aspart18 units before launch
▪Aspart14 units before dinner
▪Degludec24 units OD HS
Dr. Majdi
AlJasim
Option #2

86. Thisishomebloodsugarmonitoringchartof46year-oldman,weight
is96Kg.
What are you going to do?
Dr. Majdi
AlJasim
70
65
67
68
155
140
142
136
130
141
152
142
He is using:
▪Aspart16 units before breakfast
▪Aspart20 units before launch
▪Aspart18 units before dinner
▪Glargine 44 units OD HS
SCENARIO #8
300
270
223
280
145
136
134
130
240
260
256
238

87. Case analysis:
▪The patient has ↓ before breakfast readings.
▪The patient has ↑ before launch readings.
▪The patient has ↑ before dinner readings.
▪The basal insulin is responsible for pre-prandial readings.
Dr. Majdi
AlJasim
Case Approach: Scenario #8
Thinking…
▪Glarginedoseis↑atnightthatcauseshypoglycemiabeforebreakfast.
However,thedurationofglarginehereseemstobelessthan24hours
causinghyperglycemiabeforelaunchandbeforedinner.
▪The fix:Split the dose of glargine into PM dose and AM dose. By doing so
we will improve pre-prandial hypo and hyperglycemia.
(Eldrisietal, Twice-daily insulin glargine for patients with uncontrolled type 2 diabetes mellitus. J Clin TranslEndocrinol. 2018 Dec 11;15:35-36)

88. Case Approach: Scenario #8
▪Aspart16 units before breakfast
▪Aspart20 units before launch
▪Aspart18 units before dinner
▪Glargine 22 units at 10:00 PM and 22 units at
10:00 AM
Dr. Majdi
AlJasim

89. Thisishomebloodsugarmonitoringchartof42year-oldman,weight
is115Kg.
What are you going to do?
Dr. Majdi
AlJasim
200
190
205
215
305
270
255
295
300
288
291
289
SCENARIO #9
125
118
128
123
165
156
154
155
200
190
205
195
215
200
220
225
He is using:
▪Pre-mixed 25% insulin 48 units
before breakfast
▪Pre-mixed 25% insulin 36 units
before dinner

90. Dr. Majdi
AlJasim
AM Pre
-
mixed
insulin rapid part
effect
AM Pre-mixed insulin
intermediate part
effect
PM Pre
-
mixed
insulin rapid part
effect
PM Pre
-
mixed insulin
intermediate part
effect
PM Pre
-
mixed insulin
intermediate part
effect
Case Approach: Scenario #9

91. Dr. Majdi
AlJasim
Case Approach: Scenario #9
Thinking…
Sincethepatienthas↑readingsat3AMthatleadsto↑readingsbeforebreakfast(dawnphenomenon),and
↑readings2hrsafterdinner,itissafeto↑thePMdoseusingpre-mixed25%.
TherealchallengeisAMdose..!!!
▪Ifwe↑theAMdoseusingpre-mixed25%,wewillhaveriskofhypoglycemiabeforelaunch(75%of
mixtureisintermediatepart).
▪Ifwe↑theAMdoseusingpre-mixed50%,the2hrsafterlaunch,andbeforedinnerreadingswillnotbe
controlledatfirst(50%ofmixtureisintermediatepart);however,ifwetryto↑thedoseevenfurther,
therewillbeariskofhypoglycemia2hrsafterbreakfastandbeforelaunch.
200
190
205
215
305
270
255
295
300
288
291
289
125
118
128
123
165
156
154
155
200
190
205
195
215
200
220
225

92. Dr. Majdi
AlJasim
Case Approach: Scenario #9
Thebestapproachhereisto
convertpatienttobasal-bolus
regimen.
Anotherapproachistoadd3
rd
dose
ofpre-mixedinsulinatnoonbefore
launch.

93. Dr. Majdi
AlJasim
Case Approach: Scenario #9
Intermediate
dose 3
Rapid
dose 1
Intermediate
dose 1
Intermediate
dose 1
Intermediate
dose 1
Rapid
dose 3
Intermediate
dose 3
Rapid
dose 2
Intermediate
dose 2
Intermediate
dose 2
Intermediate
dose 2
Pre-mixed
dose 1
Pre-mixed
dose 2
Pre-mixed
dose 3

94. Dr. Majdi
AlJasim
Case Approach: Scenario #9
Advise…!!
Thisregimen(3pre-mixeddoses)isveryhardtoadjustandmyadvisetoyou
isjusttoshiftpatienttobasal-bolusregimen.
200
190
205
215
305
270
255
295
300
288
291
289
125
118
128
123
165
156
154
155
200
190
205
195
215
200
220
225

95. At24weeksofgestation,a32yearsoldladywas
diagnosedtohavegestationaldiabetes.Herweight
is56Kg.Shewasconsultedonstartinginsulinsince
shehasahighriskpregnancy,andsheagreed.
How will you approach this case?
Dr. Majdi
AlJasim
SCENARIO #10

96. Dr. Majdi
AlJasim
Case Approach: Scenario #10
▪Theapproachisassameaswithnon-pregnantindividual,butyouwillbe
morestrict.
▪You will titrate the insulin dose according to HBGM since A1C will not be
accurate indicator during 2
nd
and 3
rd
trimester of pregnancy.
▪Itisbettertousebasal-bolustypeinsteadofpre-mixedtypesincethisis
highriskperiodandnoneedtowaitforadjustingdosesatdoctoroffice.
▪Pre-prandial goal of blood sugar in pregnancy is 70 –100 mg/dl.
▪2 hours post-prandial goal of blood sugar in pregnancy is 70 –140 mg/dl.

97. Dr. Majdi
AlJasim
Case Approach: Scenario #10

98. Dr. Majdi
AlJasim
Case Approach: Scenario #10
Which insulin to use during pregnancy? Blum AK. Insulin Use in Pregnancy: An Update. Diabetes Spectr. 2016;29(2):92-7

99. Dr. Majdi
AlJasim
Case Approach: Scenario #10

100. Dr. Majdi
AlJasim
Case Approach: Scenario #10
Correcting dose with bolus insulin during pregnancy

101. Case Approach: Scenario #10
▪Aspart4 units before breakfast
▪Aspart6 units before launch
▪Aspart4 units before dinner
▪Detemir 14 units OD HS
Correcting dose
Dr. Majdi
AlJasim

102. Please,sharemanagementwithendocrinologistordiabetologistif
youhavethefollowingcasesinwhominsulinisused:
▪Type-1DM.
▪GestationalDM.
▪Type-2DMwithTDI≥2units/kg.
▪ExistenceofsevereDMcomplications.
Dr. Majdi
AlJasim
Last message