Professional Documents
Culture Documents
Practical guide to
Ministry of Health, Malaysia 2010 First published March 2011 Perkhidmatan Diabetes dan Endokrinologi Kementerian Kesihatan Malaysia
Bedtime Pre X
KEY MESSAGES
1. 2. Dinner Pre Post X Following diagnosis, progressive insulin deficiency combined with insulin resistance results in worsening glycaemic control and failure of oral anti-diabetic therapy. Insulin therapy should be initiated early when HbA1c is persistently above 8% despite optimal doses of oral anti-diabetic therapy. X The insulin regimen and insulin doses initiated should be individualised, based on the patients blood glucose profile, lifestyle factors and patients preferences. Metformin, an insulin sensitizer, should be continued at optimal doses following initiation of insulin therapy unless contraindications or intolerance exist. Self monitoring of blood glucose along with simple patient-directed dose adjustments enable gradual, safe and prompt insulin dose optimization. Glycaemic targets need to be individualised based on patients risk of hypoglycaemia, presence of complications and co-morbidities. Pancreatic beta cell dysfunction begins many years prior to diagnosis of Type 2 diabetes X
Pre-lunch rapid-acting or pre-breakfast premixed insulin. X X X Lunch Post X Pre X X Recommended timing of SMBG in different Insulin Regimens Breakfast Pre Post X X X X X X X
3. 4.
5.
6.
7.
9.
To Control
2-hours Post-breakfast BG
Pre-mixed Analogues BD
10. Continuous patient education and support is a key element for optimal treatment adherence, patient empowerment and successful insulin therapy.
Minimizing both hypoglycemia and weight gain are important additional treatment targets for patients with Type 2 diabetes requiring insulin therapy.
8.
Insulin regimens may need to be changed or intensified with time if glycaemic targets are unmet despite dose optimization.
Basal only
The development of this quick reference guide was supported by an educational grant from sanofi-aventis
Pre-dinner BG
Pre-lunch BG
SOURCES OF FUNDING
2 hours Post-lunch BG
Adjust
Intensification from Premixed Regimen to Basal Bolus Regimen PREMIXED INSULIN BD or TDS (Insulin analogue) FPG / premeals > 6 mmol/L HbA1c > 6.5 7% Switch to BASAL BOLUS REGIMEN Starting dose 0.5units/kg/day or total dose transfer Split dose 50:50 for basal and prandial insulin Divide prandial doses into 3 main meals Fix FPG < 6mmol/L using basal insulin Titrate bolus dose once / twice a week to achieve FPG and preprandial goal < 6mmol/L Stop SU, continue metformin Intensification from Prandial Regimen to Basal Bolus Regimen PRANDIAL TDS (Optimised prandial doses) FPG > 6 mmol/L HbA1c > 6.5 8% Addition of BASAL INSULIN BASAL BOLUS REGIMEN 10 units or 0.2U / kg at pre-dinner Monitor FPG , target 4-6 mmol/L Adjust basal insulin doses after 3 consecutive BG values obtained (every 3 7 days) - < 4 mmol/L ( > 1 value ) reduce dose by 2 units - 4-6 mmol/L ( all values ) maintain current dose - > 6 mmol/L ( >1 value, no hypos ) increase by 2 units
Onset
30 min 30 min 10-20 min 0-15 min 5-15 min 1.5 Hr 1 Hr 2-4 Hr 1 Hr 30 min 30 min 10-20 min 0-15 min
Peak (Hr)
1-3 2-4 1-3 1 1-2 4-12 4-10 peakless peakless dual dual dual dual
Duration (Hr)
8 6-8 3-5 3.5-4.5 3-5 18-23 16-18 20-24 17-23 18-23 16-18 18-23 16-18
Timing of insulin
30 mins before meal 5-15 mins before or immediately after meals
Pre-breakfast / Pre-bed
Same time everyday at anytime of the day 30-60 mins before meals 5-15 mins before meals
Insulin regimen
BASAL BASAL PREMIXED OD BASAL PREMIXED BD BASAL-PLUS (1) BASAL-PLUS (2) PRANDIAL PREMIXED TDS PREMIXED-PLUS PREMIXED-PLUS BASAL-BOLUS BASAL-BOLUS
4 5
Intermediate acting (NPH) insulin pre-breakfast and pre-dinner + prandial insulin pre-breakfast, pre-lunch and pre-dinner
OPTIMISATION
Dose titration to ensure maximum benefit from prescribed treatment
Dose should be adjusted every 3-7 days
INTENSIFICATION
Modification of an insulin regimen to acieve glycemic control
Requires switching to more intensive regimens for better glycemic control
PREMIXED OD (pre-dinner) or BD
PREMIXED ONCE DAILY (pre-dinner) FPG 4-6 mmol/L, pre-lunch and pre-dinner > 6mmol/L Add PRANDIAL INSULIN (at morning and midday meal) PREMIXED TWICE DAILY (pre-breakfast, pre-dinner) Pre-dinner > 6 mmol/L Add PRANDIAL INSULIN (at midday meal)
Add prandial insulin 6 units or 0.1unit/kg Titrate to next prandial BG target daily If subsequent pre-meal BG is - < 4 mmol/L ( > 1 value ) reduce dose by 2 units - 4-6 mmol/L ( all values ) maintain current dose - > 6 mmol/L ( >1 value, no hypos ) increase by 2 units
PREMIXED OD PREMIXED BD
PREMIXED BD PLUS PRELUNCH PRANDIAL PREMIXED TDS (FOR ANALOGUES) BASAL BOLUS
PREMIXED OD (pre-dinner) or BD
FPG and / or pre-dinner 4-6 mmol/L HbA1c > 6.5 8% FPG and / or pre-dinner > 6 mmol/L Titrate Premix OD or BD to achieve FPG and / or predinner < 6mmol/L
SWITCH TO PREMIXED BD OR TDS (analogues only) DAILY (OD) TWICE DAILY (BD) Starting dose 0.3units/kg/day or total dose transfer Split the dose 50:50 pre-breakfast and pre-dinner Titrate insulin dose to achieve FPG and pre-dinner<6mmol/L TWICE DAILY (BD) THREE TIMES DAILY (TDS) Add 6 units or 10% total daily dose at lunch Titrate dose once or twice a week to next pre prandial goal < 6mmol/L Down titrate morning dose ( 2 4 units ) may be needed after adding lunch dose Continue metformin Consider premixed analogues if hypos
Glycemic abnormality? FPG, SMBG Normal Fasting / prebreakfast BG High daytime BG High Fasting / prebreakfast BG Normal daytime BG Start PREMIXED OD (predinner) Optimise dose PREMIXED TDS* (premeals) Optimise dose High Fasting / prebreakfast BG High daytime BG Start PREMIXED BD (prebreakfast & predinner) Optimise dose Start BASAL BOLUS (premeals, bedtime) Optimise dose
Start PRANDIAL only (usually TDS premeals) Optimise dose Add basal insulin Sequential addition of prandial insulin
INTENSIFY
Optimise dose
BASAL BOLUS (prandial insulin at premeals, basal insulin at bedtime) Optimise dose
* refers to insulin analogues only
Note: 1. Metformin should be continued while on insulin therapy unless contraindicated or intolerant 2. Sulphonylureas / Meglitinides should be withdrawn once prandial insulin is used regularly with meals 3. Insulin dose should be optimized prior to switching / intensifying regimens
Dose Optimisation Adjust insulin doses after 3 consecutive BG values obtained (every 3 7 days) Refer to (*) Adjust insulin doses after 3 consecutive BG values obtained (every 3 7 days) Refer to (*)
Pre-breakfast BG determine pre-dinner premixed dose adjustment Pre-dinner BG determine pre-breakfast premixed dose adjustment
Optimal Dose 0.2 0.3 units/kg in lean patients 0.4 0.5 units/kg in most patients Up to 0.7 units/kg in obese patients Total daily dose of 0.5 1.0 units/kg in most patients (Maybe more than 1.0 units/kg/day in obese, insulin resistant patients)
Basal
Premixed
Prandial
Adjust insulin doses after 3 consecutive BG values obtained (every 3 7 days) Refer to (*)
Adjust the dose of prandial insulin of the preceding meal (eg: if pre lunch BG is high, adjust pre-breakfast prandial insulin)
Prandial dose for each meal will vary according to carbohydrate content and amount. Dose should ideally not exceed 0.5U/kg/dose. Generally basal insulin would contribute 50% of total daily insulin dose and prandial insulin would contribute remaining 50% (distributed over three main meals).
Refer to Prandial Section & Basal Section
Basal Bolus
Prandial Insulin: 6 units or 0.1U/kg before each meal Basal insulin: 10 units or 0.2U/kg at bedtime
Refer to Prandial Section Refer to Basal Section Aim for normal pre-breakfast BG first by adjusting the dose of bed-time basal insulin before adjusting the prandial (bolus) insulin dose.
(*) - < 4 mmol/L (> 1 value) reduce dose by 2 units - 4-6 mmol/L (all values) maintain current dose - > 6 mmol/L (>1 value, no hypos) increase by 2 units
INSUlIN INTENSIFICATION
Intensification from Basal Regimen
BASAL
PREMIXED BD BASAL BOLUS BASAL PLUS (1 / 2 / 3 PRANDIAL)
Note: Optimise Basal Before Intensification Fix Fasting Blood Glucose (FBG) first using basal insulin (dose optimisation) Goal FBG 4 6 mmol/L Consider adding bolus / meal insulin when: Hb A1c > 7% and FBG at goal or basal insulin dose > 0.5U/kg
If HbA1c > 6.5 - 7% after 3 months despite titrating prandial doses or prandial doses > 30 units per meal, consider: Resume optimisation of basal insulin up to 0.7 U/kg Perform 7- point BG profile
(*) - < 4 mmol/L (> 1 value) reduce dose by 2 units - 4-6 mmol/L (all values) maintain current dose - > 6 mmol/L (>1 value, no hypos) increase by 2 units