Insulin therapy in the management of diabetes

The presentation consists of practical issues as well as background theory regarding insulin therapy.

1. Insulin: Initiation, optimization, maintenance Dr. Mashfiqul Hasan Phase B Resident Department of Endocrinology BSMMU

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4. Milestones of insulin therapy 4 Dr. Mashfiq - Endocrine - BSMMU

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 5 Dr. Mashfiq - Endocrine - BSMMU

6. 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 Insulin 6 Dr. Mashfiq - Endocrine - BSMMU

7. 2 4 8 10 12 14 16 18 20 22 24 Plasma Insulin Levels Hours NPH (12–16 hr ) Regular (6–8 hr) Glargine (~22 hr) ASAspart , Lispro ( 4–5 hr ) Ultralente (~16–20 hr ) Insulin Profiles – schematic (duration) Detemir (~20 hr) INSULIN THERAPY in Diabetes Mellitus 6 7 Dr. Mashfiq - Endocrine - BSMMU

8. 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 Insulin Regimens 8 Dr. Mashfiq - Endocrine - BSMMU

9. Normal Insulin Secretion Serum insulin (mU/L) Time (Hours) Meal Meal Meal Basal Insulin Needs Bolus insulin needs 9 Dr. Mashfiq - Endocrine - BSMMU

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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 met 12 Dr. Mashfiq - Endocrine - BSMMU

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18. Premix insulin Dr. Mashfiq - Endocrine - BSMMU 18

19. Dr. Mashfiq - Endocrine - BSMMU 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 >7 +2

20. Dr. Mashfiq - Endocrine - BSMMU 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

21. Split-Mix insulin Dr. Mashfiq - Endocrine - BSMMU 21

22. Split Mix Regimen Insulin Intermediate acting + short-acting Before Breakfast Time of day 60 20 40 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 29 Dr. Mashfiq - Endocrine - BSMMU

30. Thank you 30 Dr. Mashfiq - Endocrine - BSMMU