REAL WORLD NP

INSULIN IN TYPE 2 DIABETES CHEAT SHEET

Corresponding video here
Adults patients in primary care only

Who needs insulin?

- Severe, symptomatic hyperglycemia (weight loss, ketonuria, malaise, etc) + A1C > 9%
or blood glucose persistently in 300+ range
- Severe, persistent hyperglycemia - can consider insulin vs dual- or triple-oral agent
therapy instead
- If in either category and unclear if it’s Type 1 or 2, they need insulin (see
hyperglycemia video​ for more info)

Initiating insulin
- Patients need to know signs of hyper/hypoglycemia and how to use a glucometer
FIRST
- Each oral agent for diabetes lowers A1C by 0.5 - 1.5%, so may not hit target of < 6.9%
or < 7.9% (depending on age)
- Need patient buy-in and informed consent of treatment - it’s their lifelong choice!

Methods
- Start with basal insulin therapy - long acting, either once or twice a day depending
on which agent you choose (look at the dosing instructions for that particular
insulin type)
- The TOTAL starting daily insulin dose is 0.1 - 0.2 units/kg/day (can do 0.3 -0.4
units/kg/day if higher blood glucose levels, see AAE algorithm for further guidance)
- Check fasting AM blood sugars and write down
- If persistently over goal of < 130 fasting blood glucose, increase by 2-4 units of total
daily insulin and keep checking fasting blood sugars
- If in 3 days, fasting blood sugar is still >130, increase by 2-4 units again until at goal
of < 130 fasting blood glucose
- See notes from video** patients may not be able to follow these instructions, may
need to have visits in person and adjust dosing every 1-2 week with nursing visit,
provider visit, etc so they aren’t confused
- If any symptoms of HYPOGLYCEMIA → decrease total daily insulin dose by either
10% or 4 units

See AACE guidelines here for full details​. The powerpoint slides # 8 & 9 on that web page
outline these steps.

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