Myrissa Melinda L Alip, MD

DI ABE T ES MA NA GE ME NT

Myri ssa Lacuna- Al i p, M. D.

INSULIN INITIATION, DOSING, ADJUSTING, AND

MONITORING



Obj ect iv e

At the end of the session:The participants will be able to know:

– When to start insulinization– How to adjust insulin– When to monitor blood glucose



In d ica t io n s f o r In su l in Th er a py

• Type 1• If not at Target with combination OHAs,

diet, and exercise• Oral Medications contraindicated• Pregnancy if medical nutrition therapy

alone does not adequately control blood sugar

Lancet 1998N Engl J Med 2003De Fronzo 1998




• Pre-conceptive women (chances of getting pregnant)

• Highly symptomatic with very high glucose levels (HHS)

Jovanavic- Peterson, JAMA 1991Diabetes Care, 1992




• Presence of Renal or Liver problems• Secondary diabetes• Acute injury, stress, infection, surgery, or

steroids• Patient’s choice



Ba r r ier s t o st a r t in g in su l in

• Starting insulin is too complex

• Hypoglycaemia• Weight gain• Lack of time/resources• Referrals are necessary• Lack of evidence for the

best use of insulinAdapted from: Korytkowski M. Int J Obes 2002;26(Suppl 3):S1-S7

• Starting insulin is too complex

• Hypoglycaemia• Weight gain• Injections will hurt• Injecting in public is

embarrassing

Myrissa Melinda L. Alip, MD Diabetes Management Skills: Insulin Dosing, Adjusting and Monitoring



St a r t in g in su l in is t o o co mpl ex

Strategy• Insulin can be initiated once or twice daily and

titrated gradually• May use fixed starting dose without calculation• Use evidence-based titration guidelines• Use modern insulin injections available in the

market (injection device)



St a r t in g in su l in is t o o co mpl ex

Strategy• Use available support services to train patients• Trained nurses• Patient organisations• Give patients take-home materials



In su l in w i l l ca u se h ypo g l y ca emia

• Encourage healthy diet and moderate exercise from the start

• Combine insulin with metformin• Explain that some insulins may cause less

weight gain than others



In j ect io n s w il l h u r t !

• Reassure patients that injections are relatively painless and are less painful than fingerstick glucose testing

• Demonstrate injection injections• Emphasize the benefits of improved

glycemic control



I do n ’t w a n t t o in j ect in pu bl ic

• Use pens rather than vials and syringes• Highlight that rapid-acting analogues

(alone or in premixed insulins) allow discreet injections immediately before eating



Ho w d o I t h en st a r t in su l in ?

* Tailor it according to your patient’s needs

8/12/2009




Ho w t o in it ia t e In su l in ?Use of Basal Insulin• 10 U or 0.2 U/kg, whichever is greater• Dose at same time every day, at dinner or

bedtime• Continue treatment and titrate dose

accordingly

8/12/2009



Wh y do es in su l in n eed a d j u st in g ?

• To meet target goal• Eliminate low blood sugar • Overall goal is to improve blood

glucose control.



Wh y d o es in su l in n eed a d j u st in g ?

• To meet target goal• Eliminate low blood sugar • Overall goal is to improve blood

glucose control.



Ba sic Pr in cipl es o f In su l in Ad j u st men t

• Make adjustments to usual insulin dose based on blood glucose patterns.

• Adjust first to eliminate low blood sugars• Adjust only one insulin at a time (unless

this will cause a low blood sugar level at a later time). Consider that when one insulin is increased, another may need to be decreased.

8/12/2009



Ba sic Pr in c ipl es o f In su l in Ad j u st men t

Increase insulin when there is a pattern of repeating high tests. DO NOT increase insulin on the basis of sporadic high tests. -Increasing the insulin dose will lower blood

sugar levels.-Decreasing the insulin dose will raise blood

sugar levels.Wait at least 3-4 test days between each insulin

adjustment to have sufficient data to determine a pattern.

8/12/2009



SMBG ca n a id in d ia bet es co n t r o l by :

• facilitating the development of an individualized blood glucose profile, which can then guide health care professionals in treatment planning for an individualized diabetic regimen;

• giving people with diabetes and their families the ability to make appropriate day-to-day treatment choices in diet and physical activity as well as in insulin or other agents;

Clinical Diabetes 20:45-47, 2002© American Diabetes Association ®, Inc., 2002




SMBG ca n a id in d ia bet es co n t r o l by :

• improving patients’ recognition of hypoglycemia or severe hyperglycemia

• enhancing patient education and patient empowerment regarding the effects of lifestyle and pharmaceutical intervention on glycemic control.

Clinical Diabetes 20:45-47, 2002© American Diabetes Association ®, Inc., 2002



Fr eq u en cy o f SMBG

When to monitor • There is no absolute recommendation• varies from person to person • frequency and timing of glucose

monitoring should be dictated by the needs and goals of the individual patient

Diabetes Care 25:S97-S99, 2002© 2002 by the American Diabetes Association, Inc.



Fr eq u en cy o f SMBG

Type 1DM: 3 or more times dailyInsulin or SU treated patients: daily• patients whose diabetes is out of control • for those having medication initiated or

being modified

Diabetes Care 25:S97-S99, 2002© 2002 by the American Diabetes Association, Inc.



SMBG• SMBG should be carried out three or more

times daily for patients using mul- tipleinsulin injections or insulin pump therapy. (A)

• For patients using less frequent insulin i nject i ons, noni nsul i n t herapi es, or me d i c a l n u t r i t i o n t h e r a p y ( MNT ) alone, SMBG may be useful in achiev- ingglycemic goals. (E)



SMBG

• To achieve postprandial glucose targets, postprandial SMBG may be appropriate. (E)

• When prescribing SMBG, ensure that patients receive initial instruction in, and routine follow-up evaluation of, SMBG technique and their ability to use data to adjust therapy. (E)



SMBG

• Continuous glucose monitoring may be a supplemental tool to SMBG for selected patients with type 1 diabetes, especially those with hypoglycemia unawareness. (E)




Ba r r ier s t o in cr ea sin g u se o f SMBG

• cost of testing, • inadequate understanding • patient psychological and physical

discomfort • inconvenience of testing



Keepin g a d ia r y

• Explain how to keep a blood glucose diary

• Give reasons for keeping a diary

• Emphasize importance of entering ALL results

• Encourage comments when daily activity is different than usual



Bl o o d g l u co se t est in gDetails to be learned

• How well did the last medication work?

• When did each insulin dose or tablet have the most or least effect?

• How did the food eaten affect levels?

• What was the benefit of physical activity?

DI AB E T ES MA NA GE ME NT


Po st -mea l g l u co se t est in gWhen to test?

• Suspected post-meal hyperglycaemia

• Monitoring treatment specifically aimed at lowering post-meal glucose

• Hypoglycaemia in post-meal state

• For information on glycaemic effect of meal

Post-meal hyperglycaemia may be associated with increased risk of cardiovascular disease in type 2 diabetes.

Ceriello 2004



• Blood glucose levels do not coincide with how one feels

• Not enough blood on strip• Finger prick may be painful• Results do not reflect HbA1c

Co mmo n pr o bl ems



Cl in ica l Aspect o f In su l in In i t ia t io n ,

Ad j u st men t , a n d CBG Mo n it o r in g


Myrissa Melinda L Alip, MD

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