Diabetes Mellitis

Insulin Therapy


Fall 2019 1

Insulin Syringes

3/10 ml syringe hold 30

or less units

1/2 ml syringe holds

31-50 units

1 ml syringe holds

51-100 units

Inhaled Insulin (Afrezza) Helps with meal time

glucose elevation

Dry powder rapid-acting inhaled insulin

Avoid in patients with chronic lung disease

Available in 3 cartridge strengths Single dose cartridges- one time use only

– 4 units

– 8 units

– 12 units

Black box warning : Avoid in

patients with chronic lung

disease

Ppl who smoke, had asthma or COPD or ppl who recently stopped

smoking or currently smoke- shouldn’t use it because can cause

acute bronchospasms

Ppl should be evaluated under pulmonary function test- check

spirometry by using FEV1 test

Insulin

Basal insulin Given once a day- provides 24 hr coverage

– Glargine (Lantus®)

– Detemir (Levemir®) Can be given twice a day- lasts about 18 hrs

– Neutral protamine Hagedorn (NPH) (Humulin® N or

Novolin® N) Intermediate acting insulin, can act as a

basal insulin because of moa and patient

variability

Bolus insulin Prandial/Meal time insulin - given 15 before

meal to reduce post prandial excursions

– Regular (Humulin® R or Novolon® R)

– Lispro (Humalog®)

– Aspart (Novolog®)

– Glulisine (Apidra®)

Target fasting blood

glucose and between

Basal Insulin meals blood glucose

levels

Most convenient initial insulin regimen and can be added

to metformin and other oral agents.

– principal action is to reduce hepatic glucose production with

a goal of maintaining euglycemia overnight and between

meals; achieved with NPH or use of long-acting agents

– Approximately 50% of daily insulin needs

– Starting doses can be estimated based on body weight

(e.g., 10 units a day or 0.1–0.2 units/kg/day) and the

degree of hyperglycemia

– Titration should be individualized (days to weeks as

needed.

Reference: ADA 2019 Standard of Medical Care in Diabetes

Prandial Insulin Bolus insulin

If after titration of basal insulin to a certain

Mealtime insulins amt and elevated a1c levels then we can use

prandial insulin. This is usually taken with the

– Limits postprandial hyperglycemia largest meal of the day

Usually placed on

– May be added to basal insulin in Type 2 diabetes patients basal insulin

– Matched to carbohydrate intake, premeal blood glucose

and anticipated activity in the Type 1 diabetes patients

– Used when immediate insulin peak is desired

– Recommended starting dose:

Either 4 units or 10% of the basal dose at each meal.

– Titration is done based on home glucose monitoring or A1C

So appropriate adjustments can be

made- necessary

Reference: ADA 2019 Standard of Medical Care in Diabetes

Premixed Insulin

NPH insulin can be mixed in the same syringe with

regular or rapid-acting insulin (Short)

Shorter-acting insulin should be drawn into syringe first

Commercially available premix combinations available:

– Humulin 70/30, Novolin 70/30, Humulin 50/50,

Humalog Mix 50/50, Humalog Mix 75/25,

Novolog Mix 70/30

NPH can be added with regular or rapid

acting insulin

Adapted from Johnson, J., Cornell, S., and William, W. (2010). Endocrinologic Disorders: Diabetes Mellitus. In

Chisholm-Burns, (2nd edition) Pharmacotherapy Principles & Practice (pp. 735-762). New York: McGraw-Hill.
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Insulin

Target Blood Glucose Target Insulin

Fasting or Pre-breakfast Bed Time or pre dinner basal insulin or NPH

If elevated; which insulin

Pre-lunch will help to overcome

Pre breakfast bolus/prandial insulin

before eating?

Pre-dinner Pre breakfast NPH (dosed once or twice) or pre lunch bolus

insulin
Bedtime Pre dinner bolus insulin

Adapted from Johnson, J., Cornell, S., and William, W. (2010). Endocrinologic Disorders: Diabetes Mellitus. In

Chisholm-Burns, (2nd edition) Pharmacotherapy Principles & Practice (pp. 735-762). New York: McGraw-Hill.
8


Insulin Therapy in Type 2 Diabetes

Continue oral agents at the same dosage

Initial Basal Insulin Dose

Most physicians prefer

0.1-0.2 units/kg or 10 units/day

as
Current guidelines recommend that insulin therapy begin with

basal insulin (given at bedtime or in the morning)

Titration of Basal Insulin Dose

Increase 2 units every 3 days until fasting glucose levels are

consistently within target range (80-130 mg/dL) without

hypoglycemia

For hypoglycemia, lower dose by 10-20%

Bed time dose if lantus or toujeo or basaglar is 24 hr

coverage

In the morning, detemir can be spilt between a morning

. and evening dose

Combination Injectable Therapy

Used if a1c has not been controlled on dual or Triple

Considerations therapy

– If basal insulin has been titrated to an acceptable

fasting blood glucose level (or if the dose is .0.5

units/kg/day)

– A1C remains above target

Approaches

– GLP-1 agonist + basal insulin (Soliqua, Xultophy)

– Multiple doses of insulin (basal/prandial) or

premix insulin If too costly for patients

See -Figure 9.2

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Insulin Therapy in Type 1 Diabetes

Multiple daily injections (MDI) guided by blood glucose

monitoring or the use of continuous subcutaneous insulin

infusions (CSII) is the standard of care for patients with

Insulin pump type 1 diabetes.

Typical requirements

• 0.4- 1.0 units/kg/day

• Higher amounts are required during:

• Puberty

• Pregnancy

• Medical illness

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Insulin Therapy in Type 1 Diabetes

Division of Daily Insulin Requirement:

• 50% of the total daily dose (TDD) is given as an intermediate-

or long-acting form of insulin (in 1-2 daily injections). Even

need
3 depending on patients

• The remaining portion of the TDD is then divided and

administered before or at mealtimes as a rapid-acting or short-

acting form of insulin.

• Premixed insulins contain both a basal and prandial

component, all coverage of both basal and prandial needs

with a single injection.

• Some patients may benefit from the use of CSII which delivers

rapid-acting insulin as a continuous infusion throughout the

day and as boluses at mealtimes via an external pump device.

Adapted from Johnson, J., Cornell, S., and William, W. (2010). Endocrinologic Disorders: Diabetes Mellitus. In

Chisholm-Burns, (2nd edition) Pharmacotherapy Principles & Practice (pp. 735-762). New York: McGraw-Hill.
12


Insulin Therapy in Type 1 Diabetes

Adjustment of Dose:

• Dosage must be titrated to achieve glucose control and avoid

hypoglycemia.

• Adjust dose to maintain preprandial plasma glucose between

80-130 mg/dL for most patients.

• Treatment and monitoring regimens must be individualized.

Usual Maintenance Range:

• 0.5-1.0 units/kg/day in divided doses. (NOTE: Insulin

requirements are patient-specific and may vary based on age,

body weight, and/or activity factors)

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Insulin Pump Therapy

Utilizes a basal rate which is infused 24 hours daily

Bolus dose delivered prior to meal

Carbohydrate-to-insulin ratio used to determine bolus

dose Patient should be educated on how to count

carbs to adjust bolus dose

– 500 (rapid insulin) or 450 (regular insulin) rule

– Divide 500 or 450 by total daily dose (TDD) of insulin

– Example:

50 units of insulin per day

Patient needs calculation to make

500 / 50 = 10 adjustments

1 unit of insulin should cover 10 g of carbs

Adapted from Johnson, J., Cornell, S., and William, W. (2010). Endocrinologic Disorders: Diabetes Mellitus. In

Chisholm-Burns, (2nd edition) Pharmacotherapy Principles & Practice (pp. 735-762). New York: McGraw-Hill.
14


Insulin Pump Therapy

Most often used in T1DM

Advantages

– May improve BG control, reduce wide fluctuations in

BG, and allow more flexibility

Disadvantages

– Complex to use, high cost, increased need to BG

monitoring Education needed for carb

counting and the amt of

monitoring that Needs to occur

Adapted from Johnson, J., Cornell, S., and William, W. (2010). Endocrinologic Disorders: Diabetes Mellitus. In

Chisholm-Burns, (2nd edition) Pharmacotherapy Principles & Practice (pp. 735-762). New York: McGraw-Hill.
15


Insulin Therapy


500 Rule – estimates the number of grams of carbs that will be

covered by 1 Unit of rapid acting insulin

450 Rule – estimates the number of grams of carbs that will be

covered by 1 unit of regular insulin

500/TDD of insulin = number of grams of carbs

covered
500/26=19

500/(14 Units glargine + 12 Units lispro) = 19;

therefore 19 grams of carb covered by 1 Unit of
insulin
TDD=total daily dose 16
 Insulin Therapy


Correction Factor – used to adjust dose of insulin when

preprandial blood glucose levels fall above or below the
range that have been established as a goal

1,500 Rule – estimates the drop in a person’s blood glucose

per unit of regular insulin

1,800 Rule – estimates the drop in a person’s blood glucose

per unit of rapid-acting insulin

1,800/TDD of insulin = drop in blood glucose per

unit of insulin
Ex in text book

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