Managing Type 2 Diabetes Insulin Therapy

Document Sample
Managing Type 2 Diabetes Insulin Therapy Powered By Docstoc
					Managing Type 2 Diabetes
    Insulin Therapy
  Natalie Jonasson, RPh, BScPhm
         February 13, 2007
               Objectives
Identify the role of insulin therapy in type 2
diabetes.
Explain how insulin treatment is usually initiated.
Illustrate various insulin regimens.
Demonstrate how to use an insulin pen.
List the signs, symptoms, causes, risk factors
and treatment of hypoglycemia.
List the various community based Diabetes
Eduaction programs.
Cost: vial $28; cart. $49, Humalog, NovoRapid vial $38, cart. $67, Detemir cart. $135, Glargine vial $72, cart. $135
                                                                                                                 New Drugs/Drug News vol 24 (3):
(*above prices include dispensing fee and mark-up)                                                               May/June 2006
ODB: all regular benefit EXCEPT: Humalog & NovoRapid- LU; Lantus, Levemir- not a benefit (Section 8)
      Humalog and NovoRapid
            LU criteria
388- For the treatment of patients with Type 1 diabetes
mellitus.
 LU Authorization Period: Indefinite.

389- For the treatment of patients with Type 2 diabetes
mellitus using insulin in an intensive regimen with 3 or
more injections per day or an insulin pump.
 LU Authorization Period: Indefinite.

390- For the treatment of patients with Type 2 diabetes
mellitus who are either experiencing recurrent
hypoglycemia OR are unable to achieve adequate post-
prandial glucose control while on a less intensive
regimen of regular insulin (1-2 injections per day).
 LU Authorization Period: Indefinite
         Lantus & Levemir
( Section 8) reimbursement criteria
For individuals with insulin-requiring diabetes
receiving at least 2 insulin injections per day who
are attempting to maintain tight control of blood
glucose but:
     Experience 1 or more episodes or nocturnal hypoglycemia
     (BS < 3) per week;
OR
     Have experienced at least 2 episodes of severe symptomatic
     hypoglycemia (BS < 3) requiring third party assistance within
     the previous 12 months.
The duration of approval is 1 year. An extended
approval of 1 year is possible with documented
reduction of A1c and/or hypoglycemic episodes.
Action Profiles of Basal Insulins


                   NPH 12–20 hours


                                  Detemir ~ 6–23 hours (dose-dependent)


                                                                          Glargine ~ 20–26 hours




                                                      Hours
Note: Action curves are approximations for illustrative purposes. Actual patient response will vary.
Adapted from Insulin Therapy for the 21st Century. American Diabetes Association;
information from insulin glargine, insulin detemir, and NPH product monographs
The healthy pancreas
The healthy pancreas / Time-action
profile of NPH
The healthy pancreas / Time-action
profile of NPHand Levemir®
The healthy pancreas / Time-action
profile of regular insulin
The healthy pancreas / Time-action
profile of regular insulin and
NovoRapid®
The healthy pancreas / Time-
action profile of Novolin® ge
30/70
Approach to Management
                              Clinical assessment and initiation of nutrition and physical activity




         Mild to moderate hyperglycemia (A1C <9.0%)                                 Marked hyperglycemia (A1C 9.0%)




        Overweight                         Non-overweight              2 antihyperglycemic agents       Basal and/or
      (BMI 25 kg/m2)                      (BMI 25 kg/m2)             from different classes †         preprandial insulin
                                                                           • biguanide
                                                                           • insulin sensitizer*
    Biguanide alone or in              1 or 2† antihyperglycemic           • insulin secretagogue
    combination with 1 of:             agents from different               • insulin
                                       classes                             • alpha-glucosidase
E




     • insulin sensitizer*                                                   inhibitor
     • insulin secretagogue                • biguanide
L




     • insulin                             • insulin sensitizer*
Y




     • alpha-glucosidase                   • insulin secretagogue
       inhibitor                           • insulin
T




                                           • alpha-glucosidase
S




                                             inhibitor
E
F




         If not at target                     If not at target                 If not at target             If not at target
I
L




        Add a drug from a different class                                      Add an oral              Intensify insulin
         or                                                             antihyperglycemic agent         regimen or add
        Use insulin alone or in combination with:                            from a different
                                                                            class or insulin*            • biguanide
           • biguanide
                                                                                                         • insulin
           • insulin secretagogue
                                                                                                           secretagogue**
           • insulin sensitizer*
                                                                                                         • insulin sensitizer*
           • alpha-glucosidase inhibitor
                                                                                                         • alpha-glucosidase
                                                                                                           inhibitor
                       Timely adjustments to and/or additions of oral antihyperglycemic agents
                                                                                                        Can J Diabetes 2003;27(Suppl 2):S39
                       and/or insulin should be made to attain target A1C within 6 to 12 months
                              Clinical assessment and initiation of nutrition and physical activity




         Mild to moderate hyperglycemia (A1C <9.0%)                                 Marked hyperglycemia (A1C 9.0%)




        Overweight                         Non-overweight              2 antihyperglycemic agents         Basal and/or
      (BMI 25 kg/m2)                      (BMI 25 kg/m2)             from different classes †           preprandial insulin
                                                                           • biguanide
                                                                           • insulin sensitizer*
    Biguanide alone or in              1 or 2† antihyperglycemic           • insulin secretagogue
    combination with 1 of:             agents from different               • insulin
                                       classes                             • alpha-glucosidase
E




     • insulin sensitizer*                                                   inhibitor
     • insulin secretagogue                • biguanide
L




     • insulin                             • insulin sensitizer*
Y




     • alpha-glucosidase                   • insulin secretagogue
       inhibitor                           • insulin
T




                                           • alpha-glucosidase
S




                                             inhibitor
E
F




         If not at target                     If not at target                 If not at target               If not at target
I
L




        Add a drug from a different class                                      Add an oral
                                                                                                         Intensify insulin
         or                                                             antihyperglycemic agent
                                                                                                         regimen or add
        Use insulin alone or in combination with:                            from a different
                                                                            class or insulin*              • biguanide
           • biguanide
           • insulin secretagogue                                                                          • insulin
           • insulin sensitizer*                                                                             secretagogue**
           • alpha-glucosidase inhibitor                                                                   • insulin sensitizer*
                                                                                                           • alpha-glucosidase
                                                                                                             inhibitor
                       Timely adjustments to and/or additions of oral antihyperglycemic agents
                                                                                                      Can J Diabetes 2003;27(Suppl 2):S39
                       and/or insulin should be made to attain target A1C within 6 to 12 months
                              Clinical assessment and initiation of nutrition and physical activity




         Mild to moderate hyperglycemia (A1C <9.0%)                                 Marked hyperglycemia (A1C 9.0%)




        Overweight                         Non-overweight              2 antihyperglycemic agents       Basal and/or
      (BMI 25 kg/m2)                      (BMI 25 kg/m2)             from different classes †         preprandial insulin
                                                                           • biguanide
                                                                           • insulin sensitizer*
    Biguanide alone or in              1 or 2† antihyperglycemic           • insulin secretagogue
    combination with 1 of:             agents from different               • insulin
                                       classes                             • alpha-glucosidase
E




     • insulin sensitizer*                                                   inhibitor
     • insulin secretagogue                • biguanide
L




     • insulin                             • insulin sensitizer*
Y




     • alpha-glucosidase                   • insulin secretagogue
       inhibitor                           • insulin
T




                                           • alpha-glucosidase
S




                                             inhibitor
E
F




         If not at target                     If not at target                 If not at target             If not at target
I
L




        Add a drug from a different class                                      Add an oral              Intensify insulin
         or                                                             antihyperglycemic agent         regimen or add
        Use insulin alone or in combination with:                            from a different
                                                                            class or insulin*            • biguanide
           • biguanide
                                                                                                         • insulin
           • insulin secretagogue
                                                                                                           secretagogue**
           • insulin sensitizer*
                                                                                                         • insulin sensitizer*
           • alpha-glucosidase inhibitor
                                                                                                         • alpha-glucosidase
                                                                                                           inhibitor
                       Timely adjustments to and/or additions of oral antihyperglycemic agents         Can J Diabetes 2003;27(Suppl 2):S39
                       and/or insulin should be made to attain target A1C within 6 to 12 months
                              Clinical assessment and initiation of nutrition and physical activity




         Mild to moderate hyperglycemia (A1C <9.0%)                                 Marked hyperglycemia (A1C 9.0%)




        Overweight                         Non-overweight              2 antihyperglycemic agents       Basal and/or
      (BMI 25 kg/m2)                      (BMI 25 kg/m2)             from different classes †         preprandial insulin
                                                                           • biguanide
                                                                           • insulin sensitizer*
    Biguanide alone or in              1 or 2† antihyperglycemic           • insulin secretagogue
    combination with 1 of:             agents from different               • insulin
                                       classes                             • alpha-glucosidase
E




     • insulin sensitizer*                                                   inhibitor
     • insulin secretagogue                • biguanide
L




     • insulin                             • insulin sensitizer*
Y




     • alpha-glucosidase                   • insulin secretagogue
       inhibitor                           • insulin
T




                                           • alpha-glucosidase
S




                                             inhibitor
E
F




         If not at target                     If not at target                 If not at target             If not at target
I
L




        Add a drug from a different class                                      Add an oral              Intensify insulin
         or                                                             antihyperglycemic agent         regimen or add
        Use insulin alone or in combination with:                            from a different
                                                                            class or insulin*            • biguanide
           • biguanide
                                                                                                         • insulin
           • insulin secretagogue
                                                                                                           secretagogue**
           • insulin sensitizer*
                                                                                                         • insulin sensitizer*
           • alpha-glucosidase inhibitor
                                                                                                         • alpha-glucosidase
                                                                                                           inhibitor
                       Timely adjustments to and/or additions of oral antihyperglycemic agents
                                                                                                        Can J Diabetes 2003;27(Suppl 2):S39
                       and/or insulin should be made to attain target A1C within 6 to 12 months
                              Clinical assessment and initiation of nutrition and physical activity




         Mild to moderate hyperglycemia (A1C <9.0%)                                 Marked hyperglycemia (A1C 9.0%)




        Overweight                         Non-overweight              2 antihyperglycemic agents       Basal and/or
      (BMI 25 kg/m2)                      (BMI 25 kg/m2)             from different classes †         preprandial insulin
                                                                           • biguanide
                                                                           • insulin sensitizer*
    Biguanide alone or in              1 or 2† antihyperglycemic           • insulin secretagogue
    combination with 1 of:             agents from different               • insulin
                                       classes                             • alpha-glucosidase
E




     • insulin sensitizer*                                                   inhibitor
     • insulin secretagogue                • biguanide
L




     • insulin                             • insulin sensitizer*
Y




     • alpha-glucosidase                   • insulin secretagogue
       inhibitor                           • insulin
T




                                           • alpha-glucosidase
S




                                             inhibitor
E
F




         If not at target                     If not at target                 If not at target             If not at target
I
L




        Add a drug from a different class                                      Add an oral              Intensify insulin
         or                                                             antihyperglycemic agent         regimen or add
        Use insulin alone or in combination with:                            from a different
                                                                            class or insulin*            • biguanide
           • biguanide
                                                                                                         • insulin
           • insulin secretagogue
                                                                                                           secretagogue**
           • insulin sensitizer*
                                                                                                         • insulin sensitizer*
           • alpha-glucosidase inhibitor
                                                                                                         • alpha-glucosidase
                                                                                                           inhibitor
                       Timely adjustments to and/or additions of oral antihyperglycemic agents
                                                                                                       Can J Diabetes 2003;27(Suppl 2):S39
                       and/or insulin should be made to attain target A1C within 6 to 12 months
Starting insulin therapy
 May be preferred to the addition of a third
 oral agent:
    More potent
    Efficacy not dependent on beta cell function
    Uniquely effective for severe hyperglycemia
    Fewer patients fail to respond
    Prompt glucose lowering effect
Barriers to Starting
 Insulin Therapy
   Patient Hesitancy to Use
Concern regarding hypoglycemia
Perceived complexity of regimen
Unwillingness to perform the required
blood glucose monitoring
Concerns regarding costs of therapy and
monitoring
Aversion to needles and injections
                   Physician Barriers
Resistance due to many factors:
    Time constraints
    Perceived patient incompetence
    Desire to avoid unpleasant confrontation
    Concerns about outcomes




Polonsky WH, Jackson RA. Clinical Diabetes 2004;22:147–50.
Physician Influence on Patients’
             Beliefs

 Inadvertent influence:
     Referring to “oral-agent failure”
     Explicitly threatening patients with insulin: “If
      you can’t make some positive changes, you’ll
      end up on insulin.”
     Reluctance to initiate sends “insulin as a last-
      ditch therapy” message
                                                              Clinical Diabetes 2004;22:147–50
 Polonsky WH, Jackson RA. Clinical Diabetes 2004;22:147–50.
           Insulin and Oral
      Antihyperglycemic Agents
Combining insulin and the following oral
agents is effective in Type 2 diabetes:
   Alpha-glucosidase inhibitors (acarbose)
   Biguanide (metformin)
   Insulin secretagogues (sulfonylureas)
Caution: glitazone + insulin
   Increased risk of heart failure, fluid retention,
    edema
   TZDs are not indicated in combination with
    insulin in Canada.
                                    Can J Diabetes 2003;27(Suppl 2):S40
           Initiating insulin
Option 1: Bedtime insulin + daytime oral
hypoglycemics
   If on SU + other oral agent, may consider
    D/C or reducing SU
   Add intermediate (NPH) insulin at bedtime
      Dose: 0.1-0.2 units/kg (usually 5-15 units)
      ↑ dose by 1-2 units every 3-4 days until FBG
      of 4-7
      If target BG not achieved at 30 units/day, or if
      daytime BG rises, may switch to split-mixed or
      more intense regimen
                                      www.RxFiles.ca
                                      Tipps Clinical Update;1(1) Apr 2005
  A Simple Regimen for Initiating
         Insulin Glargine
          Start with 10 IU per day basal insulin dose and adjust weekly

    Self-monitored FPG for 2 consecutive                                   Increase in insulin dose
    days with no episodes of severe                                                (IU/day)
    hypoglycaemia or PG 4 mmol/L
                  >10.0 mmol/L                                                        8
              7.8-10.0 mmol/L                                                         6
                6.7-7.8 mmol/L                                                        4
                5.5-6.7 mmol/L                                                        2

                                Treat-to-target FPG <5.6 mmol/L


FPG, fasting plasma glucose; PG, plasma glucose.

Adapted from Riddle MC et al. Diabetes Care. 2003; 26 (11), pp.3080-3086
Sample Prescription #1
      Bedtime Insulin Regimen
Start NPH @ 0.1-0.2 units/kg QHS

Rx:
Novolin or Humulin NPH Penfill
100 u/ml cartridge
Disp: 1 box (3ml x 5 cartridges)
Instructions: Use as directed

Pen Device:
      Novolin= Novolin Pen
      Humulin= HumaPen Ergo
Pen Needles: 1 box (100 needles)

                                   Tipps Clinical Update; 1(1) Apr 2005
               Monitoring
Check BG at least BID until dose stabilized
Weekly monitoring of BG at mid-sleep to assess
asymp. nocturnal hypoglycemia
Adjust dose only every 3 days (or less often)
after you see pattern developing
Correct for hypoglycemia first, highest blood
sugars next
Adjust dose on FBG (pre-breakfast) levels
Increase by 1-2 units every 3-7 days until target
achieved
                                 Tipps Clinical Update;1(1) Apr 2005
       Initiating insulin cont’d
Option 2: Switch to insulin therapy 1-
4X/day
   May D/C certain oral agents
E.g. Split-mixed insulin regimen
   Estimate total starting daily dose (0.3-0.6
    units/kg)
   Divide daily dose: 2/3 before breakfast; 1/3
    before supper
   Divide each dose: 2/3 intermediate-acting &
    1/3 short-acting (or 30/70 mix)
                                      www.rxfiles.ca
Sample Prescription #2
    Twice daily insulin regimen
Start insulin 30/70 @ 0.5 units/kg
   Give ~2/3 30 min before breakfast
   Give ~1/3 30 min before dinner

Rx:
Novolin or Humulin 30/70 Penfill
100u/ml cartridge
Disp: 1 box (3ml x 5 cartridges)
Instructions: Use as directed

Pen Device: as for HS regimen
Pen Needles: as for HS regimen
                                        Tipps Clinical Update;1(1) Apr 2005
                Monitoring
Check BG at least bid until dose stabilized
(pre-bkf & pre-dinner)
Adjust dose every 3 days (or less often)
after you see pattern developing
Adjust only 1 dose at a time, correcting
hypoglycemia first, then highest BG next
Adjust dose: ↑ by 1-2 units q 3-7 days until
target achieved
   FBG (pre-bkf) reflects pre dinner dose
   Pre-dinner glucose reflects the am dose
                                   Tipps Clinical Update;1(1) Apr 2005
Sample Prescription #3
             Intensive Regimen
 Start insulin at 0.5 units/kg
     Give 40% of total dose as basal insulin NPH at
      bedtime
     Give 20% of total dose 3 x/day as mealtime insulin
      15-30 min before meals (60% of total dose)
Rx:
  Novolin TO or Humulin R Penfill
               AND
  Novolin or Humulin NPH Penfill
  100u/ml cartridge
  Disp: 1 box each (3ml x 5 cartridges)
  Instructions: Use as directed           Tipps Clinical Update;1(1) Apr 2005
                      Monitoring
Check BG at least qid until dose stabilized
(before meals and hs)
Weekly monitoring of BG at mid-sleep to
assess asymptomatic nocturnal hypoglycemia
Adjust dose every 3 days (or less often) after
you see a pattern developing
Adjust only one dose at a time, correcting
hypoglycemia first, highest BG next
Adjust dose: ↑by 1-2 units every 3-7 days
until target achieved
   FBG (pre-bkf) reflects hs dose
   Pre-meal glucose reflects dose at previous meal.
    E.g. if pre-lunch reading high, increase dose at
    breakfast                            Tipps Clinical Update;1(1) Apr 2005
      Strategies for Insulin adjustments
Hypoglycemia       Hypoglycemia         Hypoglycemia         Hypoglycemia
During Night       after Breakfast      After Lunch          After Supper




↓ Evening N        ↓ R insulin in the   ↓ N insulin in the   ↓ R insulin before
insulin            AM                   AM                   supper



Hyperglycemia      Hyperglycemia        Hyperglycemia        Hyperglycemia At
before Breakfast   Before Lunch         Before Supper        Bedtime




↑ N insulin        ↑ R before           ↑ N before           ↑ R before
before supper      breakfast            breakfast            supper
    What if there is no pattern?
   Start by adjusting basal dose
   or assess other factors (diet, lifestyle,
    exercise)
         Rules for Adjusting Insulin
Example of basal-bolus regimen:
Dosage     Regular   Regular   Regular   NPH
           4U        6U        6U        22U
                                                   Comments
Date       7:00am    12:00pm   6:00pm    10:00pm
Friday       4.9       10.1      15.7      7.3     Extra snack
                                                   @ 2pm         This single high
Saturday     4.4       15.3       8        6.1                   dose does not form
                                                                 a pattern and can
Sunday        5         13       6.1       5.9                   be explained by the
                                                                 comments
Monday        6         11       5.6       6.6



            These values form pattern over 4 days. Increase 7am
            regular insulin by 1-2 units.
    Rules for Adjusting Insulin
What if patient has high fasting AM
sugars?
   Somogyi (rebound) Effect
           OR
   Dawn Phenomenon
Somogyi Effect
 When low BG leads to high BG
 Counter regulatory hormones respond to
 low BG
 Example: patient has high FBG (12
 mmol/L) in morning, but low BG level at
 3am (3 mmol/L)
 Management: ↓ insulin or increase
 evening snack
Dawn Phenomenon
 Natural slow rise of BG in morning due to
 cortisol and growth hormone
 Example: Patient has high FBG (12
 mmol/L) in morning and high BG at 3am
 (9 mmol/L)
 Management: increase insulin or
 decrease evening snack
         Rules for Switching Insulins
E.g.
  10 units regular Transfer to 10 units insulin aspart
  10 units NPH Transfer to 10 units insulin detemir
      *If moving from NPH bid, adjustment of dose may be
       required
  10 units NPH once daily          Transfer to10 units insulin
                                              glargine
  10 units NPH bid       Transfer to   reduce total daily dose
                                       of insulin glargine by 20%
Patient information on Insulin
http://www.diabetes.ca/files/insulin.pdf
   5-step process to injecting insulin
   How to manage high and low blood sugars
   Blood glucose monitoring
   Exercise

Canadian Diabetes Association
   Tel 905-528-3111
   Free literature, films and presentations
   Nutritional information and cookbooks for sale
   Blood glucose meter training and insulin pen training
   Support group meets monthly
    Community Diabetes Education
             Program
    Centretown Community Health Centre
        Group and individual sessions
        Multiple sites across Ottawa
        Nurse and dietician diabetes educators
        No charge to patient
NEW!!   Will initiate insulin (see referral form)
           Insulin order including titration must be indicated
           on referral form
           All necessary start up equipment provided
           including sample insulin cartridge
Community Diabetes Education
         Program
Who can register?
   Adults with type 2 diabetes or prediabetes
   Patients being initiated on insulin
   Patients may self refer
   Need recent blood glucose lab results
   Tel: 613-233-6655
   Fax referral to: 613-233-6713
     Hospital Based Programs
Who should be referred?
   Patients requiring more intensive management and
    care of endocrinologist
   Patients with complications associated with diabetes
   Patients who are pregnant


Locations
   Ottawa Hospital, Riverside Campus (613-738-8333)
   Montfort Hospital (613-746-4621)
   Queensway Carleton Hospital (613-721-2000)
What services are provided?
For Type 2 Diabetes:
   Three, 2&1/2 hour group education sessions
   Learning the basics, self management
For Prediabetes:
   Three hour session focuses on healthy
    lifestyle, risk factors
Starting Insulin:
   Education on initiation on insulin, self
    management skills
Insulin Pen Demo
    Practical Information for Your
                Patients
Appearance
   Short and rapid acting- clear, colourless
   Long acting and premixed- cloudy, milky
      Exception: glargine & detemir is clear
Storage
   Unopened in fridge- store until expiry date
   Opened vials, penfills- 28 days at room
    temperature
   Avoid freezing or heat
  Practical Information for Your
              Patients
Where to inject
 Tips for Insulin Administration
Pricking finger for BG monitoring hurts more
than injecting insulin
Many can’t feel insulin injections at all
Rotate sites to avoid lipohypertrophies
Roll insulin to mix. Do Not Shake!
               Hypoglycemia
        Symptoms of hypoglycemia
Neurogenic (autonomic)   Neuroglycopenia

Trembling                Difficulty concentrating
Palpitations             Confusion
Sweating                 Weakness
Anxiety                  Drowsiness
Hunger                   Vision changes
Nausea                   Difficulty speaking
Tingling                 Headache
                         Dizziness
                         tiredness
Drugs associated with Hypoglycemia

ACE inhibitors
Alcohol
Antimalarials
Beta-blockers (non-cardioselective)
Disopyramide
Fluoroquinolones (e.g. gatifloxacin)
Quinidine
Salicylates (high doses only)
    Treatment of hypoglycemia
Mild to moderate (2.8-4 mmol/L)

                    Treatment
 15g carbo (glucose or sucrose tabs or sol’n preferable
to OJ or glucose gels)
 Retest after 15 min

 Retreat if <4.0 mmol/L
15 gm Carbohydrate Food Sources

                     4 X Dex4 Tablets                     1 TBSP Honey




¾ cup of juice or                       6 Lifesavers
regular soft drink                      1= 2.5 gm carbo
       Treatment of hypoglycemia
Severe in conscious adult (<2.8 mmol/L)

                        Treatment

    20g carbo (glucose tabs or equiv. preferable)
    Wait 15 min, retest and retreat if < 4.0 mmol/L
    Treatment of hypoglycemia
Severe in unconscious (< 2.8 mmol/L)
                  Treatment
>=5 y/o
     1 mg glucagon SC or IM ***Covered by ODB***
<5 y/o

     0.5 mg glucagon
Prevent repeated hypoglycemia


Have usual meal or snack that is due at
that time of day
If meal > 1hr, a snack (including 15g carbo
and a protein source)
       Case Study- David
66 y/o male
PMH: Dyslipidemia, diabetes, gout
Rx: idomethacin 100 mg, atorvastatin 40
mg, glyburide 10 mg bid, metformin 1000
mg bid, ASA 81 mg
FBG: 12.4, HgA1C: 9.3%
New Rx: 10U NPH QHS
When should David test BG?
In morning before breakfast
   To monitor NPH bedtime insulin effect
2 hours after meals
   To monitor oral medication effect
   Test after each meal at least once per week
    (alternating times)
            3 months later…
FBG: 8-11, HgA1C: 8.4%
Current weight: 106 kg

What do you decide to do?
   Split Mix insulin
   Total insulin dose:
   Dose split:
   Mixture:
   Start with separate injections
David’s Log Book 5 days later…
         6 months later…
 Morning FBG: 9-14

What do you recommend?
Questions?