According to NICE recommendations, NPH (isophane) insulin or a long-acting analogue should be used when initiating insulin in type 2 diabetes patients (1).
In majority of patients there is suboptimal glycaemic control even with initial insulin regiments.
NICE recommends that in patients whom target HbA1C with the initial regimen is not reached without problematic hypoglycaemia and:
Some proposed insulin regimes for patients with Type 2 diabetes (2):
For twice daily regimens the most frequently used option is a premixed fixed combination of short and intermediate acting insulin or a rapid acting insulin lispro or aspart mix. A twice-daily intermediate acting insulin is an alternative choice and may be appropriate in the elderly where there is a concern regarding the risk of hypoglycaemia.
Daily insulin requirements = 0.5 units / kg body weight approximately e.g. 0.5 x 72kg = 36 units
Take e.g. 60% 'for safety' 36 units x 60% = 22 units
Split the dose 50%: 50% before breakfast and evening meal. i.e. 11 units bd. Rounded up to 12 units for ease of administration.
Generally the final insulin dose required will be nearer to 60%/40% divide.
This is the most intensive regime with three pre-prandial doses of short /rapid acting insulin and a bedtime dose of intermediate or long acting insulin. While this regime offers no improvement in metabolic control compared to any other insulin regime, this may be the most suitable regimen for people who do not have a stable daily routine as the time and dose of insulin can be varied according to when the meal is taken and its carbohydrate content.
Generally 30 - 50% of the total daily insulin requirements should be given as intermediate or long acting insulin at bedtime with the remaining insulin being given as short / rapid acting before breakfast, lunch and evening meal depending on the needs of the individual.
Daily Insulin requirements = 0.5 units / kg body weight approximately e.g. 0.5 x 72kg = 36 units
Take e.g. 60% 'for safety' 36 units x 60% = 22 units
When commencing a basal bolus regimen where three pre-prandial doses of short/rapid acting insulin are to be taken prior to breakfast, lunch and evening meal and intermediate acting/ long acting analogue insulin at bedtime the total daily dose may be calculated as follows;
22 units as above. -50% of the total daily dose is basal = 11 units e.g. 'rounding down' for ease of administration = 10 units
Daily bolus insulin dose therefore is 22 -10 (basal dose) = 12 units of short acting insulin.
This is divided into 3 for pre breakfast, lunch and evening meal = 4 units each meal. 10 units of intermediate/long acting analogue are given prior to bed.
The insulin can then be increased to the requirement of the individual.
In general, it is beneficial to commence the individual with Type 2 diabetes on a twice-daily insulin regimen initially until they feel comfortable with injections (2).
In consideration as to whether to initiate once or twice daily insulin in type 2 diabetic patients:
Notes (4):
Reference:
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