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					     First step into insulin
             therapy
(How to start insulin in a patient not controlled on OADs)

               By
     Dr.Muhammad Tahir Chaudhry
         B.Sc.M.B;B.S(Pb).C.diabetology(USA)
The breakthrough: Toronto 1921 – Banting & Best
Normal physiologic patterns of
glucose and insulin secretion in
           our body
How Is Insulin Normally Secreted?
The rapid early rise of insulin secretion in
response to a meal is critical,
because
 it ensures the prompt inhibition of endogenous
glucose production by the liver
disposal of the mealtime carbohydrate load, thus
limiting postprandial glucose excursions.
                 Basal insulins
NPH
• Humulin N (Eli Lilly)
• Insulatard (Novo)
  (also available as insulatard Novolet pen)
• Dongsulin N (Highnoon)
• Insuget N (Getz)
===========================================
Analogs
Glargine (Lantus)
Lantus Solostar Pen (Sanofi Aventis)
Detemir (Levimir) by Novo
                             Basal Insulins
 Insulin                Type              Onset of              Peak of Duration
                                           action               action of action
   NPH              Intermediate           1-2 hours            5-7 hours               13-18
                       acting
                                                                                        hours
Glargine                Long               1-2 hours           Relatively             Upto 24
  (Lantus)              acting                                    flat                 hours
   Aventis
 Detemir                Long               2-4 hours 8-12 hours                         16-20
(Levimir)Novo           acting                                                          hours
The time course of action of any insulin may vary in different individuals, or at different times in
the same individual. Because of this variation, time periods indicated here should be considered
general guidelines only.
                   Bolous insulins
                (Mealtime or prandial)
Human Regular
• Humulin R (Eli Lilly)
• Actrapid (Novo)
(Also available as Actrapid novolet pen)
• Dongsulin R (Highnoon)
• Insuget R (Getz)
==========================================
Analogs
•   Lispro (Humolog) by Eli Lilly
•   Novorapid by Novo
•   Aspart
•   Glulisine (Apidra) by Sanofi Aventis
                    Bolous insulins
                 (Mealtime or prandial)
    Insulin           Type         Onset of         Peak of       Duration of
                                    action          action          action
     Human         Short acting 30-60 minutes       2-4 hours       8-10 hours
     regular

     Insulin     Rapid acting     5-15 minutes      1-2 hours       4-5 hours
     analogs
 (Lispro,Aspart,
   Glulisine)


The time course of action of any insulin may vary in different individuals, or at
different times in the same individual. Because of this variation, time periods
indicated here should be considered general guidelines only.
                         Pre mixed
70/30 (70% N,30% R)
• Humulin 70/30 (Eli Lilly)
• Mixtard 30 (Novo)
  (Also available as Mixtard 30 Novolet Pen)
• Dongsulin 70/30 (Highnoon)
• Insuget 70/30 (Getz)
===================================
Analogs
• Novomix 30 (Novo)
• Humolog Mix 25(Lilly)
• Humolog Mix 50(Lilly)
          Types of Insulin
1. Rapid-acting (Analogs)
2. Short-acting (Regular)
3. Intermediate-acting     (NPH)
4. Premixed      (70/30)
5. Long-acting
                            (Lantus)
6. Extended long-acting
  Indications for Insulin Use in Type 2 Diabetes
Pregnancy (preferably prior to pregnancy)
Acute illness requiring hospitalization

Perioperative/intensive care unit setting

Postmyocardial infarction

High-dose glucocorticoid therapy

Inability to tolerate or contraindication to oral antiglycemic agents

Newly diagnosed type 2 diabetes with significantly elevated blood
glucose levels (pts with severe symptoms or DKA)

Patient no longer achieving therapeutic goals on combination
antiglycemic therapy
           Proposed Algorithm of therapy for Type 2
                           Diabetes

     Inadequate
 Non pharmacological
       therapy

•Severe symptoms
•Severe                               2 oral          3 oral
hyperglycaemia     1oral agent        agents          agents
•Ketosis
•pregnancy



               Add Insulin Earlier in the Algorithm
 First step into
Insulin therapy
   What we have in our
        pockets?


• Basal Insulins (NPH,Lantus)
• Bolus Insulins(Human Regular)
• Premixed (Human 70/30)
   The ADA
Recommendations
  on the Use of
     Insulin
in Type 2 Diabetes
       Touch Pad Question
Currently, roughly ____ of my patients with type
2 diabetes are taking some form of insulin.

               1. >80%
               2. 60-80%
               3. 40-60%
               4. 20-40%
               5. 0-20%
        Touch Pad Question
When it comes to first-line insulin, I tend to
prescribe:
1. An intermediate-acting insulin with
   fast-acting insulin as needed
2. A long-acting or extended long-acting
   insulin with fast-acting insulin as needed
3.A premixed insulin
 Advantages of Insulin Therapy
• Oldest of the currently available
  medications, has the most clinical
  experience
• Most effective of the diabetes medications
  in lowering glycemia
  – Can decrease any level of elevated HbA1c
  – No maximum dose of insulin beyond which a
    therapeutic effect will not occur
• Beneficial effects on triglyceride and
  HDL cholesterol levels
                              Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
Disadvantages of Insulin Therapy
• Weight gain ~ 2-4 kg
   – May adversely affect cardiovascular health


• Hypoglycemia
   – However, rates of severe hypoglycemia in
     patients with type 2 diabetes are low…
       Type 1 DM: 61 events per 100 patient-years
       Type 2 DM: 1-3 events per 100 patient-years


                                   Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
Balancing Good Glycemic Control with
    a Low Risk of Hypoglycemia…
                      Glycemic
                       control




   Hypoglycemia
                          Rates of Hypoglycemia for Premixed
                            vs. Long-Acting Insulin + OAD
                              Mean number of confirmed hypoglycemic events
                                    per patient-year in a 28-week study
                          6              p=0.0009
Events per patient-year




                               5.73
                          5                                 Premixed insulin

                          4                                 Insulin glargine + OADs

                          3
                                      2.62
                          2
                                                      p=0.0449                      p=0.0702
                          1
                                                    1.04                           0.05     0.00
                                                           0.51
                          0
                               Symptomatic          Nocturnal                       Severe




                                                                  Adapted from Janka et al. Diabetes Care 2005;28:254-9.
       Rates of Hypoglycemia for Premixed
vs. Long-Acting Insulin + OAD in Elderly Patients
                                   12
  Rate of event per patient-year



                                                                                Premixed (n=63)
                                                    p=0.01                      Glargine + OAD (n=69)
                                   10

                                    8                                    p=0.008

                                    6
                                                                                                     p=0.06
                                    4

                                    2

                                    0
                                        All episodes of      All confirmed            Confirmed
                                        hypoglycemia          episodes of            symptomatic
                                                             hypoglycemia            hypoglycemia




                                                                  Adapted from Janka HU et al. J Am Geriatr Soc 2007;55(2):182-8.
   The ADA Treatment
Algorithm for the Initiation
and Adjustment of Insulin
        Initiating and Adjusting Insulin
        Hypoglycemia                    Bedtime intermediate-acting insulin, or
 or FG >3.89 mmol/l (70 mg/dl):         bedtime or morning long-acting insulin
  Reduce bedtime dose by ≥4 units            (initiate with 10 units or 0.2 units per kg)                        Target range:
     (or 10% if dose >60 units)        Check FG and increase dose until in target range.                       3.89-7.22 mmol/L
                                                                                                                (70-130 mg/dL)


                                    If HbA1c ≤7%...                         If HbA1c 7%...


    Continue regimen; check                     If fasting BG in target range, check BG before lunch, dinner, and bed.
     HbA1c every 3 months                                   Depending on BG results, add second injection
                                                (can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)




Pre-lunch BG out of range: add      Pre-dinner BG out of range: add NPH insulin at                  Pre-bed BG out of range: add
rapid-acting insulin at breakfast      breakfast or rapid-acting insulin at lunch                   rapid-acting insulin at dinner




                                        If HbA1c ≤7%...               If HbA1c 7%...


     Continue regimen; check              Recheck pre-meal BG levels and if out of range, may need to add another
      HbA1c every 3 months             injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
                                                          and adjust preprandial rapid-acting insulin

                                                                                Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.
                                        Step One…
         Hypoglycemia
                                        Bedtime intermediate-acting insulin, or
 or FG >3.89 mmol/l (70 mg/dl):         bedtime or morning long-acting insulin
  Reduce bedtime dose by ≥4 units            (initiate with 10 units or 0.2 units per kg)                        Target range:
     (or 10% if dose >60 units)
                                       Check FG and increase dose until in target range.                       3.89-7.22 mmol/L
                                                                                                                (70-130 mg/dL)


                                    If HbA1c ≤7%...                         If HbA1c 7%...


    Continue regimen; check                     If fasting BG in target range, check BG before lunch, dinner, and bed.
     HbA1c every 3 months                                   Depending on BG results, add second injection
                                                (can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)




Pre-lunch BG out of range: add      Pre-dinner BG out of range: add NPH insulin at                  Pre-bed BG out of range: add
rapid-acting insulin at breakfast      breakfast or rapid-acting insulin at lunch                   rapid-acting insulin at dinner




                                        If HbA1c ≤7%...               If HbA1c 7%...


     Continue regimen; check              Recheck pre-meal BG levels and if out of range, may need to add another
      HbA1c every 3 months             injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
                                                          and adjust preprandial rapid-acting insulin

                                                                                Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.
  Step One: Initiating Insulin
• Start with either…
  – Bedtime intermediate-acting insulin or
  – Bedtime or morning long-acting insulin


  Insulin regimens should be designed taking
    lifestyle and meal schedules into account




                               Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
Step One: Initiating Insulin, cont’d
• Check fasting glucose and increase dose until
  in target range
  – Target range: 3.89-7.22 mmol/l (70-130 mg/dl)
  – Typical dose increase is 2 units every 3 days, but if
    fasting glucose >10 mmol/l (>180 mg/dl), can
    increase by large increments (e.g., 4 units every 3
    days)




                                Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
 Step One: Initiating Insulin, cont’d
 • If hypoglycemia occurs or if fasting glucose
   < 3.89 mmol/l (70 mg/dl)…
     – Reduce bedtime dose by ≥4 units or 10%
       if dose >60 units
                                 Nathan DM et al. Diabetes Care 2006;29(8):1963-72.




     Reduction in overnight and fasting glucose levels achieved
     by adding basal insulin may be sufficient to reduce
     postprandial elevations in glucose during the day and
     facilitate the achievement of target A1C concentrations.



While using basal insulin alone,never stop or reduce ongoing oral
therapy
         After 2-3 Months…
• If HbA1c is <7%...
  – Continue regimen and check HbA1c every 3
    months



• If HbA1c is ≥7%...
  – Move to Step Two…


                            Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
With the addition of basal insulin and titration
to target FBG levels, only about 60% of
patients with type 2 diabetes are able to achieve
A1C goals < 7%.[36] In the remaining patients
with A1C levels above goal regardless of
adequate fasting glucose levels, postprandial
blood glucose levels are likely elevated.
                                        Step Two…
        Hypoglycemia                    Bedtime intermediate-acting insulin, or
 or FG >3.89 mmol/l (70 mg/dl):         bedtime or morning long-acting insulin
  Reduce bedtime dose by ≥4 units            (initiate with 10 units or 0.2 units per kg)                        Target range:
     (or 10% if dose >60 units)        Check FG and increase dose until in target range.                       3.89-7.22 mmol/L
                                                                                                                (70-130 mg/dL)


                                    If HbA1c ≤7%...                         If HbA1c 7%...


    Continue regimen; check                     If fasting BG in target range, check BG before lunch, dinner, and bed.
     HbA1c every 3 months                                   Depending on BG results, add second injection
                                                (can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)




Pre-lunch BG out of range: add      Pre-dinner BG out of range: add NPH insulin at                  Pre-bed BG out of range: add
rapid-acting insulin at breakfast      breakfast or rapid-acting insulin at lunch                   rapid-acting insulin at dinner




                                        If HbA1c ≤7%...               If HbA1c 7%...


     Continue regimen; check              Recheck pre-meal BG levels and if out of range, may need to add another
      HbA1c every 3 months             injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
                                                          and adjust preprandial rapid-acting insulin

                                                                                Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.
    Step Two: Intensifying Insulin
If fasting blood glucose levels are in target range but
HbA1c ≥7%, check blood glucose before lunch, dinner,
and bed and add a second injection:
 • If pre-lunch blood glucose is out of range,
 add rapid-acting insulin at breakfast
 • If pre-dinner blood glucose is out of range,
 add NPH insulin at breakfast or rapid-acting insulin at
   lunch
 • If pre-bed blood glucose is out of range,
 add rapid-acting insulin at dinner
                                  Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
       Making Adjustments

• Can usually begin with ~4 units and
  adjust by 2 units every 3 days until blood
  glucose is in range


 When number of insulin Injections increase from
 1-2………..Stop or taper of insulin secretagogues
 (sulfonylureas).

                             Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
         After 2-3 Months…
• If HbA1c is <7%...
  – Continue regimen and check HbA1c every
    3 months


• If HbA1c is ≥7%...
  – Move to Step Three…



                             Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
                                      Step Three…
        Hypoglycemia                    Bedtime intermediate-acting insulin, or
 or FG >3.89 mmol/l (70 mg/dl):         bedtime or morning long-acting insulin
  Reduce bedtime dose by ≥4 units            (initiate with 10 units or 0.2 units per kg)                        Target range:
     (or 10% if dose >60 units)        Check FG and increase dose until in target range.                       3.89-7.22 mmol/L
                                                                                                                (70-130 mg/dL)


                                    If HbA1c ≤7%...                         If HbA1c 7%...


    Continue regimen; check                     If fasting BG in target range, check BG before lunch, dinner, and bed.
     HbA1c every 3 months                                   Depending on BG results, add second injection
                                                (can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)




Pre-lunch BG out of range: add      Pre-dinner BG out of range: add NPH insulin at                  Pre-bed BG out of range: add
rapid-acting insulin at breakfast      breakfast or rapid-acting insulin at lunch                   rapid-acting insulin at dinner




                                        If HbA1c ≤7%...               If HbA1c 7%...


     Continue regimen; check              Recheck pre-meal BG levels and if out of range, may need to add another
      HbA1c every 3 months             injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
                                                          and adjust preprandial rapid-acting insulin

                                                                                Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.
          Step Three:
   Further Intensifying Insulin
• Recheck pre-meal blood glucose and if out of
  range, may need to add a third injection


• If HbA1c is still ≥ 7%
  – Check 2-hr postprandial levels
  – Adjust preprandial rapid-acting insulin


                               Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
              Premixed Insulin
• Not recommended during dose adjustment

• Can be used before breakfast and/or dinner if the
  proportion of rapid- and intermediate-acting
  insulin is similar to the fixed proportions
  available



                              Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
 Key Take-Home Messages
• Insulin is the oldest, most studied, and most effective
  antihyperglycemic agent, but can cause weight gain
  (2-4 kg) and hypoglycemia

• Insulin analogues with longer, non-peaking profiles
  may decrease the risk of hypoglycemia compared
  with NPH insulin

• Premixed insulin is not recommended during dose
  adjustment
  Key Take-Home Messages, cont’d
• When initiating insulin, start with bedtime intermediate-
  acting insulin, or bedtime or morning long-acting insulin

• After 2-3 months, if FBG levels are in target range but HbA1c
  ≥7%, check BG before lunch, dinner, and bed,and, depending
  on the results, add 2nd injection (stop sulfonylureas here)

• After 2-3 months, if pre-meal BG out of range, may
  need to add a 3rd injection; if HbA1c is still ≥7% check
  2-hr postprandial levels and adjust preprandial
  rapid-acting insulin.
Regimen # 2
  First calculate total
  daily dose of insulin

    Body weight in kgs / 2

• e.g; an 80 kg person will require roughly about
40 units / day.
 Dose calculation……..contd
Split the total calculated dose into 4 (four) equal s/c
  injections.
   – ¼ of total dose as regular insulin s/c half-hour
      ( ½ hr ) before the three main meals with 6 hrs
      gap in between.
   – ¼ total calculated dose as NPH insulin s/c at
      11:00 p.m. with no food to follow.
     Dose calculation: example

For example in an 80-kg diabetic requiring 40 units per day,
  start with:

• 08:00 a.m. --- 10 units regular insulin s/c ½ hr before
  breakfast.

• 02:00 p.m. --- 10 units regular insulin s/c ½ hr before lunch.

• 08:00 p.m. --- 10 units regular insulin s/c ½ hr before dinner.

• 11:00 p.m. --- 10 units NPH/ lantus insulin s/c
        Dose adjustment

• For adjustment of dosage, check fasting
  blood sugar the next day and adjust the
  dose of night time NPH Insulin
  accordingly i.e. keep on increasing the
  dose of NPH by approximately 2 units
  daily until you achieve a normal fasting
  blood glucose level of 80-110 mg/dl.
Control BSF by adjusting
the prior the dose of NPH
Dose adjustment…contd.
• Once the fasting blood glucose has been
  controlled, check 6-Point blood sugar as
  follows:

  – Fasting.
  – 2 hours after breakfast.
  – Before lunch (and noon insulin)
  – 2 hours after lunch.
  – Before dinner (AND EVENING INSULIN)
  – 2 hours after dinner
Control random sugar level by
 adjusting the prior dose of
        regular insulin
Dose adjustment…contd.

• Now control any raised random reading by
  adjusting the dose of previously
  administered regular insulin.
• For example: a high post lunch reading will
  NOT be controlled by increasing the dose
  of next insulin (as in sliding scale), rather
  adjustment of the pre-lunch regular
  insulin on the next day will bring down
  raised reading to the required levels.
                        Examples
                                      •   We need to increase the dose
                                          of NPH at night to bring
• For the following profile:              down baseline sugar level
                                          (BSF) to around 100 mg/dl
    – Blood sugar fasting = 180           after which the profile should
      mg/dl                               automatically adjust as
    – Blood sugar after breakfast =       follows:
      250 mg/dl.                           – Blood sugar fasting = 100
    – Blood sugar pre lunch = 190            mg/dl
      mg/dl
                                           – Blood sugar 02 hrs after
    – Blood sugar post lunch 270 =           breakfast = 170 mg/dl
      mg/dl
    – Blood sugar pre dinner = 200         – Blood sugar pre-lunch =
      mg/dl                                  110 mg/dl
    – Blood sugar post dinner 260 =        – Blood sugar 2 hrs. after
      mg/dl                                  lunch = 190 mg/dl
                                           – Blood sugar pre-dinner =
                                             120 mg/dl
                                           – Blood sugar 2 hrs. post
                                             dinner = 180 mg/dl
         Examples……contd.
•   Blood sugar fasting = 130 mg/dl
•   Blood sugar after breakfast = 160 mg/dl
•   Blood sugar pre-lunch = 130 mg/dl
•   Blood sugar post lunch = 240 mg/dl
•   Blood sugar pre-dinner = 180 mg/dl
•   Blood sugar 2 hrs. post dinner = 200 mg/dl

• This patient needs adjustment of pre-lunch regular
  Insulin which will bring down post lunch and pre dinner
  readings within normal limits.

• 2 hrs post dinner blood sugar(200 mg/dl) will be
  brought down by adjusting pre dinner regular insulin.
        Combinations

• In types 2 subjects, once the blood
  sugar profile is normalized and the
  patient is not under any stress, the
  total daily dose (morning + noon +
  night + NPH at 11 p.m) may be
  divided into two 12 hourly injections
  of premixed Insulin
       Examples….contd.
• e.g-1; If a patient is   • e.g-2; If the
  stabilized on              adjusted Insulin is
• 10U R + 12U R +          • 14U R+16U R+12U
  10U R + 12U NPH;           R+8U NPH,
• then he may be           • then split the total
  shifted to                 dose:
• 44/2 = 22 units of         30 U 70/30 before
  70/30 Insulin 12           breakfast and 20U
  hourly s/c ½ hr before     70/30 before dinner
  meal.                      to compensate for the
                             high morning and lunch
                             Insulin.
     Combinations………contd.
•     Problem: Remember that BD dosing usually fails to
      cover lunch, especially if it is heavy. So:
•     Always check for post lunch hyperglycemia when using
      this regimen.
•     Solution:
1.    Patients can be advised to take their lunch (heavier
      meal) at breakfast; and breakfast (lighter meal) at
      lunch.
2.    Adding Glucobay with lunch some times provides a
      reasonable control.
3.    An alternate combination to overcome the problem is
      regular insulin for morning and noon, with premixed
      insulin at night.
            Example
• 10U R before breakfast + 12U R
  before lunch + 22U 70/30 before
  dinner.

• Insulin will be injected exactly 6 hrs
  apart as in the QID regimen.
     Choice of regimens

1.   R+ R+ R+ L****
2.   R+ R+ R+ N ***
3.   R+ R+ premixed insulin**
4.   BD premixed insulins*
Regimen # 3

 (Pre mixed)
How to start pre mixed (70/30)
           Insulin
     For pre mixed insulins(70/30 preparations)
Step1:First calculate the total daily starting requirement
of insulin;
                     body weight(kg)/2
eg, For a 60kg patient,total daily dose =30 units
Step 2:Then devide this dose into 3 equal parts;
                         10+10+10
Step 3:Give 2 parts in the morning and 1 part in the
evening;
       Morning=20U                    Evening=10 U
Dose titration of Pre-mixed(70/30)
           preparations
You can increase or decrease the dose of
pre-mixed insulin by 10 % i.e
If the patients is using,
1-10 units…………….+/- 1 unit
11-20 units……………+/- 2 units
21-30 units……………+/- 3 units
31-40 units……………+/- 4 units…………………..
Advantages and disadvantages
   of pre- mixed insulins
Advantages:
   Easy to administer for the
   physician.

   Easy to fill and inject by the
   patient.

   Provides both basal and bolus
   coverage with fewer number of
   injections.
Disadvantage:

No dose flexability

If u increase/decrease the dose of one
component ,the dose of other
component is also changed un desirably
How to solve the problem of
    dosage flexibility
Regimen # 4
Disadvantage of split- mixed regimen




       Mid-night hypoglycemia
How to solve the problem of
 nocturnal hypoglycemia
    Somogyi phenomenon
• Due to
   – excess dose of night time insulin, or
   – Night insulin taken early
• Peaks at 3:00 a.m: hypoglycemia
• Counter regulatory hormones released in excess:
• Resulting in over correction of hypoglycemia:
• Fasting hyperglycemia
• Solution:
   – Check BSL AT 3 :00 a.m
   – Give long acting at 11:00 p.m so peak comes
     later
   – Reduce dose of night time insulin
   Dawn phenomenon
• Growth hormone surge at dawn raises insulin
  requirement.
• Night time insulin taken early, fades out before
  dawn.
• Fasting hyperglycemia

   Solution
• Give long acting insulin not before 11 :00 p.m
• May need to increase dose of night time insulin
More physiologic regimens
       Remember
• Insulin
  – No miracle drug
  – Has definite indications
  As delivery route follows reverse
    physiology:
  – Good control is achieved only if residual
    pancreatic function is preserved to a
    certain extent i-e:
  – Starting insulin on time is vital
            (Concept of early insulinization)
           Pearls for practice

 Never try to control diabetes with oral hypoglycemic drugs /
    insulin without first ensuring strict diet control.
   Always bring fasting sugar to normal before trying to control
    post prandial / random blood sugar.
   Control any underlying infection/stressful condition
    vigorously.
   Keep meal timings regular with 6 hrs between the three
    meals.
   Do not inject NPH before 11 p.m.
   Keep number of calories during the meals same from day to
    day. The quantity and quality of diet should be same at same
    timings.
   Do not use sliding scale to calculate the dose of insulin.
   Use proper technique to inject s/c insulin.
   Ensure proper storage of insulin.
Common Problems
 Problems can be avoided
• Adherence to time table is all that is
  required to avoid problems:
  – Regular meals
  – Regular injections
  – Regular excercise
   Choosing an Insulin with a
  Lower Risk of Hypoglycemia
• Insulin analogues with longer, non-peaking
  profiles may decrease the risk of
  hypoglycemia…




                           Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
Injection Techniques
    Sites of injection
• Arms 
• Legs 
• Buttocks 

• Abdomen 
Sites of injection…….contd.
• Preferred site of injection is the
  abdominal wall due to
• Easy access
  – Ample subcutaneous tissue
    • Absorption is not affected by exercise.
Injection technique
           Technique
•   Tight skin fold
•   Spirit…. X
•   Appropriate needle size
•   90 degree angle
•   Change site to avoid lipodystrophy
         Injection
    technique…….contd.



INSTRUCTIONS:
  Keep the needle perpendicular to skin in order to
  avoid variability in absorption (fig-A)
  Insert needle upto the hilt (fig-A)
  Distribute daily injections over a wide area to avoid
  lipodystrophy and other local complications (fig-B)
         Storage
• Injections: refrigerate
• Pens: do not refrigerate
       Shelf life
• One month
  once opened
Thank you all
           For
Sparing your valuable time
            &
     Patient listening


				
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