Insulin: Initiation, optimization,

maintenance

Dr. Mashfiqul Hasan

Phase B Resident
Department of Endocrinology
BSMMU
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Milestones of insulin therapy

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 INDICATION FOR INSULIN
THERAPY IN TYPE 2 DIABETES
 Acute metabolic complications

 Acute illness

 Severe infection

 Pregnancy and lactation

 Fasting plasma glucose >300 mg/dl

 Failure of oral anti-diabetic agent

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 Insulin
Types Examples
Bolus (Meal) Insulin
Rapid-acting Insulin lispro,
Insulin
Short-acting aspart
Basal Regular
(Background)
Insulin NPH, Lente
Intermediate-
acting Glargine, Detemir

Long-acting
70/30, 50/50
Pre-Mixed Insulin Mix 75/25
NPH/RegularDr. Mashfiq - Endocrine - BSMMU Mix 70/30 6
INSULIN THERAPY in Diabetes Mellitus
Insulin Profiles – schematic (duration)
ASAspart Lispro (4–5 hr)
Regular (6–8 hr)
NPH (12–16 hr)
Ultralente (~16–20 hr )
Detemir (~20 hr)
Plasma Insulin

Glargine
(~22
hr)
Levels

0 2 4
6 8 10 12 14 16 18 20 22 24
7
 Insulin Regimens

• Combination of Oral Agent-Insulin

– Single bedtime injection Glargine or NPH
• Conventional Insulin Stages 2 and 3
• Physiologic Insulin Stage 4
– Basal/Bolus Regimen
– 4 or more injections/day

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 Normal Insulin Secretion

Meal Meal Meal

Serum insulin (mU/L)

50

40
Bolus insulin needs
30

20

10
Basal Insulin Needs
0
0 2 4 6 8 10 12 14 16
18 20 22 24

Time (Hours)
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BASAL, BASAL-PLUS, BASAL-BOLUS

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Guidelines for commencing insulin

● Continue oral hypoglycaemic agents

● intermediate-acting/long-acting insulin at bedtime

● Initial dose 0.2 units/kg

● Monitor FP

● Aim for FPG 4-8 mmol/L (72-

244mg/dl) (individualise)

● Adjust insulin by 2-4 units every 3-4 days until

FPG target is met
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PREMIX INSULIN

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 Start with once daily 6-10 units
•In the morning : if the pre-dinner blood glucose is high
•In the evening : if the pre-breakfast blood glucose is high

Titrate according to following schedule

Pre-breakfast or Pre-dinner BG Chang in insulin dose (U)

<6 -2
6-7 0
>7 +2

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•For human premix when dose >20 U split the dose:
2/3 in morning and 1/3 in evening
•For premix analogue split the dose when dose is >30
units, consider splitting dose equally between breakfast
and dinner.

Adjust breakfast dose Adjust pre-dinner dose

necessary based on necessary based on
post-lunch to pre post-dinner to pre-
dinner glucose levels breakfast glucose levels

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SPLIT-MIX INSULIN

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 Split Mix Regimen

60

40

20

0
Time of day
Intermediate acting + short-acting Intermediate acting + short-
Before Breakfast
acting
Before Dinner
 Others
• Regular insulin
• Sliding scale

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PRINCIPLES OF INITIATION

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 References
• Text book of diabetes
• Bangladesh Insulin guideline for type 2
diabetes
• ADA guideline 2014
• UpToDate 19.3
• Lecture of Prof. Md. Fariduddin & Prof. M A
Hasanat

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THANK YOU

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