Appendix 3

Examples of Insulin Initiation and Titration Regimens in People with Type 2 Diabetes

All people starting insulin should be counseled about the recognition, prevention and treatment of hypoglycemia. Consider a change in type or timing of insulin administration if glycemic targets are not being reached.
 
Example A: Basal insulin (Humulin®-N, Lantus®, Levemir®, Novolin®ge NPH) added to oral antihyperglycemic agents
• Insulin should be titrated to achieve target fasting BG levels of 4.0 to 7.0 mmol/L.
• Individuals can be taught self-titration, or titration may be done in conjunction with a healthcare provider.
• Suggested starting dose is 10 units once daily at bedtime.
• Suggested titration is 1 unit per day until target is reached.
• A lower starting dose, slower titration and higher targets may be considered for elderly or normal weight subjects.
• In order to safely titrate insulin, patients must perform SMBG at least once a day fasting.
• Insulin dose should not be increased if the individual experiences 2 episodes of hypoglycemia (BG <4.0 mmol/L) in 1 week or any episode of nocturnal hypoglycemia.
• For fasting BG levels consistently <5.5 mmol/L, a reduction of 1 to 2 units of insulin may be considered to avoid nocturnal hypoglycemia.
• Oral antihyperglycemic agents (especially secretagogues) may need to be reduced if daytime hypoglycemia occurs.
 
Example B: Basal Plus Strategy - Adding bolus (prandial) insulin (Apidra®, Humalog®, NovoRapid®) once daily to optimized basal insulin therapy
• When intensification of insulin therapy is necessary, start one injection of meal time insulin to either main meal or breakfast.
• Starting dose is 2 to 4 units and patient can be taught self titration or dose increase can be done by HCP.
• To safely increase dose, glucose levels should be measured at least prior to insulin dose then titrated by 1 unit daily to either of the following targets.
  – 2 hour post meal glucose of 10.0 mmol/L (or ≤ 8.0 mmol/L in certain cases)
  – pre-meal glucose of the next meal of 4.0 to 7.0 mmol/L.
• Important to keep carbohydrate intake constant. Oral antihyperglycemic agents (especially secretegogues) may need to be reduced or stopped particularly if daytime hypoglycemia occurs.
 
Example C: Basal-Bolus Insulin - Intensive insulin therapy
• Calculate total daily dose of 0.3 to 0.5 units/kg then distribute as follows:
  a. 40% of total insulin dose as basal insulin (Humulin®-N, Lantus®, Levemir®, Novolin®ge NPH).
  b. 20% of total insulin as bolus (prandial) insulin 3 times per day using either rapid-acting insulin analogue (Apidra®, Humalog®, NovoRapid®) or short-acting insulin (Humulin®, Novolin®ge Toronto).
 
Example D: Premixed insulin (Humulin® 30/70, Novolin® 30/70, Humalog® Mix 25 or Humalog® Mix 50, NovoMix® 30,) added to oral antihyperglycemic agents
• Suggested starting dose is 5 to 10 units once or twice daily (prebreakfast and/or presupper).
• Suggested titration is 1 to 2 units added to prebreakfast dose and/or presupper dose daily until target BG values are reached based on prebreakfast and presupper BG readings.
• Prebreakfast premixed insulin achieves presupper target BG value (4.0 to 7.0 mmol/L).
• Presupper premixed insulin achieves target fasting BG value (4.0 to 7.0 mmol/L).
• 30/70 premixed insulin should be given 30 to 45 minutes before meals.
• Humalog® Mix 25 or NovoMix® 30 premixed insulin should be given immediately before eating.
• Stop increasing insulin when both target BG levels are reached.
• If both BG targets are not reached, continue to increase the relevant dose until both targets achieved.
• The individual needs to self-monitor BG at least twice daily to safely titrate insulin.
• Insulin dose should not be increased if the individual experiences 2 or more episodes of hypoglycemia (BG <4.0 mmol/L) in 1 week or any episode of nocturnal hypoglycemia.
• Oral antihyperglycemic agents (especially secretagogues) may need to be reduced or stopped at the start of this regimen or when daytime hypoglycemia occurs.

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