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
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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
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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
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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
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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
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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
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11. BASAL, BASAL-PLUS, BASAL-BOLUS
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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
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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
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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
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21. SPLIT-MIX INSULIN
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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
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24. PRINCIPLES OF INITIATION
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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
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30. THANK YOU
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