1. Small concise points on Insulin

2. When to use Insulin ….. How about as an initial management?
Type I Diabetes mellitus
If you can not determine whether type I or II
In Ketosis (DKA or HHS)
If the patient has signs of hyperglycemia
If blood glucose >300 mg/dl or A1c 10 or more
Pregnancy
How about as an added on agent?
A part of the Dual, Triple therapy for type II
Or the final way after the triple therapy fails.

3. Ok, the different insulin preparations

4. Some things we need to know
How to determine the total daily insulin dose(TDD)?
For DM I … around U/Kg/day
For DM II .. Around U/Kg/day
For Basal-Bolus
-Basal is 40 % of the TDD, once on gilargine or detemir and twice for NPH.
- Bolus is the remaining 60% divided by 3 for each injection.

5. Example…
A 25 YO ♂ came to PHCC after being diagnosed with DM I last week, you want to start insulin … (Basal, Bolus)
his weight is 70 Kgs.
0.5 x 70=35 units/day
Basal is 40% … 40x35/100= 14 units
Bolus is 60% … 60x35/100= 21 units
7 with each meal.

6. Ok, as an adjunct ...
Mono-therapy (metformin) → still → Dual → still → triple → still → combined injectable therapy.
Insulin can be the other agent in the Dual
Insulin can be the third agent in the Triple.
When you decide to go for insulin, it is highly advisable to stop any sulfonylurea.

7. Ok, as an adjunct …
Adjunct is only Basal (start with 10 Units), you can then titrate up 2-4 units once or twice a week.
So again and again, basal insulin can be used with oral agents or as the main bulk for the combined injectable therapy.

8. Now you tried it all and still …
Time for combined injectable therapy …
You can choose one of three ways,
GLP1 RA, Basal-Bolus, Mixed regimens and you can always switch between the 2 main regimens (The switch).
Basal … start with 10, titrate up 2- 4 units once or twice weekly.
Bolus … start with 4, titrate up 2-4 units, once or twice weekly.
GLP 1RA … Glucagon like peptide 1 receptor antagonist

9. Basal-Bolus
Example… John was on meformin but A1c is not controlled, so he was prescribed Glipizide agent and still A1c is not controlled after 3 months. His doctor decides to start insulin?
Q#1,which type of insulin can be added?
Basal
Q#2, Can insulin be used with oral agents, generally?
yes it can
Q#3, Is there any agent here that would better to be stopped and changed?
yes, sulfonylureas

10. Still on Questions …..
Q#4, what is the recommended initial amount of basal insulin?
10 units
The doctor added the basal insulin and switched the glipiazide to canagliflozin.
So can metformin, canagliflozin and insulin be used all-together?!
That is Q#5,
yes, no reason not to.

11. Still treating John.....
After 3 months, his A1c was found to be still >8.
So the doctor decided to start combination injectable therapy,
Q#6 what are the 2 main regimens?
Basal-bolus, pre-mixed
So he decided to go with basal-bolus.
How to proceed?

12. Moving on ….. Keep the basal or the titrated up value.
Stop the oral agents but metformin is an exception
Add Bolus once with largest meal, start with 4 units and titrate up 2-4 U once or twice a day.
Still, now go with a bolus/meal.
If the patient can not tolerate the multiple injections, swith to premixed.

13. The switch …..
If you want to switch from mixed for example (70%NPH+30%regular) to (basal+bolus)
Patient is on 25 BID Mixed, now what?
Total 50, basal (NPH) is 70x50/100→35
And the regular is the rest→ 15
So your basal is 80% of the basal of the mixed and the bolus is the same.
80x35/100→28 and the regular is 5/a meal.

14. Still on the switch …..