How much 1 unit of insulin is expected to decrease the patient's blood glucose level; when the blood glucose level is above predefined targets, short-acting insulin may be added to the bolus dose or given separately between meals.
Adapted with permission from Petznick A. Insulin management of type 2 diabetes mellitus. Am Fam Physician. Augmentation therapy with basal insulin may be initiated at 10 units once daily, or by using weight-based dose calculations. The ADA suggests insulin replacement therapy with basal and rapid-acting prandial basal-bolus insulin when the blood glucose level is to mg per dL Insulin replacement therapy may also be considered in patients with newly diagnosed type 2 diabetes and elevated blood glucose or A1C and hyperglycemic symptoms.
The ADA recommends that an insulin regimen be adjusted once or twice weekly or every three or four days until self-monitoring of blood glucose SMBG targets are reached.
It should be noted that these recommendations were developed before the U. Premeal or bedtime blood glucose levels for 3 consecutive days. Fasting blood glucose levels for 3 consecutive days. Predinner blood glucose levels for 3 consecutive days. If the patient has an elevated glucose level at lunchtime, the breakfast rapid-acting dose should be adjusted; if the patient has an elevated premeal glucose level at dinnertime, the lunchtime rapid-acting dose should be adjusted; if the patient has an elevated bedtime glucose level, the dinnertime rapid-acting dose should be adjusted.
Narrative review: a rational approach to starting insulin therapy. Ann Intern Med. The ADA suggests that patients taking multiple daily insulin injections consider performing SMBG before meals and snacks, occasionally after meals, at bedtime, before exercise, when hypoglycemia is suspected and after it is treated, and before critical tasks such as driving. Twice yearly measurements are reasonable for patients with stable diabetes and an A1C level that is within the goal.
A1C goals should be individualized according to patient characteristics. Several recent trials of intensive therapy in older patients with long duration of diabetes and a high risk of atherosclerotic cardiovascular disease have shown no effect on the incidence of macrovascular complications or an increased incidence of hypoglycemic events and increased mortality.
An A1C goal of less than 6. Before , the standard concentration for all insulin formulations was U, with the exception of the U regular human insulin Humulin R. Since then, the FDA has approved several higher-concentration insulin products that are associated with less risk of hypoglycemia compared with older formulations. No generics available. The only available highly concentrated rapid-acting insulin is the U lispro pen. It is bioequivalent to the U version but requires fewer pen changes per month because less volume is injected with each dose.
Afrezza, a rapid-acting inhaled human insulin, is delivered through a specially designed inhaler comprised of single-use cartridges. In January , Sanofi-Aventis announced it would no longer distribute Afrezza because of poor sales, and it is unclear whether Afrezza will remain on the market in the United States.
Information from Afrezza prescribing information. Accessed March 14, U regular human insulin is now available as a pen. This product is indicated for patients whose total dosage of U insulin is more than units per day. Unlike the vial formulation, the pen does not require a dose conversion when switching from U insulin formulations.
Dose adjustments must be made in 5-unit increments because of the dose increments available in the pen. U regular human insulin is the most concentrated formulation of insulin available as a pen and allows for the administration of the largest number of insulin units per injection.
It is also associated with increased patient satisfaction and reduced cost. The U glargine pen Toujeo Solostar is a long-acting analogue insulin that was developed to reduce injection volume and provide a gradual insulin release to increase its duration of action to more than 24 hours. Toujeo Solostar allows dosing with 1-unit increments with even numbers visible in the dose counter window.
Although its amino acid sequence is identical to Lantus, it is not considered a biosimilar product in the United States because it did not go through the FDA's biosimilar drug approval process.
The degludec pen Tresiba Flextouch is an ultra—long-acting analogue insulin that is available in two concentrations U and U with similar safety, effectiveness, and pharmacokinetic profiles. Dose conversion is not required when switching between the two. Patients inject Tresiba Flextouch once daily at any time, but there must be at least eight hours between injections. Tresiba Flextouch can be combined in solution with rapid-acting insulin. This combination has been shown to provide similar reduction in A1C values while significantly lowering the risk of overall confirmed, nocturnal confirmed, and severe hypoglycemia.
Patients should continue their previously used short- or rapid-acting insulin at the same dose before meals not covered by this product. This article updates previous articles on this topic by Petznick , 26 and by Mayfield and White.
Data Sources : We searched PubMed using the following terms: type 2 diabetes treatment, prediabetes treatment, hypoglycemic agents, nutrition and diabetes, diabetes and cardiovascular disease. We also searched Essential Evidence Plus. Search dates: January and July Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. At the time this article was written, she was a second-year resident in ambulatory care pharmacy and academia at the University of Tennessee Health Science Center College of Pharmacy.
Reprints are not available from the authors. Defronzo RA. Banting Lecture. From the triumvirate to the ominous octet: a new paradigm for the treatment of type 2 diabetes mellitus.
Prospective Diabetes Study Group. Overview of 6 years' therapy of type II diabetes: a progressive disease. Achievement of goals in U. N Engl J Med. Centers for Disease Control and Prevention. Diabetes report card Accessed May 21, Management of blood glucose with noninsulin therapies in type 2 diabetes. Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes.
Three-year efficacy of complex insulin regimens in type 2 diabetes [published correction appears in N Engl J Med. Diabetes-related distress, insulin dose, and age contribute to insulin-associated weight gain in patients with type 2 diabetes: results of a prospective study. American Diabetes Association. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm— executive summary.
Endocr Pract. Pharmacological management of obesity: an Endocrine Society clinical practice guideline [published correction appears in J Clin Endocrinol Metab.
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Emergency hospitalizations for adverse drug events in older Americans. National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, to Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. UK Hypoglycaemia Study Group. Risk of hypoglycaemia in types 1 and 2 diabetes: effects of treatment modalities and their duration. Severe hypoglycemia and risks of vascular events and death. Hypoglycemia: minimizing its impact in type 2 diabetes.
Risk of dementia in diabetes mellitus: a systematic review [published correction appears in Lancet Neurol. Lancet Neurol. Comparative effect of human soluble insulin and insulin aspart upon hypoglycaemia-induced alterations in cardiac repolarization. Br J Clin Pharmacol. Does hypoglycaemia increase the risk of cardiovascular events? Eur Heart J.
Petznick A. Red Book online. Accessed September 30, Long-acting insulin analogues versus NPH insulin human isophane insulin for type 2 diabetes mellitus. Cochrane Database Syst Rev. Short acting insulin analogues versus regular human insulin in patients with diabetes mellitus. A randomised, week, treat-to-target trial comparing insulin detemir with insulin glargine when administered as add-on to glucose-lowering drugs in insulin-naive people with type 2 diabetes.
Frequency of self-monitoring blood glucose and attainment of HbA1c target values. Acta Diabetol. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risks of complications in patients with type 2 diabetes UKPDS 33 [published correction appears in Lancet.
Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes UKPDS 34 [published correction appears in Lancet. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. Glucose control and vascular complications in veterans with type 2 diabetes [published correction appears in N Engl J Med.
Intensive glycaemic control for patients with type 2 diabetes: systematic review with meta-analysis and trial sequential analysis of randomised clinical trials. Clin Pharmacol Drug Dev. Humalog U website. Afrezza website. Technosphere insulin Afrezza : a new, inhaled prandial insulin. Ann Pharmacother. Humulin R U website. Accessed April 10, Clinical use of U regular insulin: review and meta-analysis.
When using replacement therapy, 50 percent of the total daily insulin dose is given as basal, and 50 percent as bolus, divided up before breakfast, lunch, and dinner. Augmentation therapy can include basal or bolus insulin. Replacement therapy includes basal-bolus insulin and correction or premixed insulin. Glucose control, adverse effects, cost, adherence, and quality of life need to be considered when choosing therapy.
Metformin should be continued if possible because it is proven to reduce all-cause mortality and cardiovascular events in overweight patients with diabetes.
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