Appendix 9

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

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 (degludec U-100 or U-200, detemir, glargine U-100 or U-300, NPH) added to non-insulin antihyperglycemic agents
  • Insulin ahould be titrated to achieve target fasting BG levels of 4.0 to 7.0 mmol/L or individualized targets (e.g. 4.0 to 5.5 mmol/L if A1C target ≤7.0% not achieved; higher fasting BG targets may be considered in some people with diabetes where the goal of avoiding hypoglycemia is important, see Targets for Glycemic Control, p. S42).
  • Individuals can be taught self-titration, or titration may be done in conjunction with a health-care provider.
  • Suggested starting dose is 10 units once daily at bedtime.
  • Suggested titration is 1 unit per day until targets is reached. (Degludec should be titrated by 2 units every 3 to 4 days or 4 units once a week).
  • A lower starting dose, slower titration and higher targets may be considered for elderly or normal-weight subjects.
  • In order to safely titrate insulin, people with diabetes must perform self-monitoring of blood glucose at least once a day fasting.
  • Insulin dose should bot be increased if the individual experiences 2 episodes of hypoglycemia (BG <4.0 mmol/L) in 1 week or any episode of nocturnal hypoglycemia.
  • Noninsulin antihyperglycemic agents (especially insulin secretagogues) may need to be reduced if daytime hypoglycemia occurs.
Example B: Basal Plus Strategy – Adding bolus (prandial or mealtime) insulin (aspart, faster-acting insulin aspart, glulisine, lispro) once daily to optimized basal insulin therapy
  • When intensification of insulin therapy is necessary, start one injection of mealtime insulin to either main meal or breakfast.
  • Starting dose is 2 to 4 units and the person with diabetes can be taught self titration or dose increase can be done by health-care provider.
  • To safely increase dose, blood 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 ≤8.0 mmol/L
    • pre-meal glucose of the next meal of 4.0 t o7.0 mmol/L.
  • Important to keep carbohydrate intake constant and may consider reduction or discontinuation of insulin secretagogues
Example C: Basal-Bolus Insulin – Multiple Daily Injections Therapy
  • Calculate total daily dose of 0.3 to 0.5 units/kg then distribute as follows:
    1. 40% of total insulin dose as basal insulin (degludec U-100 or U-200, detemir, glargine U-100 or U-300, NPH)
    2. 20% of total insulin as bolus (prandial) insulin 3 times per day using rapid-acting insulin analogue (aspart, faster-acting insulin aspart, gluslisine, lispro).
Example D: Premixed Insulin (Humulin 30/70, Novolin 30/70, Humalog Mix 50, NovoMix 30, added to noninsulin 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 doses when both target BG levels are reached.
  • If both BG targets are not reached, continue to increase the relevant does until both targets achieved.
  • The individual needs to self-monitor BG at least twice daily to safely titrate insulin.
  • Insulin dose should not be increase if the individual experiences 2 or more episodes od hypoglycemia (BG <4.0 mmol/L) in 1 week or any episode of nocturnal hypoglycemia.
  • Noninsulin antihyperglycemic agents (especially insulin secretagogues) may need to be reduced or stopped at the start of this regimen or when daytime hypoglycemia occurs
Sample Instructions for Patients with Type 2 Diabetes Who are Starting and Adjusting Insulin
You will be taking ___________________________ at ___________________________.
It is important that you continue to take your other diabetes medications as prescribed unless you have been told to change the dose or stop them. How to adjust your insulin dose
  • Your target fasting blood glucose level is ____________________ mmol/L.
  • You will inject ____________________ units of ____________________ at ____________________.
  • You will continue to increase your insulin dose by ____________________ unit(s) every ____________________ day(s) until your fasting blood glucose level is ____________________ mmol/L.
  • Do not increase your insulin when your fasting blood glucose is ____________________ mmol/L.
  • You should call for further instructions when your blood glucose reaches ____________________ mmol/L for 3 or more days: phone number ____________________.
  • A side effect of insulin is low blood glucose (hypoglycemia); low blood glucose can occur with too much insulin, increased activity or not enough food.
Monitoring your blood glucose
  • It is important to test your blood glucose while your insulin treatment is being modified.
  • You should test your blood glucose and record the value every day before breakfast and ____________________.
  • Test before each meal, unless you are instructed differently.
  • It is important to record your blood glucose values and any changes in activity or food in your diary and bring this to your next appointment; this information helps your diabetes health-care team understand your diabetes control.
  • Unless otherwise instructed, you are trying to reach a target blood glucose of 4.0 to 7.0 mmol/L before meals, and 5.0 to 8.0 mmol/L after meals.
  • If you think your blood glucose is low, check it and record that information in your diary.
Instructions for taking your other glucose-lowering diabetes medications:
Current medications Dose Time of day Special instructions
 
 
 		  
 
 		  
 
 		  
 
 
 
 
 		  
 
 		  
 
 		  
 
 
 
 
 		  
 
 		  
 
 		  
 
 
 
 
 		  
 
 		  
 
 		  
 
 
 
 
 		  
 
 		  
 
 		  
 
 

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