FAMILY MEDICINE RESIDENY TRAINING

PROGRAM-NATIONAL GURAD-Riyadh

WADA 2020

INSULIN THERAPY INITIATION,

AND ADJUSTMENT
Saeed M Al-Qahtani, MD, SB-FM, ABFM, Dip Av Med
Consultant &Trainer ,FM & PHC, KAMC-Riyadh.
Assistant Professor, FM Block Coordinator, KSAU-HS
Flight Surgeon, Aviation Medicine Department

12 OCTOBER 2020
Why Insulin?
Why Insulin?
When to start Insulin?
q Severe hyperglycemia on presentation
§ symptomatic (eg, weight loss, polydipsia, polyuria) or
severe hyperglycemia with ketonuria
§ severe hyperglycemia (FBG >250 mg/dL [13.9 mmol/L],
random glucose consistently >300 mg/dL [16.7 mmol/L],
A1C >10% [85.8 mmol/mol]) but without ketonuria or
spontaneous weight loss
q Difficulty distinguishing type of diabetes
q Pancreatic insufficiency
q Persistent hyperglycemia on oral agents
A1C >9% or with persistent symptoms of hyperglycemia
How to start Insulin?
 How to start Insulin?

AUGMENTATION REPLACEMENT
Add-on therapy Insulin monotherapy

Add basal Insulin to non- Stop non-insulin (except

insulin regimen GLP1-SGLT2i) and start
basal or basal/bolus
insulin
A 50-year-old obese male with 4 months history of
polyurea. RBS 13.4 mmol/L.

What is best medication to start at this start?

A. Insulin
B. Metformin
C. Liraglutide
D. Glimepiride
A 50-year-old obese male with 4 months history of
polyurea. RBS 13.4 mmol/L.

What is best medication to start at this start?

A. Insulin
B. Metformin
C. Liraglutide
D. Glimepiride
You are caring for a patient with T2DM whose measures of
control have been worsening despite maximal doses of oral
medications. You are considering adding insulin therapy to
help with her post-prandial hyperglycemia and want to start
a preparation with a rapid onset of action.
Which of the following insulin types has the most rapid onset
of action?

A. Aspart
B. Regular
C. Detemir
D. Neutral protamine Hagedorn (NPH)
You are caring for a patient with T2DM whose measures of
control have been worsening despite maximal doses of oral
medications. You are considering adding insulin therapy to
help with her post-prandial hyperglycemia and want to start
a preparation with a rapid onset of action.
Which of the following insulin types has the most rapid onset
of action?

A. Aspart
B. Regular
C. Detemir
D. Neutral protamine Hagedorn (NPH)
You are thinking about starting a patient with T2DM on
insulin therapy to improve her glucose control. You would
like to provide her with steady insulin action without much
of a peak time.
Which of the following insulin preparations provides the
most stable insulin coverage without a peak time of
maximum activity?

A. NPH
B. Lispro
C. Regular
D. Glargine
You are thinking about starting a patient with T2DM on
insulin therapy to improve her glucose control. You would
like to provide her with steady insulin action without much
of a peak time.
Which of the following insulin preparations provides the
most stable insulin coverage without a peak time of
maximum activity?

A. NPH
B. Lispro
C. Regular
D. Glargine
A 52-year-old male with 8 years history of type 2 DM on
Metformin XR 1500 mg, Glimepiride 4 mg OD and Sitagliptin 100
mg OD
Came with the following labs: Test Result Unit
FBS 211 mg/dl
2hPP 356 mg/dl
HbA1c 10.8 %

Which of the following is the most appropriate action at this stage?

A. Start NPH at night

B. Add Dapagliflozin
C. Increase Metformin dose
D. Add dulaglutide Injections
A 52-year-old male with 8 years history of type 2 DM on
Metformin XR 1500 mg, Glimepiride 4 mg OD and Sitagliptin 100
mg OD
Came with the following labs: Test Result Unit
FBS 211 mg/dl
2hPP 356 mg/dl
HbA1c 10.8 %

Which of the following is the most appropriate action at this stage?

A. Start NPH at night

B. Add Dapagliflozin
C. Increase Metformin dose
D. Add dulaglutide Injections
A 48-year old with T2DM was started on titration dose
of insulin glargine 2 weeks ago came for follow up and
his readings now show Test Result Unit
FBS 118 mg/dl
2hPP 169 mg/dl
HbA1c 11.3 %

What is the most appropriate next step?

A. Increase glargine dose

B. Add aspart with largest meal
C. Increase glargine dose
D. Continue the current glargine dose
A 48-year old with T2DM was started on titration dose
of insulin glargine 2 weeks ago came for follow up and
his readings now show Test Result Unit
FBS 118 mg/dl
2hPP 169 mg/dl
HbA1c 11.3 %

What is the most appropriate next step?

A. Increase glargine dose

B. Add aspart with largest meal
C. Increase glargine dose
D. Continue the current glargine dose
THANK
YOU