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

2. Physiologic Insulin Release

3. 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

4. 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

5. 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

6. 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

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

8. How to initiate Insulin
Consider starting basal insulin first
Glargine 10U, or U/kg
Titrate up to FS target
If FS at goal but HbA1c is not, or using 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

9. Blood sugar Goals Most patients:
HbA1c < 7%
Average blood glucose < 154 mg/dL
Fasting sugars 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 mg/dL
Post-prandial (1-2h after meal) < 200 mg/dL
Different goals are appropriate for different patients

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

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

12. How to prescribe Insulin

13. 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

14. 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

15. 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

16. References https://clinical.diabetesjournals.org/content/37/1/11
diabetes-mellitus?source=history_widget