Transitioning to Insulin Therapy

Question 1

Define Basal Insulin

Answer 1

Constant insulin

Question 2

Define Bolus Insulin

Answer 2

Mealtime insulins

Question 3

Bolus Insulin Options

Answer 3

Rapid acting (aspart, lispro, glulisine) and short acting (regular)

Question 4

Basal Insulin Options

Answer 4

Intermediate and long acting (NPH, glargine, detemir, degludec)

Question 5

Rapid Acting Onset, Peak, Duration

Answer 5

O: 5-15 minutes
P: 1-2 hours
D: 4-6 hours

Question 6

Short Acting Onset, Peak, Duriation

Answer 6

O: 30-60 minutes
P: 1-5 hours
D: 6-10 hours

Question 7

Rapid Acting Insulins

Answer 7

Aspart (novolog)
Lispro (humalog)
Glulisine (apidra)

Question 8

NPH type, onset, peak, duration, dosing

Answer 8

Intermediate
O: 1-2 hours
P: 4-8 hours
D: 10-20 hours
Dosing: Daily or BID

Question 9

Determir type, onset, peak, duration, dosing

Answer 9

Levemir is intermediate to long acting
O: 2-4 hours
P: 6-8 hours or 3-4 hours if less than 0.4u/kg
D: 24 hours or 14 hours if less than 0.4 u/kg
Dosing: daily or BID if less than 0.4 u/kg

Question 10

Glargine type, onset, peak, duration, dosing

Answer 10

Lantus is long acting
O: 1-2 hours
P: NONE
D: ~24 hours
Dosing: daily or BID if wearing off

Question 11

Degludec type, onset, peak, duration, dosing

Answer 11

Tresiba is ultra long acting
O: 1 hour
P: NONE
D: >42 hours
Dosing: daily

Question 12

Mixed Insulins Formulations

Answer 12

o Insulin 70/30: 70% NPH 30% Regular
o Novolog Mix 70/30: 70% NPH 30% Aspart
o Humalog 75/25: 75% NPH 25% Lispro
o Humalog 50/50: 50% NPH 50% Lispro

Question 13

Starting Insulin Steps

Answer 13

Basal –> 1 rapid insulin injection before largest meal or premixed insulin twice daily –> 2 or more insulin injection before meals (basal/bolus)

Question 14

**Basal Insulin Starting Dose, Adjustments and if Hypo occurs

Answer 14

10 U/day or 0.1-0.2 u/kg/day
Ad: Increase dose by 10-15% or 2-4 once or twice weekly to reach FBG
Hypo: decrease dose by 4 units or 10-20%

Question 15

***Add 1 Rapid Insulin Injection Starting Dose, Adjustment and if hypo occurs

Answer 15

4 U, 0.1 u/kg, OR 10% of basal dose (if A1c is less than 8% consider decreasing basal by same)
Adjust: Increase by 1-2 units or 10-15%
Hypo: Decrease dose by 4 units or 10-20%

Question 16

***Change to premixed insulin BID starting dose, adjustment and for hypo

Answer 16

Start: Divide current basal by 2/3 AM and 1/3 PM
Adjust: Increase by 1-2 units or 10-15%
Hypo: Decrease dose by 4 units or 10-20%

Question 17

***Basal Bolus start, adjustment and for hypo

Answer 17

4 U, 0.1 u/kg, OR 10% of basal dose (if A1c is less than 8% consider decreasing basal by same)
Adjust: Increase by 1-2 units or 10-15%
Hypo: Decrease dose by 4 units or 10-20%

Question 18

What about Non-Insulin Meds?

Answer 18

o Metformin = generally continue
o Secretagogues : Continue with basal insulins, avoid with prandial insulin
o TZDs = reduce dose/stop to avoid edema and weight gain
o GLP1s/DPP4s = ok to continue with basal insulin
o SGLT2s = ok with basal insulin, not with bolus insulin