INSULIN

INITIATION AND
INTENSIFICATION
DR.ASHRAF SHAABAN
Professor in Internal Medicine
CONSULTANT Endocrinologist
GNP HOSPITAL.
Active member of ADA
Active member of EASD
Active member of ESH

 Mr Fahad is 50 Y old Saudi teacher

with history of Diabetes Mellitus 20 y
back.
He has strong family history of DM .
Non smoker but he is practicing
sedentary life style & not adherent to
diabetic diet.
No history of previous DKA or
recurrent hypoglycemia.

MEDICATION HISTORY

Current medications are:

Metformin 2 gm/day.
Gliclazide 30 mg 4 tablet od
Linagliptin 5 mg od
Pioglitazone 30 mg od
Disprin 81mg od

Medication History
PITIVASTATIN 4 mg Od
Irbisartan 150mg od.
Neurobion 100 mg tds.

Physical examination

Body weight: 86.4 kg

BMI is 30 Kg/m2.
Waist circumference: 110 cm
Blood pressure: 150/90 mm Hg
Ankle-brachial index: 1.08
No peripheral edema.
+ve peripheral neuropathy.
Fundus Exam:Background Retinopathy

Fundus Examination:

Laboratory investigation

Blood cells
Normal value
Hematocrit: 45%
Hemoglobin: 14 g/dL
White blood cells: 6. 103/mm3
Red blood cells: 7. 106/mm3

Glycemia
Fasting serum glucose: 192 mg/dL
HbA1c: 11.8 %

Laboratory investigation
Lipid profile
Serum cholesterol: 163 mg/dL
LDL-cholesterol: 100 mg/dL
HDL-cholesterol: 38 mg/dL
Triglyceride: 189 mg/dL
Renal function
Serum creatinine: 1.1 mg/dL
eGFR: 90 mL/min/1.73 m2
Microalbuminuria is positive
Liver function
SGPT 34 IU/L

ECG
Within the normal limits.

What is cardiometabolic risk?

The overall risk of developing type 2

diabetes and/or cardiovascular
disease which is due to a cluster of
risk factors.

What Are the Cardiometabolic risk factors?

Traditional risk factors for

(CVD):

Hypertension .
Dyslipidemia
Glucose intolerance.
Obesity.
Insulin resistance.

Non-traditional CVD risk factors

Inflammatory processes.
Abnormalities of the blood coagulation system .

Management
AC<7%
1

BLOODPRESSURE<130/80mmhg

CHOLESTEROLLDL<70mg/dl
CHOLESTEROL
American Diabetes Association,Egyptian diabetes CenterEducation,Detection,Care

ON EXAMINATION:

BP is 150/90 mm.Hg
Heart: Normal S1, S2+0
Pulse;80/m regular, no special
character
CHEST : NAD
Abdomen: only enlarged soft liver.
Neurological examination: signs of P
neuropathy in the form of diminished
sense of vibration and loss of p
sensations in 4 regions of foot.

WHAT is THE NATURAL HISTORY OF DIABETES?

HOW is the Natural history is related to the need for

Insulin use?

In people with type 2 diabetes beta-cell

function will progressively decline
UKPDS: at 6 years, more than 50% of
patients need insulin to reach target (FPG
6.0 mmol/L)

Beta-cell function (%, HOMA)

100
Diabetes
diagnosis

80

60

40

20

0
12

10

Years from diagnosis

Extrapolation of beta-cell function prior to diagnosis
HOMA, homeostasis model assessment

Lebovitz. Diabetes Rev 1999;7:13953 (data are from the UKPDS population: UKPDS 16. Diabetes 1995;44:124958); Wright et al. Diabetes Care 2002;25:3306

Insulin replacement therapy

becomes necessary in most cases
Obesity

IFG

Diabetes

Uncontrolled hyperglycaemia
Insulin resistance

Relative
function (%)

250
200

Normal

150
100

Beta-cell failure

Glucose level
(mmol/L)

50

Insulin level

20
18
16
14
12
10
8
6
4

Postprandial glucose
Fasting glucose

Normal

10

10

Years of diabetes
IFG, impaired fasting glucose

Adapted from Bergenstal et al. Endocrinology. 4th ed. 2001;82135

15

20

25

30

Most people with type 2 diabetes will,

in time, need insulin therapy

Patients requiring
additional insulin (%)

60
50
40
30
20
10
0
1

Years from start of UKPDS

(Patients treated with chlorpropramide)

Wright A et al. Diabetes Care 2002;25:3306

ARE we Satisfied with current antidiabetic

medications & HBA1c?

Individualised targets
Individualised to the patient, considering:
Body mass index (BMI)
Cardiovascular (CV) risk
Patient choice
Age

Micro/macrovascular
complications or
disease duration
>10 years

HbA1c (%)

Young

Elderly

Middle-aged

<6

<6.5

<6.5

6.57

<7

78

HbA1c %
Polizzi et al. Diab Metab Res Rev 2010;26:23944

Insulin treatment

Improving control reduces risks

of long-term complications

Every 1% drop in HbA1c can reduce

long-term diabetes complications
43%

37%

19%

16%

14%

Heart failure

Myocardial
infarction

12%
Stroke

Cataract
extraction
Microvascular
disease
Lower extremity
amputation or fatal
peripheral vascular
disease

UKPDS 35: Stratton et al. BMJ 2000;321:40512.

ACCORDING TO ADA 2016 position statement ,

what is next step to control DM?

Why should insulin be

initiated?
1. Type 2 diabetes is a progressive
disease; over time oral agents can
no longer control glucose in most
patients

2. Maintaining near-normal glucose

control is important in maximising
outcomes

Schematic Time-Activity Curves for Selected Insulin

Formulations

McMahon G and Dluhy R. N Engl J Med 2007;357:1759-1761

Insulin Initiation

Insulin Lantus 10 units OD was addedd to previous TTT

PIOglitazone was reduced to 15 mg od
Patient was instructed to uptitrated the dose according to the FBG
Aprovel was up-titrated to 300 mg od
Rest of medications were continued

Initiating Basal Insulin

Most insulin regimens take into account the individuals weight at initiation
because doing so will help prevent adverse reactions caused by overinsulinization (most notably hypoglycemia and weight gain).
Basal insulin is typically begun at a low dose (e.g., 0.10.2 units/kg per day).
The most convenient strategy is with a single injection of basal insulin
administered before the evening meal or at bedtime, at an initial dose of
0.1units/kg. This will ensure that changes in blood glucose levels will be gradual.
Under special conditions, such as significant hyperglycemia (HbA1c 9%) and/or
obesity, a starting dose of 0.2 units/kg may be used.
An alternative, non-weight-based option is to start most individuals empirically
with 10 units, or in obesity up to 20 units, of basal insulin (i.e., long-acting or
intermediate-acting).

Advancing Basal Insulin

If most AM fasting BG
>120 mg/dL
(>6.7 mmol/L)

Titrate until fasting glucose at target BG

Increase 2 units [or 4 units if FBG >180

mg/dl ] every 3 days
If dose reaches ~0.5 units/kg body
weight, consider adding mealtime insulin
Test preevening meal and bedtime
(or 2-hour postevening meal)
and consider need for mealtime insulin

If most AM fasting BG
<120 mg/dL
(<6.7 mmol/L) and
A1C remains above target
If hypoglycemia or FPG Reduce insulin dose by 3 units or 10%,
< 70 mg/dL whichever is greater

Follow UP after 3 months

Mr Fahad uptitrated Lantus to 40 units od

Fbs :120 mg/dl
HBA1c dropped to 9.7%
BP now 130/80 mm.GH
Microalbuminuria improved but still positive.

ARE we Satisfied?
Should we increase the dose of insulin
Glargine?

Basal insulin can be convenient, but does not

address PPG
Evening
meal

Midnight

6pm
50% of the day is spent in
the postprandial state

Lunch
Midday

4
hour
s
PPG

Breakfast
6am

Adapted from Monnier. Eur J Clin Invest 2000;30(Suppl. 2):311.

# injections
1

Approach to starting and

adjusting insulin in type 2
diabetes (2015)

Add 1 rapid insulin injection before

largest meal
*

Start:
Start: 4
4 U,
U, 0.1
0.1 U/kg,
U/kg, or
or 10%
10% basal
basal dose.
dose.
If
HbA
<8%,
consider

basal
1c
If HbA1c <8%, consider basal by
by same
same
amount
amount
Adjust:
Adjust:
dose
dose by
by 1-2
1-2 U
U or
or 10-15%
10-15%
once-twice
weekly
until
SMBG
once-twice weekly until SMBG target
target
reached
reached
For
For hypo:
hypo: determine
determine and
and address
address
cause;

corresponding
cause; corresponding dose
dose by
by 2-4
2-4 U
U
or
10-20%
or 10-20%
If
If not
not
controlled,
controlled,
consider
consider
basal-bolus
basal-bolus

3
+

complexity

Basal Insulin
(usually with metformin +/- other noninsulin agent)

lo
w

Start:
Start: 10
10 U/day
U/day or
or 0.1-0.2
0.1-0.2 U/kg/day
U/kg/day
Adjust:
Adjust: 10-15%
10-15% or
or 2-4
2-4 U
U once-twice
once-twice weekly
weekly to
to reach
reach FBG
FBG
target
target
For
For hypo:
hypo: determine
determine and
and address
address cause;
cause;
dose
dose by
by 4
4U
U or
or
10-20%
10-20%

If
If not
not controlled
controlled after
after
FBG
FBG target
target is
is
reached
reached (or
(or if
if dose
dose >
>
0.5
0.5 U/kg/day),
U/kg/day), treat
treat
PPG
PPG excursions
excursions with
with
mealtime
mealtime insulin
insulin
(Consider
(Consider initial
initial
GLP
GLP1-RA
1-RA trial)
trial)

Change to premixed insulin*

twice daily

Add 2 rapid insulin* injections before meals

(basal-bolus)

Start:
Start: divide
divide current
current basal
basal dose
dose into
into
2/3
2/3 AM,
AM, 1/3
1/3 PM
PM or
or 1/2
1/2 AM,
AM, 1/2
1/2 PM
PM
Adjust:
Adjust:
dose
dose by
by 1-2
1-2 U
U or
or 10-15%
10-15%
once-twice
once-twice weekly
weekly until
until SMBG
SMBG target
target
reached
reached
For
For hypo:
hypo: Determine
Determine and
and address
address
cause;
cause;
corresponding
corresponding dose
dose by
by 2-4
2-4
U
U or
or 10-20
10-20%
%

If
If not
not
controlled,
controlled,
consider
consider
basal-bolus
basal-bolus

m
o
d

Start:
Start: 4
4 U,
U, 0.1
0.1 U/kg,
U/kg, or
or 10%
10% basal
basal
dose/meal.
If
HbA
<8%,
consider

dose/meal. If HbA1c
1c <8%, consider
hi
basal
g
basal by
by same
same amount
amount
h
Adjust:
Adjust:
dose
dose by
by 1-2
1-2 U
U or
or 10-15%
10-15%
once-twice
once-twice weekly
weekly until
until SMBG
SMBG target
target
reached
reached
flexibility
More flexible For hypo: determine and address
less flexible
For hypo: determine and address
cause;
cause;
corresponding
corresponding dose
dose by
by 2-4
2-4
FBG, fasting blood glucose; PPG, post-prandial glucose; GLP-1RA, glucagon-like peptide-1 receptor agonist; SMBG, self-monitoring of blood glucose
*Regular human insulin and human NPH-Regular premixed formulations (70/30) are less costly alternatives to rapid-acting insulin analogues and premixed insulin analogues, but their pharmacodynamic profiles make them suboptimal for the coverage of postprandial glucose excursions.
U
or
10-20%
U or 10-20%
Inzucchi SE et al. Diabetes Care 2015;38:140149

# injections
1

Approach to starting and

adjusting insulin in type 2
diabetes (2015)

Add 1 rapid insulin injection before

largest meal
*

Start:
Start: 4
4 U,
U, 0.1
0.1 U/kg,
U/kg, or
or 10%
10% basal
basal dose.
dose.
If
HbA
<8%,
consider

basal
1c
If HbA1c <8%, consider basal by
by same
same
amount
amount
Adjust:
Adjust:
dose
dose by
by 1-2
1-2 U
U or
or 10-15%
10-15%
once-twice
weekly
until
SMBG
once-twice weekly until SMBG target
target
reached
reached
For
For hypo:
hypo: determine
determine and
and address
address
cause;

corresponding
cause; corresponding dose
dose by
by 2-4
2-4 U
U
or
10-20%
or 10-20%
If
If not
not
controlled,
controlled,
consider
consider
basal-bolus
basal-bolus

3
+

complexity

Basal Insulin
(usually with metformin +/- other noninsulin agent)

lo
w

Start:
Start: 10
10 U/day
U/day or
or 0.1-0.2
0.1-0.2 U/kg/day
U/kg/day
Adjust:
Adjust: 10-15%
10-15% or
or 2-4
2-4 U
U once-twice
once-twice weekly
weekly to
to reach
reach FBG
FBG
target
target
For
For hypo:
hypo: determine
determine and
and address
address cause;
cause;
dose
dose by
by 4
4U
U or
or
10-20%
10-20%

If
If not
not controlled
controlled after
after
FBG
FBG target
target is
is
reached
reached (or
(or if
if dose
dose >
>
0.5
0.5 U/kg/day),
U/kg/day), treat
treat
PPG
PPG excursions
excursions with
with
mealtime
mealtime insulin
insulin
(Consider
(Consider initial
initial
GLP
GLP1-RA
1-RA trial)
trial)

Change to premixed insulin*

twice daily

Add 2 rapid insulin* injections before meals

(basal-bolus)

Start:
Start: divide
divide current
current basal
basal dose
dose into
into
2/3
2/3 AM,
AM, 1/3
1/3 PM
PM or
or 1/2
1/2 AM,
AM, 1/2
1/2 PM
PM
Adjust:
Adjust:
dose
dose by
by 1-2
1-2 U
U or
or 10-15%
10-15%
once-twice
once-twice weekly
weekly until
until SMBG
SMBG target
target
reached
reached
For
For hypo:
hypo: Determine
Determine and
and address
address
cause;
cause;
corresponding
corresponding dose
dose by
by 2-4
2-4
U
U or
or 10-20
10-20%
%

If
If not
not
controlled,
controlled,
consider
consider
basal-bolus
basal-bolus

m
o
d

Start:
Start: 4
4 U,
U, 0.1
0.1 U/kg,
U/kg, or
or 10%
10% basal
basal
dose/meal.
If
HbA
<8%,
consider

dose/meal. If HbA1c
1c <8%, consider
hi
basal
g
basal by
by same
same amount
amount
h
Adjust:
Adjust:
dose
dose by
by 1-2
1-2 U
U or
or 10-15%
10-15%
once-twice
once-twice weekly
weekly until
until SMBG
SMBG target
target
reached
reached
flexibility
More flexible For hypo: determine and address
less flexible
For hypo: determine and address
cause;
cause;
corresponding
corresponding dose
dose by
by 2-4
2-4
FBG, fasting blood glucose; PPG, post-prandial glucose; GLP-1RA, glucagon-like peptide-1 receptor agonist; SMBG, self-monitoring of blood glucose
*Regular human insulin and human NPH-Regular premixed formulations (70/30) are less costly alternatives to rapid-acting insulin analogues and premixed insulin analogues, but their pharmacodynamic profiles make them suboptimal for the coverage of postprandial glucose excursions.
U
or
10-20%
U or 10-20%
Inzucchi SE et al. Diabetes Care 2015;38:140149

Therapy Following Basal Only

Insulin
Non-insulin regimens

Number of
injections

Basal insulin only

1
1

(usually
(usually with
with oral
oral agents)
agents)

Basal insulin + 1
(mealtime) rapidacting insulin
injection

Basal insulin +
2
(mealtime) rapidacting insulin
injections

Premixed insulin
twice daily

2
2

mod.
mod.

3+
3+

high
high

Flexibility

Inzucchi SE, et al. Diabetes Care. 2012;35(6):1364-1379.

If basal
insulin
fails,
low
low
what is the
next best
approach?

Regimen
complexity

Two questions that may be relevant

1. Add one injection of rapid acting insulin to

basal insulin or switch to premix?

2. How should I think about increasing dose

frequency?

Insulin lispro low mixture twice daily versus basal

insulin glargine once daily and prandial insulin
lispro once daily in patients with type 2 diabetes
requiring insulin intensification: a randomized phase
IV trial
F. J. Tinahones1 J. L. Gross2
A. Onaca3 S. Cleal4 & A. Rodrguez5

1 Hospital Universitario Virgen de la Victoria, Mlaga and CIBER Fisiopatologa Obesidad y Nutricin
(CIBEROBN), Instituto de Salud Carlos III, Mlaga, Spain
2 Centro de Pesquisas em Diabetes, Porto Alegre, Brazil
3 Pelican Hospital of Oradea, Oradea, Romania
4 Eli Lilly, Windlesham, UK
5 Lilly Spain, Alcobendas, Spain

Objective
To compare the efficacy and safety of 2 insulin-

intensification strategies in patients with inadequate

glycaemic control on once-daily basal insulin
glargine plus metformin and/or pioglitazone

Insulin lispro low mixture, insulin lispro protamine

suspension 75% and insulin lispro solution 25% (LM25),
twice-daily vs.
Basal insulin glargine once-daily and prandial insulin
lispro
once-daily (IGL)

Tinahones et al. Diabetes Obes and Metab 2014;(Ahead of print).

Mean (SD) Blood Glucose

Level (mmol/L)

Mean 7-point Self-monitoring of Blood Glucose Levels at

Baseline and 24 Weeks (ITT Population)

**
**

** p.01
Tinahones et al. Diabetes Obes and Metab 2014;(Ahead of print).

Summary
Noninferiority (PP population), and then superiority (ITT population), of LM25 vs. IGL
was shown in terms of change in HbA1c at 24 weeks
Mean blood glucose, glycaemic variability, overall tolerability, and hypoglycaemic
episodes per patient-year did not show significant differences between treatments
during the study
Total daily insulin doses for each regimen were not found to be significantly different
at end of study
No significant differences in the frequency of hypoglycaemic episodes and health
outcomes were observed between the two regimens

Tinahones et al. Diabetes Obes and Metab 2014;(Ahead of print).

Endpoint hemoglobin A1c (%)

Insulin Lispro Mix 25 vs Insulin Glargine:

DURABLE 24-wk ResultsHbA1c and
Dose

Endpoint
insulin
dose
(U/kg/day)

7.3

7.3
7.2
7.0

0.40 0.23

0.33 0.19

GL QD+OAD

0.47 0.23*

0.40 0.19*

LM25 BID+OAD

INSULIN INTENSIFICATION
MR Fahad was not accepting multiple injections.
He was satisfied with only 2 injections of Humalog
Mix 25 twice daily
Diamicron tablet was stopped.
Metformin was continued .
Tradjenta 5 mg od was continued.
Actos 15 mg was continued

 Most

Initiating Premixed
Insulin

insulin regimens take into account the individuals

weight at initiation because doing so will help prevent
adverse reactions caused by over-insulinization (most
notably hypoglycemia and weight gain).
When using premixed insulin, insulin secretagogues are
often discontinued and other non-insulin therapies should be
reconsidered.
The effectiveness of these medications should be
reconsidered in light of the action of the premixed insulin.
If the HbA1c is 9%, the starting dose of premixed insulin is
0.2 units/kg before the morning and evening meals (total
daily dose 0.4 units/kg).
If the HbA1c is <9%, the starting dose is 0.1 units/kg before
the morning and evening meals (total daily dose 0.2 units/kg).
Based on glucose monitoring, premixed insulin
adjustments of 2 units is typically recommended.

Follow up

Mr Fahad received 16 units of Humalog Mix 25 BD.

He uptitrated the dose to 20 units bd.
Within 3 months HbA1c dropped to 8%
2hours post lunch B.G was 258 mg/dl
Micro albuminuria improved more and became to
nearer point for normalization.

ARE we Satisfied With

postprandial hyperglycemia?
WHAT does the Guidelines
say?

What is good glycaemic control?

Overall aim to achieve glucose levels as close to
normal as possible
Minimise development and progression of
microvascular and macrovascular complications

ADA1

IDF2

FPG
<130 mg/dL
(7.2 mmol/L)

HbA1c
< 7.0%

PPG
<180 mg/dL
(10.0 mmol/L)

FPG
<6.0 mmol/L
(110 mg/dL)

HbA1c
< 6.5%

PPG
<8.0 mmol/L
(145 mg/dL)

1. American Diabetes Association Diabetes Care 2009;32 (Suppl 1):S1-S97

2. IDF Clinical Guidelines Task Force. International Diabetes Federation 2005.

Post Prandial Hyperglycaemia

Relationship between postprandial glucose levels and CV

mortality

San Luigi
DECOD Gonzaga
E
Study
1
1999
20068Pacific and
Indian Ocean
19992
CVD

Honolulu
Heart Program
19877
The
RanchoppBG
death Funagata
Bernardo
Study 19986
Diabetes
Diabetes
Study 19993
Whitehall,
Intervention
Paris and Helsinki
Study 19965
Study
19984
ppBG, postprandial blood glucose; CV, cardiovascular

1. DECODE Study Group. Lancet 1999;354:61721; 2. Shaw et al. Diabetologia 1999;42:10504; 3. Tominaga et al. Diabetes Care 1999;22:9204; 4. Balkau et al.
Diabetes Care 1998;21:3607; 5. Hanefeld et al. Diabetologia 1996;39:157783; 6. Barrett-Connor et al. Diabetes Care 1998;21:12369; 7. Donahue et al.
Diabetes 1987;36:68992; 8. Cavalot et al. J Clin Endocrinol Metabol 2006;91:8139

Humalog Mix 50:

Mimics normal physiology of non diabetic individuals
Humalog Mix 50 3 times a day mimics normal
physiology of non diabetic individuals

In Non-diabetic Individuals, Basal Secretion

represents approximately 50% Total Daily Insulin

Schernthaner G, Kopp HP, Ristic S, Muzyka S, Peter L, Mitteregger G . Metabolic control in patients with type 2 diabetes using Humalog Mix50 injected three times daily: crossover

comparison with human insulin 30/70. Horm Metab Res. 2004; 36: 188- 193.
Polonsky KS, Given BD, Hirsch LJ, et al. Abnormal patterns of insulin secretion in non-insulin- dependent diabetes mellitus. N Engl J Med. 1988; 318 (19): 1231-1239.
Heise T, Weyer C, Serwas A, et al. Time-action profiles of novel premixed preparations of insulin lispro and NPL insulin. Diabetes Care. 1998; 21: 800-803.

Data on file, Eli Lilly and Company.

10

Comparing Insulin Lispro Mix 50 TID

With Basal/Bolus (Glargine/Lispro)
Therapy
in Type 2 Diabetic Patients Without
Glycemic Control on Glargine Plus Oral
Therapy

Rosenstock J, et al. Diabetes Care 2008; 31:20-25

Humalog Mix 50 vs Basal/Bolus therapy

Background and Study

Objectives

Background
Basal/bolus is considered the ideal insulin treatment for diabetes in
terms of physiological action and overall glycemic control1
Insulin lispro mix 50 (50% lispro / 50% insulin lispro protamine
suspension; LM50) TID provides both basal and rapid-acting insulins,
similar to basal/bolus treatment2
Study Objectives
Demonstrate non-inferiority of lispro mix 50 TID to basal/bolus
Primary Objective: Change in HbA1c at endpoint
Secondary Objective: 8-point PG profiles, hypoglycemia, insulin
doses, and body weight
1 Hirsch et al, Clinical Diabetes 2005; 23:78-86
2 Rosenstock J, et al. Diabetes Care 2008; 31:20-25

Starting Daily Dose

1/3
Dose

LM50
TID

Breakfast

Basal/Bol
us

1/6 Dose
(lispro)

1/3
Dose

1/3
Dose

Lunch

Dinner

1/6 Dose
(lispro)

1/6 Dose
(lispro)

Preprandial PG target <6.1

mmol/L (110 mg/dL)
Rosenstock J, et al. Diabetes Care 2008; 31:20-25

Bedtime

3/6 Dose
(glargine)

HbA1c at Each Visit in

Completer Population

LM50 TID + OAMs

n= 158 TID
LM50
OAMs
+
n=158
Basal/Bolus+ OAMs
n= 158
Basal/Bolus
OAMs
+
n=158

9.50
9.50

A1C (%)

HbA1c (%)

9.00
9.00
8.50
8.50
8.00
8.00
7.50
7.50

6.95%

6.95%

7.00
7.00
6.50
6.50

6.78%
*
6.78%

6.00
6.00

20

36

12
4

Weeks
Weeks

18
5

624

* P=0.02
p=0.02

A1C was reduced significantly from baseline for both therapies.

Data on file, 2006 Eli Lilly & Company

Rosenstock J, et al. Diabetes Care 2008; 31:20-25

24-wk parallel group

PG Profile
LM50 TID + OAMs
n=158
Basal/Bolus + OAMs
n=158

Baseline

Endpoint

t
Ni
gh

im
e
Be
dt

PM

2hr

PP

ea
l
No
on

No
on

Pr
em

2hr

PP

g
AM

Pr
em
ea
l
PM
2hr
PP

Fa
st
in

* p<0.05 (between
treatments at
endpoint)

At 24 weeks both therapies significantly reduced PG values from

baseline at all time points
24-wk parallel group
Rosenstock J, et al. Diabetes Care 2008; 31:20-25

Fup
After application of Humalog mix 50 15 Units
tds by 3 months.
HBA1c Dropped to 7.5%
2H PP BG was 180 mg/dl
Microalbuminuria now is _ve.
Diabetic Retinopathy is stable.

Thank you