Insulin in Type 2 Diabetes Shamili Allam, PGY3 8/1/19

Physiologic Insulin Release https://ai2-s2-public.s3.amazonaws.com/figures/2017-08-08/913b0ba7a16aeb239733dd205283ef1b6f89387d/2-Figure1-1.png

Insulin formulations Insulin Onset Peak Duration Lispro 3-15 min 2-4 hours Regular 30 min 5-8 hours NPH 2 hours 4-12 hours ~12 hours Glargine None 20-24 hours https://www.diabetes.co.uk/forum/threads/changing-insulin-to-nph.109906/ https://www.uptodate.com/contents/image?imageKey=ENDO%2F73676&topicKey=ENDO%2F1752&source=see_link

Glargine-Lispro Total daily dose 1/2 glargine 1/2 lispro 1/3 breakfast 1/3 dinner 1/3 lunch Fingerstick Glucose Insulin to adjust Pre-breakfast Glargine Pre-lunch Breakfast lispro Pre-dinner Lunch lispro Nighttime Dinner lispro

NPH-Regular Total daily dose 2/3 AM 1/3 PM 2/3 AM NPH 1/3 AM regular 1/2 PM NPH 1/2 PM regular Fingerstick Glucose Insulin to adjust Pre-breakfast PM NPH Pre-lunch AM Regular + AM NPH Pre-dinner AM NPH Nighttime PM Regular + PM NPH

Novolin 70/30 Total daily dose 2/3 AM 1/3 PM Fingerstick Glucose Insulin to adjust Pre-breakfast PM Pre-lunch AM Pre-dinner Nighttime

When to initiate insulin Poorly controlled DM on diagnosis HgA1c > 10% FS > 300 Symptomatic hyperglycemia Weight loss Polyuria Polydipsia After failing oral agents

How to initiate Insulin Consider starting basal insulin first Glargine 10U, or 0.1-0.2 U/kg Titrate up to FS target If FS at goal but HbA1c is not, or using 0.7-1.0 U/kg basal: Stepwise initiation of prandial insulin Can start with 1 meal first (biggest meal first) Eventually will need full basal-prandial regimen Discontinue: Sulfonylureas Pioglitazone

Blood sugar Goals Most patients: HbA1c < 7% Average blood glucose < 154 mg/dL Fasting sugars 80-130 mg/dL Post-prandial (1-2h after meal) < 180 mg/dL Lenient control (h/o hypoglycemia, limited life expectancy) HbA1c < 8% Average blood glucose < 183 mg/dL Fasting sugars 100-140 mg/dL Post-prandial (1-2h after meal) < 200 mg/dL Different goals are appropriate for different patients http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/checking-your-blood-glucose.html

How to prescribe insulin Each pen = 3mL = 300 units

How to prescribe Insulin clear cloudy Each vial = 10mL = 1000 units

How to prescribe Insulin

Practical Considerations When to inject Glargine: bedtime, but can switch to qAM (to avoid early morning lows) Lispro: ~10 min before meals NPH/Regular: ~30 min before breakfast & dinner How to store insulin All unopened insulin should be stored in the fridge Vials (NPH, regular, 70/30) can be kept at room temp (< 77F) for 6 weeks Pens (Basaglar, Humalog) can be kept at room temp (<86F) for 4 weeks Accuracy Pens are more accurate for small doses (< 5 units) Hypoglycemic education Always carry 15g of carbs (4 oz of juice, small apple) Consider prescribing glucagon Medical bracelet

How to inject Insulin Rotate injection sites Mixing Syringes: Pens Draw up regular insulin before drawing up NPH in the syringe (“clear before cloudy”) Syringes: Pinch a fold of skin Inject at 90 degrees Pens Keep thumb on plunger for 5 seconds https://www.uptodate.com/contents/images/PC/78710/Insulin_injection_sites.jpg

MkSAP Question A 64-year-old man with type 2 diabetes mellitus and stage 4 chronic kidney disease is evaluated for continued glycemic management. He is followed closely by the nephrology service in preparation for impending hemodialysis, with initiation of erythropoietin therapy within the last 3 months. His average fasting and preprandial blood glucose values are in the 145 to 190 mg/dL (8.0 – 10.5 mmol/L) range. He does not have hypoglycemia. His insulin regimen consists of insulin detemir at bedtime and insulin glulisine before meals. His most recent hemoglobin A1c value has decreased from 7.5% to 6.2% Which of the following is the most appropriate management for this patient’s diabetes? A. Continue current therapy B. Decrease insulin detemir dose C. Discontinue preprandial insulin glulisine D. Measure postprandial glucose level

References https://clinical.diabetesjournals.org/content/37/1/11 https://care.diabetesjournals.org/content/27/suppl_1/s106 https://www.uptodate.com/contents/general-principles-of-insulin-therapy-in- diabetes-mellitus?source=history_widget