The Profile of

Insulin Glargine & Insulin

Glulisine for treatment of
Diabetes Patients
Insulin Glargine:
The True Once Daily 24 hour
Basal Insulin Analogue
Jenis Preparat Insulin
 Basal Insulin
akan berperan terhadap gula darah puasa (fasting) & diantara makan
(between meal)

Contoh Basal Insulin Analog:

Insulin Glargine (Lantus)

Bolus / Prandial / Mealtime Insulin

akan berperan terhadap gula darah setelah makan (prandial)

Contoh Prandial Insulin Analog (Rapid):

Insulin Glulisine (Apidra)
 Profil sekresi insulin fisiologis
selama 24 jam

Prandial insulin
50
Insulin
(U/mL) 25
Basal Insulin
0
Breakfast Lunch Dinner

Post Prandial Glucose

150
Glucose
(mg/dL) 100
50 Basal Glucose
0 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
AM PM

Time of day
Adapted from Kruszynska Y et al. Diabetologia 1987;30:16.
 Replacement terapi dengan insulin idealnya
meniru sekresi insulin fisiologis
The basalbolus insulin regimen

Breakfast Lunch Dinner Physiological insulin

Ideal basal insulin
45
Ideal prandial insulin
Insulin (mU/L)

30

15

0
06:00 12:00 18:00 24:00 06:00
Time
Figure adapted from Kruszynska YT, et al. Diabetologia 1987;30:1621
 Basal and postprandial contributions to hyperglycemia by A1c range

290 T2DM patients on diet OAD

Mean A1c 8.86%
Standard meals at 0800, 1200 hrs
4-point daytime glucose profiles (0800, 1100, 1400, 1700 hrs)
Calculations assume hyperglycemia is >6.1 mmol/L (110 mg/dL)

100
30%
History !
80 Basal
50% 55% hyperglycemia
60%
70%
60

40
70%
50% 45% Postprandial
20 40%
30% hyperglycemia

0
<7.3 7.3-8.4 8.5-9.2 9.3-10.2 >10.2
A1c ranges (quintiles)
Postprandial hyperglycemia is most important except at high A1c
Monnier L et al. Diabetes Care 2003;26:881-885
 Gula darah puasa (fasting/basal) berkontribusi besar terhadap nilai keseluruhan gula
darah pada kondisi gula darah yang tinggi

Pooled baseline data from 6 Treat-to-Target design studies

1699 T2DM patients on diet OAD
Mean A1c 8.69%, FPG 10.8 mmol/L (194 mg/dL)
7-point ambulatory SMBG profiles (ac, 2hr-pc, and hs)
Calculations assume hyperglycemia is >5.6 mmol/L (100 mg/dL)

Basal
hyperglycemi

Postprandia
hyperglycemi

<8.0 8.0-8.4 8.5-8.9 9.0-9.4 9.5

Baseline A1c ranges

On oral therapy, fasting hyperglycemia dominates over a wide range of A1c

Riddle MC et al. Diabetes 2010;59(Suppl. 1):A171

 Pendekatan tahapan dalam pengobatan pasien
T2DM

A1C Basal Bolus

<7.0%
Preprandial capillary PG Basal Plus
80130 mg/dl Basal Plus Basal +
Peak postprandial capillary PG <180 Two prandial three prandial
mg/dl for largest
ADA-2015 One prandial glucose
Basal Insulin for largest excursion
glucose
excursion
Once daily
OHA (optimized)
mono or
combination
therapy
Diet and
exercise
HbA1c HbA1c uncontrolled, FBG on target
uncontrolled PPBG>8.8 mmol/l (>160 mg/dl)
Time

Raccah D. Diabetes Ob Met 2008; 10: 76-82

Adapted from ADA. Diabetes Care 2015;38(Suppl.1)
Glargine merupakan Basal insulin dengan profil 24 jam
Dapat diberikan dengan dosis satu kali sehari
Sedangkan Detemir profilnya hanya kurang lebih 16
jam

24 hours
16 hours
Case discussion
 KASUS 1
Seorang pria, 52 tahun diketahui DM sejak 3 tahun ya
ng lalu. Saat kontrol ke
GD puasa : 163 mg%
GD 2 jam pp : 188 mg/dL
HbA1c : 9,5%
Penderita selama ini dalam terapi: Glimepiride 4mg 1x
perhari dan Metformin 3x500mg
 Apa yang akan saudara lakukan?

A. Lanjutkan OAD, ulang HbA1c 3 bulan kemudian

B. Tambahkan OAD ketiga yang bisa bekerja pada gula puasa
C. Tambahkan insulin basal dengan OAD dilanjutkan
D. Ganti dengan Insulin basal-bolus
E. Ganti dengan Insulin Rapid/Premixed dan Metformin
Berapa target HbA1c untuk kasus in
i?
a. 6-6.5%
b. 6,5-7%
c. 7-7,5%
d. 7,5-8%

52 thn, BMI ?, C -; D=3 tahun;H=-;H=9,5%,

GDP=163 mg%,GDPP 188 mg%, Terapi : Glimepiride 4,Metformin 3x500
mg
 ABCs of type 2 diabetes: AACE/ACE 2011 and ADA 2013

Target treatment goals

AACE/ACE 2011 ADA 2013

<7.0%,
AIC 6.5% in certain situations can be <6.5% (more
stringents) or <8% (less stringents)

Blood pressure (mmHg) <140/80,

< 130/90 in certain situations like young patients
<130/80

Cholesterol (lipids) LDL-C < 100 mg/dL LDL-C < 100 mg/dL
(<70 mg/dL an option for patients with diabetes (<70 mg/dL for patients with diabetes and
and coronary artery disease) coronary artery disease)
HDL-C >40 mg/dL in men; >50 mg/dL in HDL-C >40 mg/dL in men; >50 mg/dL in
women women
Triglycerides < 150 mg/dL Triglycerides <150 mg/dL

Handelsman, et al. Endoor Pearl 2011;17 (suppl 2):1-53; Standars of Medical Care in Diabetes 2013. Diabetes
Care 2013;36 (suppl 1):11-66.
LDL-C, low-density lipoprotein-cholesterol; HDL-C, high-density lipoprotein-cholesterol; AACE/ACE, American Ass
ociation of Clinical Endocrinologists/American College of Endocrinology; ADA, American Diabetes Association.
 Target Pengendalian DM2

Risiko Risiko
Kardiovaskular Kardiovaskular
(-) (+)

IMT (kg/m2) 18,5 - < 23

Glukosa darah
Puasa (mg/dL) < 100
2 jam PP (mg/dL) < 140

A1C (%) < 7,0 < 7,0

Tekanan darah
Sistolik (mmHg) 130 130
Diastolik (mmHg) 80 80

Profil Lipid
Total kolesterol (mg/dL)

Trigliserid (mg/dL)

HDL kolesterol (mg/dL)

LDL kolesterol (mg/dL) < 100 < 70

 Approach to management of hyperglycaemia :

More Less
stringent stringent

Patient attitude and Highly modivated, adherent, Less motivated, non-adherent,

Expected treatment effosrts excellent self-care capacities Poor self-care capacities

Risks potentially associated Low High

with hypoglycaemia, other
adverse events
Disease duration Newly diagnosed Long-standing

Life expectancy Long Short

Important comorbidities Absent Few / mild Severe

Established vascular Absent Few / mild Severe

complications

Resources, support system Readily available Limited

Berapa target HbA1c untuk kasus in
i?
a. 6-6.5%
b. 6,5-7%
c. 7-7,5%
d. 7,5-8%

52 thn, BMI ?, C -; D=3 tahun;H=-;H=9,5%,

GDP=163 mg%,GDPP 188 mg%, Terapi : Glimepiride 4,Metformin 3x500 mg
 Kasus 1
Seorang pria, 52 tahun diketahui DM sejak 3 tahun yang lalu
. Saat kontrol ke TS, penderita membawa hasil lab 2 hari yan
g lalu sbb:
GD puasa : 163 mg/dL
GD 2 jam pp : 188 mg/dL
HbA1c : 9,5%
Penderita selama ini dalam terapi: Glimepiride 4mg 1x perh
ari dan Metformin 3x500mg
Greater Contribution of PPG as A1C Approaches Target
80
a,b
70
60 c
c
% contribution

50 a
PPG
40 b a FPG
30
20
10
0
<7.3 7.3-8.4 8.5-9.2 9.3-10.2 >10.2
A1C quintiles
a. Significant difference between FPG and PPG (paired t-test). b. Significant difference from all othe
r quintiles (ANOVA) c. Significant difference from quintile 5 (ANOVA)

Monnier L et al. Diabetes Care 2003;26:881.

Management of type 2 diabetes: ADA/EASD 2015 Consens
us Statement
American Diabetes Association and the
European Association for the Study of Diabetes

ADA/EASD

Diabetes Care Diabetologia

2006;29:1963-72 2006;49:1711-21
Pasien mendapat OA
D:
glimepiride 1x4mg, m
etformin3x500mg, Hb
A1c 9,5%
 Kadar HbA1c
<7% 7-8% 8-9% 9% 9-10% >10%

GHS GHS Pasien mendapat OA

+ D:
Gaya Hidup Seha
t glimepiride 1x4mg, m
Monoterapi GHS etformin3x500mg, Hb
- Penurunan Berat
Badan
Met, SU, AGI, Gli + A1c 9,5%
- Mengatur diit
nid, TZD, DPP-IV GHS
Kombinasi 2 o
- Latihan Jasmani t
bat
eratur +
GHS
Met, SU, AGI, Kombinasi 3 o
Glinid, TZD, D bat +
PP-IV
Met, SU, AGI, Kombinasi 2 o
Catatan Glinid, TZD, D bat
1. Dinyatakan gagal bila dengan terapi 2-3 b PP-IV
ulan tidak mencapai target HbA1c <7% Met, SU, AGI, Gl
2. Bila tidak ada pemeriksaan HbA1c dapat d inid, TZD
igunakan pemeriksaan glukosa darah, Rat
a-rata glukosa darah sehari dikonversikan
+ GHS
ke HbA1c menurut kriteria ADA 2010
Basal Insulin +
Insulin Inten
sif

Bagan 3. Algoritma pengelolaan DM tipe 2 tanpa disertai dekompensasi

Perkeni 2011
 KASUS 1
Apa yang akan saudara lakukan?
A.Lanjutkan OAD, ulang HbA1c 3 bulan kemudian
B.Tambahkan OAD ketiga yang bisa bekerja pada gula puasa
C.Tambahkan insulin basal dengan OAD dilanjutkan
D.Ganti dengan Insulin basal-bolus
E.Ganti dengan Insulin Rapid/Premixed dan Metformin
 KASUS 1
Jika anda memilih insulin, insulin mana yang
akan anda berikan?
A. Basal
Pasien mendapat OAD:
B. Analog glimepiride 1x4mg, metfo
rmin3x500mg, HbA1c 9,5
C. Premixed %
GDP 163 mg%
GDPP : 168 mg%
D. Human insulin
 INSULIN CHOICES

BASAL RAPID-ACTIN PRE-MIXED

G Human or Analog
Detemir Aspart 70/30
Glargine Lispro 50/50
Glulisine
NPH Other mixes
Regular
1. If Fasting BG is elevated, start for basal insulin
with long acting insulin

2. If Prandial BG is elevated, start for prandial /bolus ins

ulin with rapid acting insulin

3. If Fasting and Post Prandial are elevated :

- Oral agent with basal insulin
- premix insulin
- basal/bolus as in multiple daily injection (MDI)
 KASUS 1
Seorang pria, 52 tahun diketahui DM sejak 3 tahun
yang lalu. Saat kontrol ke TS, penderita membawa
hasil lab 2 hari yang lalu sbb:
GD puasa: 163 mg/dL
GD 2 jam pp: 188 mg/dL
HbA1c: 9,5%
Penderita selama ini dalam terapi: Glimepiride 4mg
1x perhari dan Metformin 3x500mg
 Treatment Based on the Pathophysiology
Hyperglycemia in Type 2 Diabetes

Fasting Hyperglycemia Prandial Hyperglycemia

Basal Insulin Prandial Insulin

Prandrial Basal
 KASUS 1
Jika anda memilih insulin, insulin mana yang
akan anda berikan?
A. Basal
B. Analog
C. Premixed
D. Human insulin
 KASUS 1
Berapa dosis yang saudara anjurkan?
A. 10 unit
B. 4 unit
C. 14 unit
D. 12 unit
 The simple way to add basal insulin
Initiate insulin with a single injection of a basal insulin

Bedtime or morning long-acting insulin OR

Bedtime intermediate-acting insulin
INITIATE
Daily dose: 10 units or 0.2 units/kg

Check FBG Dail

y
In the event of hypoglycemia or F
Increase dose by 2 units every 3 days until
BG level < 3.89 mmol/L (< 70 mg/d
FBG is 3.897.22 mmol/L (70130 mg/dL)
L)
if FBG is > 10 mmol/L (> 180 mg/dL),
TITRATE increase dose by 4 units every 3 days
Reduce bedtime insulin dose
by 4 units, or by 10% if > 60 un
its

Continue regimen and

MONITOR check HbA1c every 3 months

FBG, fasting blood glucose Adapted from Nathan DM, et al. Diabetologia 2006;49:171121
 KASUS 1
2 minggu kemudian pasien datang dengan membawa hasil laborat
orium sbb:
Hb: 11,7 gr/dL (N:13,5-15,5)
Kol.total: 234 mg/dL HDL: 31, LDL: 167 mg/dL
Trigliserida: 363 mg/dL
Ureum: 41 mg/dL, Kreatinin: 1,7 mg/dL
Urin: protein (++).GDP 140,GDPP 170 mg%
TB: 167 cm, BB: 73kg dengan TD: 140/80 mmHg
 KASUS 1
Berapa dosis yang saudara anjurkan?
A. 10 unit
B. 4 unit
C. 14 unit
D. 12 unit
 The simple way to add basal insulin
Initiate insulin with a single injection of a basal insulin
GDP 140,GDPP 170 mg%
Bedtime or morning long-acting insulin OR
Bedtime intermediate-acting insulin GDP 140 mg%
INITIATE GDPP 170 mg%
Daily dose: 10 units or 0.2 units/kg

Check FBG Dail

y
In the event of hypoglycemia or F
Increase dose by 2 units every 3 days until
BG level < 3.89 mmol/L (< 70 mg/d
FBG is 3.897.22 mmol/L (70130 mg/dL)
L)
if FBG is > 10 mmol/L (> 180 mg/dL),
TITRATE increase dose by 4 units every 3 days
Reduce bedtime insulin dose
by 4 units, or by 10% if > 60 un
its

Continue regimen and

MONITOR
check HbA1c every 3 months

FBG, fasting blood glucose Adapted from Nathan DM, et al. Diabetologia 2006;49:171121
 KASUS 1
3 bulan kemudian, pasien datang kembali ke sej
awat dengan keadaan lebih segar. Pemeriksaa
n fisik lain tidak ada kelainan
Hasil Lab:
GD p/GD 2 jam pp: 112/245mg/dL
HbA1c: 7,6%
 KASUS 1
Apa yang akan saudara lakukan?
A. Tetap lanjutkan OAD dan basal insulin, ulang HbA1c 3 b
ulan kemudian
B. Stop insulin basal dan kembali ke OAD
C. Tambahkan insulin rapid dengan insulin basal (regimen
basal-bolus)
D. Tambahkan insulin premixed di makan yang terbanyak

GD P/GD 2 jam pp: 112/245mg/dL

HbA1c: 7,6%
Langkah-langkah pendekatan pengobatan DM
T2

A1C Basal Bolu

<7.0% s
Glukosa plasma sebelum makan 80130 mg/dl Basal Plu
Puncak glukosa plasma setelah makan <180 mg/dl Basal +
ADA-2015 Basal Plu s
3 suntikan pra
s 2 suntikan pr ndial
andial utk as
1 suntikan pr upan glukos
Insulin Basal andial utk as a terbesar
upan glukos
Sehari 1x a terbesar
OAD (sampai optimal)
Monoterapi
atau
kombinasi
Diet dan ola
hraga A1C A1C tdk terkendali, GDP sesuai target
Tdk terkendali GDPP>8.8 mmol/l (>160 mg/dl)

Waktu

Konsensus PERKENI 2011 ; Raccah D. Diabetes Ob Met 2008;10:76-82.

 Initiating and adjusting insulin
Bedtime intermediate-acting insulin, or
bedtime or morning long-acting insulin
(initiate with 10 units or 0.2 units per kg)

Check FG and increase dose until in target range

Target range FBG:
3.89-7.22 mmol/L
(70-130mg/dL)

If HbA1c < 7% If HbA1c 7%

Continue regimen; check Hb If FBG in target range, check BG before lunch, dinner, and bed. Depending on BG
A1c every 3 months results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)

Pre-lunch BG out of range: add rapi Pre-dinner BG out of range: add NPH insulin at breakf Pre-bed BG out of range: add rap
d-acting insulin at breakfast ast or rapid-acting insulin at lunch id-acting insulin at dinner

If HbA1c < 7% If HbA1c 7%

Continue regimen; check Hb Recheck pre-meal BG levels and if out of range, may need to add another injection; if HbA1c
A1c every 3 months continues to be out of range, check 2-hr postprandial levels and adjust preprandial rapid-ac
ting insulin

Nathan DM, et al. Diabetes Care 2009;32 193-203.

CASE 2
 Kasus 2
Seorang wanita berumur 48 tahun diketahui sebagai
penderita DM tipe 2 sejak 6 thn.
Sebulan terakhir ini penderita merasakan fatigue, tanpa
disertai polidipsi, poliuria atau perubahan berat badan;
tidak ada perubahan pada penglihatan, tidak ada rasa
kesemutan atau terbakar pada ekstremitas.
Saat ini obat yang dimakan adalah
Metformin 1000 mg 2x1
glibenclamide 10 mg 2x1
 Kasus 2
Pola makan dan pemeriksaan SMBG (Self Monitoring
Blood Glucose) tidak terlalu diperhatikan
Dia menolak melakukan terapi insulin oleh karena
takut akan suntikan
Pada saat makan malam merupakan porsi terbanyak
penderita
TB: 157 cm dan BB: 53 kg; BMI 21,50 kg/m2
 Kasus 2
Hasil laboratorium:
HbA1c sekarang: 9,0%
HbA1c sebelumnya (6 bulan sebelumnya): 8,8%
Pemeriksaan GD puasa 3 hari sebelumnya 170 mg/dL

Sebutkan target GD puasa dan postpandrial sert

a HbA1c yang saudara inginkan?
 ABCs of type 2 diabetes: AACE/ACE 2011 and ADA 2013

Target treatment goals

AACE/ACE 2011 ADA 2013

<7.0%,
AIC 6.5% in certain situations can be <6.5% (more
stringents) or <8% (less stringents)

Blood pressure (mmHg) <140/80,

< 130/90 in certain situations like young patients
<130/80

Cholesterol (lipids) LDL-C < 100 mg/dL LDL-C < 100 mg/dL
(<70 mg/dL an option for patients with diabetes (<70 mg/dL for patients with diabetes and
and coronary artery disease) coronary artery disease)
HDL-C >40 mg/dL in men; >50 mg/dL in HDL-C >40 mg/dL in men; >50 mg/dL in
women women
Triglycerides < 150 mg/dL Triglycerides <150 mg/dL

Handelsman, et al. Endoor Pearl 2011;17 (suppl 2):1-53; Standars of Medical Care in Diabetes 2013. Diabetes Care 2013;36 (supp
l 1):11-66.
LDL-C, low-density lipoprotein-cholesterol; HDL-C, high-density lipoprotein-cholesterol; AACE/ACE, American Association of Clinical
Endocrinologists/American College of Endocrinology; ADA, American Diabetes Association.
 Target Pengendalian DM2

Risiko Risiko
Kardiovaskular Kardiovaskular
(-) (+)

IMT (kg/m2) 18,5 - < 23

Glukosa darah
Puasa (mg/dL) < 100
2 jam PP (mg/dL) < 140
A1C (%) < 7,0 < 7,0
Tekanan darah
Sistolik (mmHg) 130 130
Diastolik (mmHg) 80 80
Profil Lipid
Total kolesterol (mg/dL)

Trigliserid (mg/dL)
HDL kolesterol (mg/dL)

LDL kolesterol (mg/dL) < 100 < 70

ADA 2015
 Approach to management of hyperglycaemia :

More Less
stringent stringent

Patient attitude and Highly modivated, adherent, Less motivated, non-adherent,

Expected treatment effosrts excellent self-care capacities Poor self-care capacities

Risks potentially associated Low High

with hypoglycaemia, other
adverse events
Disease duration Newly diagnosed Long-standing

Life expectancy Long Short

Important comorbidities Absent Few / mild Severe

Established vascular Absent Few / mild Severe

complications

Resources, support system Readily available Limited

Berapa target HbA1c untuk kasus in
i?
a. 6-6.5%
b. 6,5-7%
c. 7-7,5%
d. 7,5-8%

48 thn, BMI 21,50 kg/m2, C -; D=6 tahun;H=-;H=9,0%,

GDP=170 mg% (3 hari yl),GDPP mg%,
Terapi : Glibenclamide 10 2x1,Metformin 2x1000 mg
 Kasus 2
Apa yang akan saudara lakukan untuk mencapai target tersebut?
A. Menambahkan Obat Hipoglikemik Oral yang lain golongan (sel
ain sulfonilurea dan Metformin)
B. Menambahkan Insulin basal dan melanjutkan terapi oral
C. Memulai insulin basal bolus plus, stop terapi oral
D. Memulai insulin analog premixed 2x perhari dan stop terapi or
al

A=48 yo,BMI= 21,50 kg/m2 ;C=-,D 6 yr,HbA1c 9,0,

GDP 3 hari ; 170 mg%
Pasien mendapat OA
D:
Glibenclamide 2x10 m
g, metformin 2x1000
mg, HbA1c 9,0%
Langkah-langkah pendekatan pengobatan DM
T2

A1C Basal Bolu

<7.0% s
Glukosa plasma sebelum makan 80130 mg/dl Basal Plu
Puncak glukosa plasma setelah makan <180 mg/dl Basal +
ADA-2015 Basal Plu s
3 suntikan pra
s 2 suntikan pr ndial
andial utk as
1 suntikan pr upan glukos
Insulin Basal andial utk as a terbesar
upan glukos
Sehari 1x a terbesar
OAD (sampai optimal)
Monoterapi
atau
kombinasi
Diet dan ola
hraga A1C A1C tdk terkendali, GDP sesuai target
Tdk terkendali GDPP>8.8 mmol/l (>160 mg/dl)

Waktu

Konsensus PERKENI 2011 ; Raccah D. Diabetes Ob Met 2008;10:76-82.

 ADA:STANDARDS OF, MEDICAL CARE IN DIABETES2015

Preprandial blood glucose valu Dose change

e
<80 mg/dl -2U
80-110 mg/dl 0
110-140 mg/dl +2 U
141-180 mg/dl +4 U
>180 mg/dl +6 U
How to Initiate
Basal Insulin
How to start basal insulin

Start with basal insulin 10 U

Or
0,1-0,2 U per Kg BB

Once daily injection, anytime injection but in same time per each day

Consensus Perkeni 2011, American Diabetes Association. Diabetes Care 2015.

 How to titrate basal insulin
Levemir Dose Titration Guidelines:
3-0-3 Algorithm

Simple Dose titration with Levemir

Mean 3-day FPG (mg/dL)

Start with Levemir 10 U or 0,1-0,2 U per Kg BB

FPG>110 mg/dL +3U

80-110 mg/dL 0

FPG <80 mg/dL -3U

Patients who experienced hypoglycemia reduced their daily dose by 3 units

Blonde L et al. Diabetes Obes Metab. 2009; 11(6):623-631.

 Insulin Titration schemes-Perkeni consensus

Fasting Blood Glucose Co

Basal Insulin Titration
ntent (mg/dl)

BASAL INSUL <70 mg/dl Reduce dosage with 2 units

IN
70-130 mg/dl Maintain dosage

130-180 mg/dl Increase dosage 2 units per 3 day

s
>180 mg/dl Increase dosage 4 units per 3 day
s

Once titrated, continue to monitor HbA1c every 3 months

Start with basal insulin 10 units, titrate every three days untill target fa
sting plasma glucose on target

Perkeni consensus, 2011

 Simple Way to Start Basal Insulin
Bedtime or morning long-acting insulin
OR
Bedtime intermediate-acting insulin
Daily dose: 10 units or 0.2 units/kg

Check
FPG
daily

Increase dose by 2 units every 3 days until FPG In the event of hypoglycemia or F
is 70-130 mg/dL PG level < 70 mg/dL
If FPG is >180 mg/dL, increase dose by 4 units Reduce bedtime insulin dose by 4
every 3 days units,
or by 10% if >60 units

Continue regimen and check HbA1c e

very 3 months

Nathan D, et al. Diabetologia. 2006;49:1711-1721.

 Take Home Messages
Individually achieve and maintain optimal glycemic goal
Add medications, transition to new regimens quickly
- Whenever HbA1c levels are >7% (or individualized target)
After basal failed :
- Basal plus (0-3)
- Premixed
A glargine/glulisine stepwise approach a more favorable
benefit/risk profile to T2D patients than a premixed insulin therapy
at achieving target glycemic control