Home Fayyaa Diabetes: Unit – 7: Insulin Initiation and Titration in Type Diabetes Mellitus

Diabetes: Unit – 7: Insulin Initiation and Titration in Type Diabetes Mellitus


UNIT – 7

Learning objectives
At the end of this module participants will be able to:
• Describe the approaches in management of Type 2 diabetes
• List the rationale and indications for insulin
initiation in Type 2 DM
• Choose the right insulin type and dose
• Educate the patient and family members on proper injection of insulin
• Address barriers to optimal use of insulin
• Support patients on insulin therapy

• Diabetes is a progressive disease
• T2DM progression is characterised by decline in ß-cell function and worsening insulin resistance.
• Getting to, or maintaining, target HbA1c levels in T2DM requires intensified treatment over time.

Indications for insulin therapy in Type 2 DM
1. Severe Hyperglycemia at diagnosis
– FBS > 250 mg/dl
– RBS > 300 mg/dl
– HbA1C > 9.5 %
– Ketonuria or HHS
– Severe symptoms
2. Patients not meeting targets on two OHA and Life Style Modification
3. Intolerable side effects or unable to take medications
4. Preconception Control and Pregnancy
5. Plans for surgery, especially CV Surgery;
6. Severe illness and Hospitalization
7. Use of steroids or chemotherapy
Most patients with type 2 DM will eventually need insulin therapy

Insulin Therapy in type 2 DM Options
• Offer NPH insulin injected at once or twice
daily according to need.
• Consider starting both NPH and short-acting
insulin if person’s HbA1c is 9.0% or higher, administered either:
– separately or
– as a pre-mixed (biphasic) human insulin

Insulin therapy options
• Basal insulin
– Once or twice daily, intermediate or long-acting
• Premix insulin
– Once or twice daily
• Rapid-acting insulin (bolus)
– Meal-time
• Combination (e.g. basal-bolus)

Insulin initiation regimens
• Basal insulin
– 10 units at bed time
– Increase by 2-4 units every 3 days until fasting glucose < 130 mg/dl
• Intensive insulin therapy/MDI
– 0.3-0.5 units/kg total
• Divide dose 2/3 in AM + 1/3 in PM
– Increase by 2-4 units every 3 days until fasting glucose < 130 mg/dl
• Pre-mixed insulin
– 10 units bid OR 0.3-0.5 units/kg divided in 2/3 in AM + 1/3 in PM
– Most difficult to titrate

MDI- multiple daily injections

Practical aspects of insulin initiation
• Start low and titrate up
• Basal insulin therapy:
– Begin at 0.1 to 0.2 U/kg of body weight = ~ 10
units at bed time and titrate to achieve target
fasting, if the bed time insulin is ≥24 units, split
2/3 in AM + 1/3 in PM
– Continue metformin therapy
Continue sulfonylureas during the day if started
with bed time NPH

Practical aspects of insulin initiation…
• If patients have post prandial high blood glucose
(>180 mg/dl):
– Continue Metformin and DPP-IV inhibitors
– Stop sulfonylureas
– Calculate 0.3 to 0.5 u of insulin/kg body weight
– Premixed insulin twice daily: divide as 2/3 in AM and 1/3 at supper and titrate
– Patients can also mix NPH insulin and regular insulin in 2/3 and 1/3 proportions respectively
– Have patients work closely with diabetes nurse educator or frequent follow ups in the office for adjustment.

Practical aspects of insulin…
• Insulin therapy requires a structured program
employing active insulin dose titration that
– injection technique, including rotating injection sites and avoiding repeated injections at the same point within sites
– self-monitoring
– dose titration to target levels
– dietary understanding
– management of hypoglycaemia

Barriers to insulin therapy
• There is resistance to initiate insulin despite efficacy and guideline recommendations (‘clinical inertia’)
– Patients remain on OHA therapy for years, even those with poor glycemic control
• Barriers to insulin initiation are shared by patients and clinicians
• Health system factors (Access to insulin, monitoring of DM)
• Patient concerns continue even after insulin initiation

Barriers to Insulin Use: Patients
• Fear of hypoglycaemia
• Fear of reduced quality of life
• Fear of needles/pain from injections
• Reluctance to inject in public
• Perception that the disease is becoming more severe
• Patients do not feel empowered to take control of their diabetes
• Perception that insulin therapy leads to complications or death
• Misperception that insulin is only necessary in type 1 diabetes

Barriers to Insulin Use: Professionals
• Lack of
– Training
– Time
– Support & Resources
• Do not treat to target
• Fear of
– Hypo
– Weight gain
– Patients’ anger
– Complex RX regimens

Determinants of insulin efficacy
• Type of insulin
• Size of subcutaneous tissue
• Injection technique
• Site of injection
• Alterations in subcutaneous blood flow

Insulin injection technique
• Injection technique is the same with insulin syringes and pen injectors
• Both the angle of needle entry and depth of penetration affect the rate of absorption
• Injections are made into the subcutaneous tissue. Most individuals are able to lightly grasp a fold of skin and inject at a 90° angle
• Thin individuals or children can use short needles or may need to pinch the skin and inject at a 45° angle to avoid intramuscular injection, especially in the thigh area

Injection sites
• Insulin may be injected into the subcutaneous
tissue of the upper arm and the anterior and
lateral aspects of the thigh, buttocks, and
• Rotation of the injection site is important to
prevent lipohypertrophy or lipoatrophy.
• Rotating within one area is recommended (e.g.,
rotating injections systematically within the
abdomen) rather than rotating to a different
area with each injection

Insulin storage
• Although manufacturers recommend storing insulin in the refrigerator, injecting cold insulin can sometimes make the injection more painful
• To avoid this, many providers suggest storing the bottle of insulin being used at room temperature
• Insulin kept at room temperature will last approximately 1 month

Case Study 1
A 42 year old man with diabetes for the last 03
years is taking Metformin 1000mg po bid and
Glibenclamide 5mg po bid.
His FBS is 210mg/dl today. His HbAlc is 9%. His
FBS was 300mg/dl at diagnosis but he refused
insulin initiation because of fear of
hypoglycemia and interference with his daily
He has background retinopathy and dyslipidemia.

Case Study 1 Answer:
• This patient has poor control of both Fasting and Post Prandial blood.
• His life expectancy is long so his target HBA1C should be ~7%
• Starting with premixed insulin twice per day is
preferable(0.1-0.2 units/kg)
• Educate on Insulin and Hypoglycemia
• If patient still refuses insulin add a 3rd PO agent (SGLT2 inhibitor or DPP IV inhibitor)
• Moderate Intensity Statins— Simvastatin 20-40mg or Rosuvastatin 10mg or Atorvastatin 20mg
• Refer to ophthalmologist for further evaluation


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