For insulin-naive patients, start insulin at 0.5 U/Kg to 0.8 U/kg body weight per day with half of that being basal (long-acting) insulin and the other half pre-meal, divided into three doses to be given before each meal. You will then adjust the insulin as needed. When to Feed the patient
Full Answer
When is insulin therapy indicated for type 2 diabetes?
Insulin therapy is recommended for patients with type 2 diabetes mellitus and an initial A1C level greater than 9 percent, or if diabetes is uncontrolled despite optimal oral glycemic therapy. Insulin therapy may be initiated as augmentation, starting at 0.3 unit per kg, or as replacement, starting at 0.6 to 1.0 unit per kg.
When should long-acting insulin be used for diabetes?
The American Diabetes Association suggests the use of long-acting (basal) insulin to augment therapy with one or two oral agents or one oral agent plus a glucagon-like peptide 1 receptor agonist when the A1C level is 9% or more, especially if the patient has symptoms of hyperglycemia or catabolism.
Which type of insulin should be used during the transition to IV?
Patients who will be eating will require both basal and prandial insulin, with correction doses as needed. For patients who will be on NPO status or eating very little, basal insulin with correction doses can be used. Several authors have published protocols for the transition from IV to subcutaneous insulin.
What is the target range for insulin therapy?
All four sets of guidelines recommend initiating insulin therapy in patients with persistent hyperglycemia (blood glucose > 180 mg/dl). After insulin is initiated, the target blood glucose range should be 140-180 mg/dl for the majority of patients.
When do you start insulin guidelines?
The American Diabetes Association (ADA) recommends initiation of basal insulin at 10 units/day or 0.1–0.2 units/kg/day, adjusted by 10–15% or 2–4 units once or twice weekly to reach a target fasting plasma glucose (FPG) in patients whose A1C remains uncontrolled after >3 months of triple combination therapy, whose A1C ...
When should you consider insulin therapy?
Goals of insulin therapy If you have type 1 diabetes, insulin therapy is vital for replacing the insulin your body doesn't produce. Sometimes, people with type 2 diabetes or gestational diabetes need insulin therapy if other treatments haven't been able to keep blood glucose levels within the desired range.
At what level of HbA1c do you start insulin?
Insulin should be initiated when A1C is ≥7.0% after 2–3 months of dual oral therapy. The preferred regimen for insulin initiation in type 2 diabetes is once-daily basal insulin.
Which medication should be considered prior to starting insulin?
You probably know biguanide much better by another name: metformin. These meds lower your blood sugar level by decreasing the amount of glucose that your liver produces. When you take metformin, it makes your muscles more sensitive to insulin, which makes it easier for them to absorb glucose.
You don't understand what you've done wrong
Diabetes usually progresses over time. There comes a time when more and stronger treatment is needed. When the pills that have controlled your blood glucose no longer work, insulin is needed. This doesn't mean you have failed. It is expected in the course of the disease.
You feel isolated
You are not alone! Most healthy patients with diabetes can expect to live long lives after their disease is diagnosed. A large number will require insulin at some point. Many are not happy about taking injections, but most adjust to them well.
You feel like your life is going to change
In some cases, insulin treatment may be temporary. In others, it is not. Whatever is needed to control your blood glucose should be used. That's what keeps you healthy.
You've heard that insulin causes blindness and kidney failure
Nothing could be further from the truth. High blood glucose cause blindness, kidney failure, and other problems, such as nerve damage that can lead to amputations. But eye, kidney, and nerve damage can be delayed or prevented by good control. Insulin will NOT make your diabetes worse, and it is one of the most natural diabetes treatments available.
You're afraid to take injections or worried about a complicated insulin routine
Insulin needles today are so small and thin that patients barely feel them. And most starting insulin routines are fairly simple. Your provider may even be able to prescribe an insulin pen device, which makes injections even easier.
You're afraid injections will hurt or that you'll have low blood glucose reactions (hypoglycemia)
Most patients find that insulin shots don't hurt. Severe hypoglycemia is far more common in people with type 1 diabetes. Mild hypoglycemia may sometimes occur in patients with type 2 diabetes, but your provider will teach you how to detect, prevent, and treat it.
Case Presentation
A 48-year-old African-American man presents to his primary care physician for follow-up of his type 2 diabetes. His diabetes is complicated by peripheral neuropathy, although he has no evidence of retinopathy or nephropathy. His medical history also includes obesity, hyperlipidemia, hypertension, and obstructive sleep apnea.
Discussion
The initiation of insulin is an important stage in the management of type 2 diabetes. Like the patient in this case, many patients with diabetes are unable to achieve a goal A1C on oral therapies alone.
What is IV infusion?
Intravenous (IV) infusion is the preferred route of insulin delivery in critical care, labor and delivery, and perioperative inpatient settings because the rapid onset and short duration of action associated with IV infusion allow for matching insulin requirements to rapidly changing glucose levels.
What is a transition protocol?
A transition protocol provides guidance regarding which patients are likely to require transition to subcutaneous insulin and when and how to make the transition. Patients with type 1 diabetes and most patients with type 2 diabetes who were treated with insulin before hospitalization will require such a transition.
Is insulin infusion a basal bolus?
Open in a separate window. Insulin infusion may be an alternative to a basal-bolus insulin regimen outside of the critical care setting for perioperative and other patients who are not eating (NPO status) and patients whose glycemia is poorly controlled with subcutaneous insulin.
Is hypoglycemia more common in intensive care?
Although hypoglycemia was more common among patients in the intensive treatment group, the association of hypoglycemia with an increased hazard ratio for death was similar in the two groups, suggesting that hypoglycemia contributed to the excess mortality in the intensively treated group.15.
Is capillary blood glucose reading inaccurate?
Some situations may render capillary blood glucose monitoring inaccurate, including shock, hypoxia, dehydration, extremes in hematocrit, elevated bilirubin and triglycerides, and the use of some medications (e.g., mannitol, icodextrin/maltose, and acetaminophen).
Can you stop insulin infusion for hypoglycemia?
Some hypoglycemia protocols temporarily stop the insulin infusion for hypoglycemia and restart it at a lower rate once hypoglycemia has resolved. However, failure to restart the infusion can result in profound hyperglycemia and ultimately diabetic ketoacidosis (DKA) in patients with type 1 diabetes.
Why do you stop taking oral insulin?
They may reason that since oral agents are used to obviate the need for insulin, they are no longer necessary when insulin is required because of persistent hyperglycemia. This approach is usually the most cost-effective.
Is a secretagogue needed for insulin?
The first is that a secretagogue is sometimes needed in patients who are initially given a single injection of insulin glargine-a popular way of starting insulin therapy.
Can you use insulin with TZD?
A second caveat is that the use of insulin in combination with a TZD is associated with an increased risk of weight gain and edema. These adverse effects may outweigh the benefits of such a regimen in some patients.
