Many people with type 2 diabetes need insulin therapy. There are two methods for introducing a multidose insulin regimen. Insulin treatment that mimics normal physiological patterns as closely as possible remains the cardinal principle of treatment for type 1 diabetes. Pdf objective glucose variability induces endothelial dysfunction and cardiac autonomic nerve abnormality. Ispad clinical practice consensus guidelines 2018 compendium. Keeping a record of your blood glucose levels with information. Isophane insulin is a suspension of insulin with protamine. Insulin aspart, insulin glulisine, and insulin lispro have a faster onset of action within 15 minutes and shorter duration of action approximately 25 hours than soluble insulin, and are usually given by subcutaneous injection for maintenance regimens, these insulins should ideally be injected immediately before meals. If blood glucose levels are too high, two types of insulin may be used to improve blood glucose. Estimate the mealtime injected dose by dividing half of the total daily injected premixed insulin dose equally among the three meals of the day. Canadian agency for drugs and technologies in health 600865 carling avenue, ottawa, ontario, 1s 5s8. Your mealtime insulin injection is designed to mimic the bursts of insulin your body used to produce in response to food. Recognize the warnings and precautions associated with insulin use.
Mealtime insulin management what is mealtime insulin. Clinical inertia, the failure to initiate or intensify insulin therapy when indicated, is a multifactorial problem resulting from barriers to insulin initiation and intensification, including treatment regimen inconvenience, needle phobia, and. Insulin initiation and titration in patients with type 2. Understanding insulin therapy educational objectives. If after 3 months if a1c is greater than 7% and optimal bedtime dose has been reached with fasting blood glucose at goal, consider adding a pre meal bolus insulin at the largest meal of the day, pre meal bolus insulin at each meal or 7030 premix insulin. Consult your medical provider about specific insulin dose recommendations.
Mealtime and basal insulins are used in various combinations to achieve close to normal glycemia during pregnancy. If patient unable to do multiple daily injections, consider switching to mixed insulin instead of adding prandial insulin. When compared to insulin regular, insulin nph has a slower onset and longer duration of activity. Consensus on insulin dose and titration algorithms in. Or, they can take a premixed insulin, which, as the name implies, combines a background insulin with a mealtime. Shortacting insulin before meals should be stopped until the patient has a meal.
Insulin pumps and multidose insulin injection regimens using basal analog insulin combined with a rapidacting insulins provide patients with the greatest. Insulin is usually injected into the upper arms, thighs, buttocks or abdomen. Nph insulin has a pronounced and variable peak and should be avoided during. An insulin algorithm based on physiological insulin demand evoked by foods in healthy subjects may be a useful tool for estimating mealtime insulin dose in patients with type 1 diabetes. Several different regimens have been developed involving multiple subcutaneous injections per day when insulin is used alone in the treatment of type 1 diabetes figures 34. Continue to repeat 10 units subcut and poc blood sugar checks every 30 minutes until blood glucose is less than 300 mgdl, then resume normal poc blood sugar check and insulin aspart sliding scale. Oct 18, 2007 the texas diabetes council algorithm recommends insulin for treatment naive patients with a fpg of at least 260 mgdl or an hba1c of at least 10%. Patients taking only bedtime nph insulin or only table 1. Improving the estimation of mealtime insulin dose in.
Insulin should be kept away from direct heat and sunlight. Recommendations for dosing and titration of basal, basalplus, premixed and basalbolus insulins were. Another available option is the use of an insulin pump, in the form of a battery powered pump controlled by a microprocessor figure 5. Principles of adjusting insulin doses table 1 summarizes the most important relationships among various components of the insulin prescrip. Also, there are many variations of insulin therapy. Represents about 10% to 20% of the daily insulin requirement at each meal, or about 50% of the bodys daily insulin needs. Usually a basal insulin nph, glargine, detemir, degludec.
In people with type 1 diabetes, their bodies make no insulin whatsoever, and they must take insulin the rest of their lives. Focus on modest weight loss of 57% total body weight. A oncedaily longacting insulin glargine typically given at bedtime achieves a steadystate within 2 hours, does not display a distinct peak, and has a 2024 hour duration of action in most patients. About 5 hours insulin aspart novolog novo nordisk analog syringe, pen, or pump 10 to 20 min. To best match the insulin action with the glycemic effect of meals, regular insulin is optimally given 30 minutes before the meal and the rapidacting insulins 1520 minutes before the meal. There is a 2hour delay in the onset of its effect because insulin is injected as a complex of. Apr 05, 2019 sliding scale insulin therapy is one way a person with diabetes can work out how much insulin to take before a meal without causing negative effects on the body. Augmentation therapy can include basal or bolus insulin. Dec 27, 2019 insulin nph is an intermediateacting insulin formulation which is usually administered subcutaneously once or twice daily.
Multiple health care organizations offer guidelines for glycemic control, including recommendations for medical nutrition therapy mnt and consistentcarbohydrate meal plans. There are different types of insulin depending on how quickly they work, when they peak, and how long they last. Let your physiciancare team know that you had low blood sugar. Convert each estimated injected mealtime dose to an appropriate afrezza dose using figure 1 administer half of the total daily injected. Consider starting at this stage when blood glucose is. But it can also be intimidating or overwhelming to take, since every dose of mealtime insulin needs to be calculated based on different factors. Stepwise dosing and titration of insulin for type 2 diabetes. Insulin nph is an intermediateacting insulin formulation which is usually administered subcutaneously once or twice daily. For patients with type 1 diabetes, the basal bolus insulin strategy is optimal, and these patients should always receive basal insulin, even during periods of fasting. Rapid acting insulin can be used to cover the carbohydrate in your meals. Longacting insulin helps control blood glucose throughout the day, while rapidacting insulin manages levels at meal time. Guide to starting and adjusting insulin for type 2 diabetes cadth. An overview on types of insulin, deciding how much insulin to take, and how they work.
Background and mealtime insulin regimen is the most physiological and flexible regimen. The desired frequency of smbg testing for insulin dose adjustments is an important issue. Relationships among components of the insulin prescription, injection times, and blood glucose testing. If blood sugar is under 70, drink 12 cup of juice or soda or eat something that contains sugar. Recommendations for insulin using patients when fasting. All insulin available in the united states is manufactured in a laboratory, but animal insulin can still be imported for personal use. If you are taking rapid acting mealtime insulin, this information may be helpful to you. These handouts may be reproduced for educational purposes only through the expiration date with credit granted to ddpg. The basalbolus insulin concept basal insulin suppresses glucose production between meals and overnight. Weight based formulas and the use of multidose insulin regimens offer more individualized insulin. Mnt is a wellrecognized component of diabetes management, and experts agree that it should be integrated into the glycemic management of hospitalized patients.
It starts to work within 15 minutes of being injected, peaks in about an hour, and lasts in your system for about two to four hours. Insulin use and persistence in patients with type 2 diabetes adding mealtime insulin to a basal regimen. The objective of this study was to characterize insulin use and examine factors associated with persistence to mealtime insulin among patients with type 2 diabetes t2d on stable basal insulin therapy initiating mealtime insulin therapy. It is difficult to 9obtain optimal control without occasional, mild episodes of hypoglycemia. List questions to ask patients who are using insulin to identify if they may need additional counseling from a pharmacist. People who take a background insulin along with a mealtime insulin have two options. Administer 12 units subcut, notify provider, and repeat poc blood sugar check in 30 minutes. In type 1 diabetes management, premeal insulin dosage and physiological insulin requirement must be matched to optimize postprandial blood glucose profiles 1.
Please keep in mind, the estimated insulin regimen is an initial best guess and the dose may need to be modified to keep your blood sugar on target. Insulin management of type 2 diabetes mellitus american family. The absorption may be increased if the limb is used in strenuous exercise. Pdf mealtime dosing of a rapidacting insulin analog reduces. Insulin initiation and titration is a challenge for many primary care providers pcps involved in the treatment of patients with type 2 diabetes. You may benefit from taking part of the mealtime insulin beforehand and the rest after eating, or, if you are using an insulin pump, use the extended bolus feature. Insulin dosing using an insulintocarb ratio and correction factor.
Consider using a basalbolus and supplemental correction insulin regimen. Despite this being a noninferiority treattotarget study, fasp, dosed at mealtime, yielded a slightly 0. How to initiate, titrate, and intensify insulin treatment in. Consultation with an experienced healthcare professional is advised for patients with complicated insulin needs, e. Initiate and progressively advance insulin therapy in type 2 diabetes. Testing before and 2 hours after a meal will show you if the dose you have injected has worked effectively. Insulin treatment summary bnf content published by nice. Background basal and mealtime bolus insulin calculate background and mealtime doses initially, mealtime insulin dose is divided evenly between meals calculate tdi dose as 0. Comparison of a multiple daily insulin injection regimen basal oncedaily glargine plus mealtime lispro and continuous subcutaneous insulin infusion lispro in type 1 diabetes a randomized open parallel multicenter study geremia b. Insulin regimens should be tailored to the individual, taking into account the patients type of diabetes, previous control, age, dexterity, eyesight, and personal and cultural preferences.
It can be a gamechanger for many who need extra help keeping blood sugar levels stable. Comparison of a multiple daily insulin injection regimen. Its job is to help lower blood sugars after you eat. Patient education handouts previously called patient education slicks the following are reproducible patient education handouts available in pdf format. Onehalf the tdd is divided into equal meal time doses. A multidose insulin regimen does not need to be started at once. Clinical inertia, the failure to initiate or intensify insulin therapy when indicated, is a multifactorial problem resulting from barriers to insulin initiation and intensification, including treatment regimen inconvenience. The basal insulin dose may need to be reduced by one half or one third, particularly for morning dosage regimens. Treated with intensive insulin diabetes education online. Since the last guidelines were published in 20141 the changes have been modest with respect to insulin treatment, but the different modes have been refined especially when it pertains to insulin pump. Premeal bolus with rapid acting or regular insulin and with lantus glargine or levemir detemir or nph insulin a1c greater than 7% with optimal long acting basal insulin.
Insulin pharmacology, therapeutic regimens, and principles. Research design and methods people with type 1 diabetes on nphbased. People with type 2 diabetes usually still make some but not enough insulin, and often also have what is known as insulin resistance. B intermediateacting nph is the oldest basal insulin that is still in common use. You will need to work out your specific insulin requirements and dose regimen with your medical provider and diabetes team. Sliding scale insulin therapy is one way a person with diabetes can work out how much insulin to take before a meal without causing negative effects on the body. Basic nutrition recommendations include elimination of sweetened beverages, eat minimum three mealsday each containing three carbohydrate choices 45 gmeal. Management of diabetes and hyperglycemia has become an important quality care indicator in the hospital setting. Insulin use and persistence in patients with type 2. See table 2 for blood glucose targets self monitoring of blood glucose values assist in determining an effective dose and regimen and therefore should be obtained immediately pre and one hour post meal during insulin therapy as. Objective insulin pump therapy continuous subcutaneous insulin infusion csii and multiple daily injections mdis with insulin glargine as basal insulin and mealtime insulin lispro have not been prospectively compared in people naive to either regimen in a multicenter study. Bolus insulin is usually provided by rapidacting insulin analogs, such as insulin aspart, insulin lyspro, and insulin glulisine or regular insulin.
Lly announced today that the european medicines agencys ema committee for medicinal products for human use chmp has issued a positive opinion for lillys new mealtime insulin for the treatment of adults with diabetes as part of a multiple daily injection regimen or delivered by an. Its purpose is to control your postmeal glucose level. Changes in insulin strength, manufacturer, type, or method of administration may affect glycemic control and predispose to hypoglycemia see warnings and precautions 5. Replacement therapy includes basalbolus insulin and correction or premixed insulin. Pdf comparison of a multiple daily insulin injection. Types of insulin and how they work basal, mealtime. You can also take glucose tablets to bring your blood sugar into normal range. Type 2 diabetes adult outpatient insulin guidelines if post meal glucose levels 180. If you are taking exenatide or pramlintide before a meal, you will need to reduce your mealtime insulin dose. Stepwise dosing and titration of insulin for type 2.
Type 2 diabetes adult outpatient insulin guidelines if postmeal glucose levels 180. Bolus insulin mealtime or prandial limits hyperglycemia after meals. Increase prandial dose by 10 or 12 units if 2h postprandial or net premeal glucose consistently 140 mgdl if hypoglycemia reduce tdd basal andor prandial insulin by bg consistently 0 mgdl 10 20. Jan 01, 2018 insulin degludec, an ultralongacting basal insulin, versus insulin glargine in basalbolus treatment with mealtime insulin aspart in type 2 diabetes begin basalbolus type 2. Consider insulin as initial therapy if a1c very high, such as 10. Insulin for gestational and pregestational diabetes. Mixed insulin is more likely to cause hypoglycemia8,19 and generally requires a fixed meal schedule8. Comparison of a multiple daily insulin injection regimen basal oncedaily glargine plus mealtime lispro and continuous subcutaneous insulin infusion lispro in type 1 diabetes. They can take the background insulin once or twice a day, as prescribed, and take the mealtime insulin just before eating a meal, also as prescribed. Your insulin dose regimen provides formulas that allow you to calculate how much bolus insulin to take at meals and snacks, or to correct high blood sugars. Prandialbasal insulin regimens plus oral antihyperglycaemic agents to improve mealtime glycaemia.
Calculating insulin dose diabetes education online. This article will summarize that information and provide a more detailed personal approach to starting insulin, intensifying insu lin regimens when necessary, and adjusting insulin doses. Guide to starting and adjusting insulin for type 2 diabetes. Insulin doses should be individualized based on patient needs. Glucose monitoring is essential for patients receiving insulin therapy. Mealtime insulin is used to help regulate the normal spike that occurs in your blood sugar after eating a meal. Insulin use and persistence in patients with type 2 diabetes. Prescribe evening basal insulin and the use of a premeal correction dose scale of rapid acting insulin see insulin table at meals e.
Ideally, for insulin replacement therapy, each component should come from a different insulin with a specific profile. Patients should be advised to eat a meal or snack and to resume their normal insulin regimen following the laboratory tests or procedure. Insulin degludec, an ultralongacting basal insulin, versus insulin glargine in basalbolus treatment with mealtime insulin aspart in type 2 diabetes begin basalbolus type 2. Instruct patient to check smbg 2 hours after meal s to assess peak affect of insulin on meal and blood glucose level instruct the patient to check fasting smbg to assess the effect of the basal insulin dose. Types of insulin and how they work insulin is a hormone the body makes to control the level of glucose sugar in the blood.
Identify available insulin products and discuss how they are used in diabetes treatment plans. Rapidacting insulin insulin aspart fiasp novo nordisk analog syringe or pen 2. Insulin glargine basaglar, lantus, toujeo no peak time. Mealtime insulin management y twice a day, longacting insulin benefits considerations greater control more food choices and flexibility with timing of meals and snacks easy to use after meal blood glucose closer to goals how will taking mealtime insulin affect your lifestyle. Symlin therapy should only be considered in patients with type 1 diabetes or patients with type 2 diabetes using mealtime insulin who fulfill the following criteria. Longacting insulin covers insulin needs for about one full day.