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Insulin Therapy Quick Guide
Insulin Therapy Quick Guide
Practical guide to
Insulin
Therapy
in Type 2
Diabetes Mellitus
X
SMBG and Insulin Titratuion
Pre Breakfast BG
2-hours Post-breakfast BG
Pre-lunch BG
2 hours Post-lunch BG
Pre-dinner BG
Post-dinner/Pre-bed BG
KEY MESSAGES
X
X
X
X
X
X
Pre-mixed Analogues BD
X
X
Pre-mixed Human BD
Adjust
To Control
X
X
X
X
X
X
Basal bolus (rapid-acting)
X
X
X
Bedtime
Pre
Dinner
Pre
Post
Lunch
Post
Pre
Breakfast
Pre
Post
SMBG in basal/basal-bolus regimen
X
Basal bolus (short-acting)
Basal only
SOURCES OF FUNDING
The development of this quick reference guide was supported by
an educational grant from sanofi-aventis
Onset
Peak (Hr)
Duration (Hr)
Timing of insulin
30 min
30 min
1-3
2-4
8
6-8
30 mins
before meal
10-20 min
0-15 min
5-15 min
1-3
1
1-2
3-5
3.5-4.5
3-5
c) Intermediate-acting, NPH
- Insulatard*
- Humulin N*
1.5 Hr
1 Hr
4-12
4-10
18-23
16-18
Pre-breakfast / Pre-bed
d) Long-acting analogue
- Glargine*
- Detemir*
2-4 Hr
1 Hr
peakless
peakless
20-24
17-23
30 min
30 min
dual
dual
18-23
16-18
30-60 mins
before meals
10-20 min
0-15 min
dual
dual
18-23
16-18
5-15 mins
before meals
a) Short-acting, regular
- Actrapid*
- Humulin R*
b) Rapid-acting analogue
- Novorapid (Aspart)*
- Humalog (Lispro)*
- Apidra (Glulisine)
f) Premixed analogue
- NovoMix 30
- Humalog Mix 25
* Available at Ministry of Health, Malaysia.
Insulin regimen
BASAL
BASAL
PREMIXED OD
BASAL
PREMIXED BD
BASAL-PLUS (1)
BASAL-PLUS (2)
PRANDIAL
PREMIXED TDS
PREMIXED-PLUS
PREMIXED-PLUS
BASAL-BOLUS
BASAL-BOLUS
OPTIMISATION
INTENSIFICATION
Starting insulin
PREMIXED OD (pre-dinner) or BD
PREMIXED ONCE DAILY (pre-dinner)
PREMIXED OD
PREMIXED BD
PREMIXED BD PLUS PRELUNCH PRANDIAL
BASAL BOLUS
PREMIXED OD (pre-dinner) or BD
FPG and / or pre-dinner 4-6 mmol/L
Glycemic abnormality?
FPG, SMBG
High Fasting / prebreakfast BG
Normal daytime BG
Start
BASAL only
(bedtime)
Optimise dose
Sequential addition of
prandial insulin
BASAL PLUS
(premeal and bedtime)
Optimise dose
Add 3 prandial
insulin
Start PRANDIAL
only (usually TDS
premeals)
Optimise dose
Add basal insulin
INTENSIFY
INITIATE &
OPTIMISE
Start
PREMIXED OD
(predinner)
Optimise dose
PREMIXED TDS*
(premeals)
Optimise dose
Start
BASAL BOLUS
(premeals, bedtime)
Optimise dose
PREMIXED BD PLUS
PRANDIAL (prelunch)
Optimise dose
Note: 1. Metformin should be continued while on insulin therapy unless contraindicated or intolerant
2. Sulphonylureas / Meglitinides should be withdrawn once prandial insulin is used regularly with meals
3. Insulin dose should be optimized prior to switching / intensifying regimens
Starting Dose
Dose Optimisation
Optimal Dose
Basal
Premixed
Prandial
Basal Bolus
Insulin Intensification
Intensification from Basal Regimen
BASAL
PREMIXED BD
BASAL BOLUS
Intensification from
Basal to Premixed Regime
Switch to PREMIXED
TWICE DAILY
Total dose transfer
Split dose 50:50
pre-breakfast : pre-dinner
Titrate dose once / twice a
week to next preprandial
goal
Stop SU, continue metformin
Consider premixed analogue
Intensification from
Basal to Basal Bolus regimen
Intensification from
Basal to Basal Plus regimen