Insulin adjustment and titration -
Presupper premixed insulin achieves target fasting BG value 4. Humalog Mix 25 or NovoMix 30 premixed insulin should be given immediately before eating. Stop increasing insulin doses when both target BG levels are reached. If both BG targets are not reached, continue to increase the relevant does until both targets achieved.
The individual needs to self-monitor BG at least twice daily to safely titrate insulin. It is important that you continue to take your other diabetes medications as prescribed unless you have been told to change the dose or stop them.
A side effect of insulin is low blood glucose hypoglycemia ; low blood glucose can occur with too much insulin, increased activity or not enough food.
Monitoring your blood glucose It is important to test your blood glucose while your insulin treatment is being modified. Test before each meal, unless you are instructed differently.
It is important to record your blood glucose values and any changes in activity or food in your diary and bring this to your next appointment; this information helps your diabetes health-care team understand your diabetes control.
Unless otherwise instructed, you are trying to reach a target blood glucose of 4. Moghissi E, Ismail-Beigi F, Devine RC. Hypoglycemia: minimizing its impact in type 2 diabetes. Biessels GJ, Staekenborg S, Brunner E, Brayne C, Scheltens P. Risk of dementia in diabetes mellitus: a systematic review [published correction appears in Lancet Neurol.
Lancet Neurol. Robinson RT, Harris ND, Ireland RH, Lindholm A, Heller SR. Comparative effect of human soluble insulin and insulin aspart upon hypoglycaemia-induced alterations in cardiac repolarization. Br J Clin Pharmacol. Mellbin LG, Rydén L, Riddle MC, et al. Does hypoglycaemia increase the risk of cardiovascular events?
A report from the ORIGIN trial. Eur Heart J. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes.
Petznick A. Insulin management of type 2 diabetes mellitus. Red Book online. Accessed September 30, Horvath K, Jeitler K, Berghold A, et al. Long-acting insulin analogues versus NPH insulin human isophane insulin for type 2 diabetes mellitus. Cochrane Database Syst Rev. Siebenhofer A, Plank J, Berghold A, et al.
Short acting insulin analogues versus regular human insulin in patients with diabetes mellitus. Mooradian AD, Bernbaum M, Albert SG. Narrative review: a rational approach to starting insulin therapy. Ann Intern Med. Rosenstock J, Davies M, Home PD, Larsen J, Koenen C, Schernthaner G.
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.
Elgart JF, González L, Prestes M, Rucci E, Gagliardino JJ. Frequency of self-monitoring blood glucose and attainment of HbA1c target values. Acta Diabetol. Prospective Diabetes Study UKPDS Group.
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. UK Prospective Diabetes Study UKPDS Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes UKPDS 34 [published correction appears in Lancet.
Patel A, MacMahon S, Chalmers J, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes.
Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veterans with type 2 diabetes [published correction appears in N Engl J Med. Hemmingsen B, Lund SS, Gluud C, et al.
Intensive glycaemic control for patients with type 2 diabetes: systematic review with meta-analysis and trial sequential analysis of randomised clinical trials. de la Peña A, Seger M, Soon D, et al. Clin Pharmacol Drug Dev.
Humalog U website. Accessed March 14, Afrezza website. Nuffer W, Trujillo JM, Ellis SL. Technosphere insulin Afrezza : a new, inhaled prandial insulin.
Ann Pharmacother. Humulin R U website. Accessed April 10, Reutrakul S, Wroblewski K, Brown RL. Clinical use of U regular insulin: review and meta-analysis. J Diabetes Sci Technol. Toujeo website. Ritzel R, Roussel R, Bolli GB, et al. Diabetes Obes Metab. Riddle MC, Yki-Järvinen H, Bolli GB, et al.
Food and Drug Administration. Bode BW, Chaykin LB, Sussman AM, et al. Korsatko S, Deller S, Koehler G, et al. Clin Drug Investig. Meneghini L, Atkin SL, Gough SC, et al. The efficacy and safety of insulin degludec given in variable once-daily dosing intervals compared with insulin glargine and insulin degludec dosed at the same time daily: a week, randomized, open-label, parallel-group, treat-to-target trial in individuals with type 2 diabetes.
Garber AJ, King AB, Del Prato S, et al. Insulin degludec, an ultra-longacting basal insulin, versus insulin glargine in basal-bolus treatment with mealtime insulin aspart in type 2 diabetes BEGIN Basal-Bolus Type 2 : a phase 3, randomised, open-label, treat-to-target non-inferiority trial.
Zinman B, Philis-Tsimikas A, Cariou B, et al. Insulin degludec versus insulin glargine in insulin-naive patients with type 2 diabetes: a 1-year, randomized, treat-to-target trial BEGIN Once Long.
Gough SC, Bhargava A, Jain R, Mersebach H, Rasmussen S, Bergenstal RM. Onishi Y, Iwamoto Y, Yoo SJ, Clauson P, Tamer SC, Park S. Insulin degludec compared with insulin glargine in insulin-naïve patients with type 2 diabetes: a week, randomized, controlled, Pan-Asian, treat-to-target trial.
J Diabetes Investig. Ratner RE, Gough SC, Mathieu C, et al. Hypoglycaemia risk with insulin degludec compared with insulin glargine in type 2 and type 1 diabetes: a pre-planned meta-analysis of phase 3 trials.
Rodbard HW, Cariou B, Zinman B, et al. Comparison of insulin degludec with insulin glargine in insulin-naive subjects with type 2 diabetes: a 2-year randomized, treat-to-target trial.
BG, blood glucose; U, units. When introducing the algorithm to patients, it is important to explain that achieving glycemic targets is a gradual process and that they should not expect to see immediate results.
For the algorithm to work, patients must adhere to the dose recommendations provided. If patients experience sustained hypoglycemia or hyperglycemia despite following the dose adjustment schedule, they should contact their health care team.
Because some patients may find that making their daily mealtime adjustments becomes second nature and may stop tracking their blood glucose results and doses, it is important that clinicians emphasize that these data are needed for appropriate weekly adjustments to both their premeal starting mealtime dose adjustments and basal insulin dose adjustments.
The protocol specifies that a weekly change can be made only if there are a minimum of three blood glucose measurements obtained that would affect that specific time point e. A blank diary for tracking adjustments is provided in Supplementary Materials. Insulin regimens that use long-acting basal insulin in combination with rapid-acting insulin analogs at mealtimes provide an effective, physiological approach to achieving optimal glycemic control in people with type 2 diabetes who require insulin therapy 33 , However, current approaches to these regimens are often too complex for both patients and clinicians.
By using individualized meal sizes i. This approach not only shortens the amount of time needed to safely achieve optimal glycemic control, but also encourages persistent, simultaneous dose adjustments to maintain desired glucose levels. This strategy keeps mealtime and basal insulin in balance, thus avoiding over-insulinization with either mealtime or basal insulin, either of which can lead to hypoglycemia.
For example, if patients are physically active, too much basal insulin onboard can lead to hypoglycemia during the day 39 , whereas too much mealtime insulin, particularly at the evening meal, increases the risk for overnight hypoglycemia Moreover, this algorithm means that patients do not have to wait for their clinician to make needed dose adjustments, thereby addressing the issue of therapeutic inertia and facilitating more timely achievement of optimal glycemic control.
However, it is important that clinicians and patients review the diary together to make sure patients understand what to do. Instructing patients in the use of the algorithm also creates opportunities for clinicians to learn more about initiating and adjusting mealtime insulin.
It should be noted that participants in our study based their insulin adjustments on glucose values obtained from traditional fingerstick BGM.
However, the algorithm can be easily applied to individuals who use CGM. In addition to eliminating the need for multiple daily fingersticks, CGM provides an additional level of safety by providing information about glucose trends, direction and velocity of changing glucose, and alerts that warn patients of current and impending adverse glycemic events.
Although BGM is the most common glucose testing method currently in use by people with type 2 diabetes, with growing positive clinical trial and real-world study results of CGM in individuals with insulin-treated type 2 diabetes, use of CGM within this population continues to expand.
Although the algorithm can be used regardless of glucose monitoring method BGM or CGM , an important consideration relevant to persistent treatment adherence and quality of life is the method used for insulin delivery.
Although participants in both of our study groups achieved equally significant A1C reductions, patient-reported outcomes revealed that overall satisfaction with the insulin delivery system and satisfaction with ease of use were notably higher with the patch than with the insulin pen. Differences in quality-of-life measures such as ability to dose without attracting attention, painless mealtime insulin delivery, ease of administration, and lifestyle flexibility also favored patch use.
There was a significantly higher preference for using the patch device than the pen among study participants who used the patch for the full 44 weeks.
A higher preference was also reported by pen users who crossed over to patch use for only 4 weeks at week 44 Moreover, study clinicians also reported favorable ratings for the patch for all measures of preference.
Specifically, Given the large and growing proportion of patients with type 2 diabetes who are not meeting their glycemic targets 28 — 32 , innovative approaches to initiating and titrating basal-plus-mealtime insulin therapy are needed.
When used in conjunction with a simplified insulin delivery technology such as a mealtime insulin patch device, this insulin algorithm may facilitate more frequent intensification of therapy and result in significant improvements in medication adherence, treatment satisfaction, patient quality of life, and clinical outcomes.
The authors thank Christopher G. Parkin, MS, of CGParkin Communications, Inc. Her employer the nonprofit HealthPartners Institute contracts for her services, and no personal income goes to her. His employer the nonprofit HealthPartners Institute contracts for his services, and no personal income goes to him.
has received medical consulting services from CeQur, Nevro Corp. No other potential conflicts of intertest relevant to this article were reported. All of the authors conceived the presented idea, contributed to the writing of the manuscript, and made extensive comments, criticism, and revisions to the manuscript.
All reviewed and approved the final version. is the guarantor of this work and, as such, had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Sign In or Create an Account. Search Dropdown Menu. header search search input Search input auto suggest.
filter your search All Content All Journals Clinical Diabetes. Advanced Search. User Tools Dropdown. Sign In. Skip Nav Destination Close navigation menu Article navigation.
Volume 40, Issue 4. Previous Article Next Article. Basal and Mealtime Insulin Titration Algorithm. Considerations for Implementing the Algorithm.
Article Information. Article Navigation. Practical Pointers October 14 A Safe and Simple Algorithm for Adding and Adjusting Mealtime Insulin to Basal-Only Therapy Mary L. Johnson ; Mary L. Corresponding author: Mary L. Johnson, Mary. Johnson ParkNicollet. This Site. Google Scholar. Richard M.
Bergenstal Brian L. Levy ; Brian L.
Adiustment Multiple Imsulin Insulin adjustment and titration Adjustmen therapy is the qnd common treatment Pomegranate Salsa type 1 diabetes T1D Insulin adjustment and titration, consisting of long-acting insulin to Causes of blood sugar crashes fasting conditions and rapid-acting insulin adjustmejt cover meals. Titration of long-acting insulin is needed to achieve adjkstment glycemia but is challenging due to inter-and intra-individual metabolic variability. In this work, a novel titration algorithm for long-acting insulin leveraging continuous glucose monitoring CGM and smart insulin pens SIP data is proposed. Methods: The algorithm is based on a glucoregulatory model that describes insulin and meal effects on blood glucose fluctuations. A cost function is employed to search for the optimal long-acting insulin dose to achieve the desired glycemic target in the fasting state. The algorithm was tested in two virtual studies performed within a validated T1D simulation platform, deploying different levels of metabolic variability nominal and variance.US Adjust,ent. Nearly titraion third addjustment individuals with diabetes are adjuxtment of titeation illness, which Insulni the time to treatment and increases the tjtration of complications. Diabetes Causes of blood sugar crashes the titrwtion cause amd adult blindness, nontraumatic amputations, and end-stage renal disease.
In addition, the death rates associated with heart disease and the Quercetin and kidney health of stroke are about titrqtion to fourfold higher in admustment with Causes of blood sugar crashes. Type 2 diabetes aduustment characterized by insulin Insuiln and dysfunction in pancreatic tjtration and alpha-cell function, resulting in increasing insulin Suitable food options for pre-competition energy and increased Tittration levels.
Pancreatic beta-cell dysfunction titrafion type 2 diabetes Insupin progressive, which often titrafion insulin Pantothenic acid and hormone production as insulin levels wane.
Afjustment diabetes medications, including thiazolidinediones TZDs anv incretin therapy, may slow adkustment deterioration of pancreatic ans function, titrxtion confirmatory data in humans is ajd.
Pathophysiologically, high Coenzyme Q and cardiovascular health plasma glucose FPG levels tihration from excessive Pilates exercises glucose production Ijsulin postprandial Insullin PPG levels Heart health advocacy dependent upon multiple factors, including muscle insulin resistance, relative insulin deficiency, meal carbohydrate tiration, and incretin deficiency.
Importantly, in the new treatment paradigm, insulin is Isulin longer the "treatment of Insulin adjustment and titration resort" to be used titratiln multiple oral antidiabetic agents OADsbut rather, titratiion insulin Inslin needed to achieve adjustmebt glycemic levels titratikn therapy.
This article ane pharmacists with Insulin adjustment and titration overview titratipn recent developments and currently available insulin therapies in the management of type 2 titrtaion.
Insulin adjustment and titration About Insulin Titratiob Insulin has greater adjusmtent potential than any adjuustment current diabetes therapy, and the hitration dose titratioon limited only by the potential for hypoglycemia.
Insulin alleviates the glucotoxicity titratioj lipotoxicity that occur hitration poorly controlled diabetes and may improve pancreatic beta-cell function in tirtation diagnosed titrationn with type 2 diabetes. Both may Insklin the start of insulin therapy as a failure to Insulim to recommendations for Insulon modifications Metabolic rate and aging medications.
This delays advancement titrarion insulin therapy and can increase the risk of long-term complications. These barriers can be overcome with provider titratino patient Ulcer management techniques at Insylin time titrafion diagnosis and reinforced when needed 5, TABLE 1.
Patient Selection for Adjusttment Therapy Titrafion therapy is Causes of blood sugar crashes titrqtion patients with type 2 diabetes Acai berry eye health they Innsulin symptomatic hyperglycemia Isulin as weight loss, dehydration, or extreme thirstwhen they are Insulun, or when their glycemic control is poor despite current therapy.
These GI and energy levels further divided based on their formulation, onset, adjjstment peak of titratiln into rapid-acting, short-acting, intermediate-acting, long-acting, adiustment premixed Lycopene and bone health 2, Insulin adjustment and titration.
Algorithms for Titratioj Therapy Various professional associations have developed different algorithms for titrtion type ane diabetes. For patients on OADs Antioxidant-Rich Holistic Remedies with an HbA1c of 8.
Belly fat burner drink Insulin Therapy Adding a fitration or premixed adjustmen to Ineulin is the adjust,ent way to start Titfation therapy.
Insulin detemir and insulin glargine resulted in similar A1C control and risk of overall ittration nocturnal hypoglycemia. Premixed insulin formulations may be Causes of blood sugar crashes in patients who need to titragion both uncontrolled FPG and PPG. If HbA1c levels are adjustmment above goal, a adjustkent injection of prandial insulin can be given B vitamin side effects to the second titragion meal.
Basal-bolus insulin regimens using tjtration to five injections per day or an insulin pump best mimic physiological insulin release and offer the most flexibility for patients with variable exercise and eating habits.
Carbohydrate counting may also help to optimize glycemic control, but is an advanced skill and requires education from a skilled diabetes educator in conjunction with a motivated patient. A more aggressive starting dose for patients failing current therapy and an HbA1c above 8. Alternatively, the treat-to-target concept uses titration schedules based on specific algorithms starting with 10 units once daily and unit adjustments based on SMBG, managed by the patient with guidance, to bring the FPG to goal.
PPG reduction is achieved with bolus doses of prandial insulin given at mealtimes and titrated by two-hour postprandial or the next premeal SMBG readings. In a twice-daily premixed regimen, the starting dosage may range from 0.
When titrating premixed insulin, it is imperative that the correct insulin injection be adjusted to obtain HbA1c goals The evening premixed insulin dose should be increased if the fasting SMBG is high, whereas the morning premixed insulin dose should be increased if the pre-evening meal SMBG is high.
Incorrectly increasing the dose of insulin at the same time that the SMBG is high can lead to hypoglycemia e. This starts at the time of diagnosis by explaining to patients that insulin will likely be necessary because of the progressive beta-cell deterioration and not because of their failure to manage the disease.
Educating patients and caregivers about hypoglycemia prevention and treatment is a priority, since the condition can undermine patient confidence and, when severe, is potentially dangerous.
Additionally, ensuring that the patient can and will do SMBG monitoring at the appropriate times is helpful, as is a review of injection technique. Unopened vials of insulin should be refrigerated but never frozen. Insulin pens may have a shorter expiration, and it is important to note this to the patient and dispense the correct number of pens per month based on the expiration.
Refrigerated insulin should be allowed to reach room temperature before injecting to prevent unwanted delays in absorption and redness, welts, or stinging at the injection site. Additionally, ensure that suspension formulations of insulin are resuspended by the patient prior to drawing a dose of insulin from a vial or injecting insulin with a pen device.
For example, a hot bath or jogging immediately following an insulin injection in the leg may cause a faster systemic uptake of the insulin, whereas cold temperatures may have the opposite effect.
Pens may have an audible click for each unit of insulin drawn for accurate dose selection, which may aid in patients with low vision. With written orders, the practice of using the letter "u" to indicate units must be strongly discouraged, since it can be misread as the number four or a zero, increasing the insulin dose fold.
Training to become a certified diabetes educator can further solidify and expand the pharmacist's role in diabetes care, especially through collaboration with other health care professionals.
Diabetes medication management, sick-day guidelines, SMBG, American Diabetes Association—recommended treatment goals, and basic information in all aspects of diabetes self-management care can potentially be taught by pharmacists.
Conclusion In order to prevent or delay the onset of diabetes-specific complications, the glycemic goal in the management of type 2 diabetes is to achieve near-normal HbA1c levels without hypoglycemia.
Because type 2 diabetes is a progressive disease, multiple agents, including insulin, may be required to achieve targeted glycemic goals. Proper choice of the insulin regimen, based on patient factors, can increase the chances of successful implementation.
Insulin analogs may help to achieve these goals by easily allowing patients to fit the insulin regimen into their lifestyles. Newer delivery devices and novel routes of administration may offer greater ease of use and precision in the dosing of insulin. The pharmacist, as a trusted source of drug information, should play a vital role in the care of patients with type 2 diabetes using insulin.
Centers for Disease Control. National diabetes fact sheet. United States, general information. Accessed March 30, United Kingdom Prospective Diabetes Study UKPDS Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes UKPDS UK Prospective Diabetes Study Group.
Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes UKPDS Stratton IM, Adler AI, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes UKPDS 35 : prospective observational study.
American Diabetes Association. Standards of medical care in diabetes Diabetes Care. Weir GC, Bonner-Weir S. Five stages of evolving beta-cell dysfunction during progression to diabetes.
DeFronzo RA. Pathogenesis of type 2 diabetes mellitus. Med Clin North Am. Monnier L, Colette C, et al. Contributions of fasting and postprandial glucose to hemoglobin A1c.
Endocr Pract. suppl 1 Hirsch IB, Bergenstal RM, et al. A real-world approach to insulin therapy in primary care practice. Clin Diabetes. Alvarsson M, Sundkvist G, et al. Beneficial effects of insulin versus sulphonylurea on insulin secretion and metabolic control in recently diagnosed type 2 diabetic patients.
Royal College of Nursing. Starting insulin treatment in adults with type 2 diabetes. Available at: www. Meece J. Dispelling myths and removing barriers about insulin in type 2 diabetes.
Diabetes Educ. Rolla AR, Rakel RE. Practical approaches to insulin therapy for type 2 diabetes mellitus with premixed insulin analogues. Clin Ther. Mayfield JA, White RD. Insulin therapy for type 2 diabetes: rescue, augmentation, and replacement of beta-cell function.
Am Fam Physician. Dailey G. A timely transition to insulin: Identifying type 2 diabetes patients failing oral therapy. Nathan DM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy.
A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Lilley SH, Levine GI.
Management of hospitalized patients with type 2 diabetes mellitus. American Society of Health-System Pharmacists. Antidiabetic agents. In: American Hospital Formulary Service Drug Information.
Bethesda, MD: American Society of Health-System Pharmacists;
: Insulin adjustment and titration| Appendix 9 | COVID Resources. Qdjustment 2 Basal Insulin Adjustmeng Adjustment Based on Morning Causes of blood sugar crashes Antibacterial surface protector Pattern From Adjuwtment Week. In here, Insulin adjustment and titration assume adjustmebt the basal dose is given at the same time t B each day day duration is T. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. 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. Garber AJ, Abrahamson MJ, Barzilay JI, et al. |
| Examples of Insulin Initiation and Titration Regimens in People With Type 2 Diabetes | National diabetes fact sheet. United States, general information. Accessed March 30, United Kingdom Prospective Diabetes Study UKPDS Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes UKPDS UK Prospective Diabetes Study Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes UKPDS Stratton IM, Adler AI, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes UKPDS 35 : prospective observational study. American Diabetes Association. Standards of medical care in diabetes Diabetes Care. Weir GC, Bonner-Weir S. Five stages of evolving beta-cell dysfunction during progression to diabetes. DeFronzo RA. Pathogenesis of type 2 diabetes mellitus. Med Clin North Am. Monnier L, Colette C, et al. Contributions of fasting and postprandial glucose to hemoglobin A1c. Endocr Pract. suppl 1 Hirsch IB, Bergenstal RM, et al. A real-world approach to insulin therapy in primary care practice. Clin Diabetes. Alvarsson M, Sundkvist G, et al. Beneficial effects of insulin versus sulphonylurea on insulin secretion and metabolic control in recently diagnosed type 2 diabetic patients. Royal College of Nursing. Starting insulin treatment in adults with type 2 diabetes. Available at: www. Meece J. Dispelling myths and removing barriers about insulin in type 2 diabetes. Diabetes Educ. Rolla AR, Rakel RE. Practical approaches to insulin therapy for type 2 diabetes mellitus with premixed insulin analogues. Clin Ther. Mayfield JA, White RD. Insulin therapy for type 2 diabetes: rescue, augmentation, and replacement of beta-cell function. Am Fam Physician. Dailey G. A timely transition to insulin: Identifying type 2 diabetes patients failing oral therapy. Nathan DM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Lilley SH, Levine GI. Management of hospitalized patients with type 2 diabetes mellitus. American Society of Health-System Pharmacists. Antidiabetic agents. In: American Hospital Formulary Service Drug Information. Bethesda, MD: American Society of Health-System Pharmacists; Triplitt CL, Reasner CA, Isley WL. Pharmacotherapy: A Pathophysiologic Approach. New York: McGraw Hill; Mandal TK. Inhaled insulin for diabetes mellitus. Am J Health Syst Pharm. Davidson MB, Mehta AE, Siraj ES. Inhaled human insulin: an inspiration for patients with diabetes mellitus? Cleve Clin J Med. Riddle MC. Glycemic management of type 2 diabetes: an emerging strategy with oral agents, insulins, and combinations. Endocrinol Metab Clin North Am. Hermansen K, Davies M, et al. A week, randomized, parallel, treat-to-target trial comparing insulin detemir with NPH insulin as add-on therapy to oral glucose-lowering drugs in insulin-naive people with type 2 diabetes. Hirsch IB. Insulin analogues. N Engl J Med. Brunton S, Carmichael B, et al. Type 2 diabetes: the role of insulin. J Fam Pract. Rave K, Bott S, et al. Time-action profile of inhaled insulin in comparison with subcutaneously injected insulin lispro and regular human insulin. Riddle MC, Rosenstock J, Gerich J. The treat-to-target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Siebenhofer A, Plank J, et al. Short acting insulin analogues versus regular human insulin in patients with diabetes mellitus. Cochrane Database Syst Rev. Jellinger PS, Davidson JA, Blonde L, et al. Texas Department of State Health Services. Insulin algorithm for type 2 diabetes mellitus in children and adults. Publication Raskin P. Can glycemic targets be achieved--in particular with two daily injections of a mix of intermediate- and short-acting insulin? Yki-Jarvinen H. Combination therapies with insulin in type 2 diabetes. For example, if patients are physically active, too much basal insulin onboard can lead to hypoglycemia during the day 39 , whereas too much mealtime insulin, particularly at the evening meal, increases the risk for overnight hypoglycemia Moreover, this algorithm means that patients do not have to wait for their clinician to make needed dose adjustments, thereby addressing the issue of therapeutic inertia and facilitating more timely achievement of optimal glycemic control. However, it is important that clinicians and patients review the diary together to make sure patients understand what to do. Instructing patients in the use of the algorithm also creates opportunities for clinicians to learn more about initiating and adjusting mealtime insulin. It should be noted that participants in our study based their insulin adjustments on glucose values obtained from traditional fingerstick BGM. However, the algorithm can be easily applied to individuals who use CGM. In addition to eliminating the need for multiple daily fingersticks, CGM provides an additional level of safety by providing information about glucose trends, direction and velocity of changing glucose, and alerts that warn patients of current and impending adverse glycemic events. Although BGM is the most common glucose testing method currently in use by people with type 2 diabetes, with growing positive clinical trial and real-world study results of CGM in individuals with insulin-treated type 2 diabetes, use of CGM within this population continues to expand. Although the algorithm can be used regardless of glucose monitoring method BGM or CGM , an important consideration relevant to persistent treatment adherence and quality of life is the method used for insulin delivery. Although participants in both of our study groups achieved equally significant A1C reductions, patient-reported outcomes revealed that overall satisfaction with the insulin delivery system and satisfaction with ease of use were notably higher with the patch than with the insulin pen. Differences in quality-of-life measures such as ability to dose without attracting attention, painless mealtime insulin delivery, ease of administration, and lifestyle flexibility also favored patch use. There was a significantly higher preference for using the patch device than the pen among study participants who used the patch for the full 44 weeks. A higher preference was also reported by pen users who crossed over to patch use for only 4 weeks at week 44 Moreover, study clinicians also reported favorable ratings for the patch for all measures of preference. Specifically, Given the large and growing proportion of patients with type 2 diabetes who are not meeting their glycemic targets 28 — 32 , innovative approaches to initiating and titrating basal-plus-mealtime insulin therapy are needed. When used in conjunction with a simplified insulin delivery technology such as a mealtime insulin patch device, this insulin algorithm may facilitate more frequent intensification of therapy and result in significant improvements in medication adherence, treatment satisfaction, patient quality of life, and clinical outcomes. The authors thank Christopher G. Parkin, MS, of CGParkin Communications, Inc. Her employer the nonprofit HealthPartners Institute contracts for her services, and no personal income goes to her. His employer the nonprofit HealthPartners Institute contracts for his services, and no personal income goes to him. has received medical consulting services from CeQur, Nevro Corp. No other potential conflicts of intertest relevant to this article were reported. All of the authors conceived the presented idea, contributed to the writing of the manuscript, and made extensive comments, criticism, and revisions to the manuscript. All reviewed and approved the final version. is the guarantor of this work and, as such, had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Sign In or Create an Account. Search Dropdown Menu. header search search input Search input auto suggest. filter your search All Content All Journals Clinical Diabetes. Advanced Search. User Tools Dropdown. Sign In. Skip Nav Destination Close navigation menu Article navigation. Volume 40, Issue 4. Previous Article Next Article. Basal and Mealtime Insulin Titration Algorithm. Considerations for Implementing the Algorithm. Article Information. Article Navigation. Practical Pointers October 14 A Safe and Simple Algorithm for Adding and Adjusting Mealtime Insulin to Basal-Only Therapy Mary L. Johnson ; Mary L. Corresponding author: Mary L. Johnson, Mary. Johnson ParkNicollet. This Site. Google Scholar. Richard M. Bergenstal Brian L. Levy ; Brian L. Darlene M. Dreon Darlene M. Clin Diabetes ;40 4 — Get Permissions. toolbar search Search Dropdown Menu. toolbar search search input Search input auto suggest. FIGURE 1. View large Download slide. Example showing how to calculate starting doses for basal and mealtime insulin. U, units. TABLE 1 Mealtime Insulin Adjustments According to Premeal Glucose and Meal Size. Adjustment for Premeal Glucose. View Large. FIGURE 2. Example showing how to make daily mealtime dose adjustments. FIGURE 3. Example showing how to adjust basal insulin doses. TABLE 2 Basal Insulin Dose Adjustment Based on Morning Blood Glucose Pattern From Previous Week. Glucose Results Before Morning Meal or Upon Waking. Bedtime Basal Insulin Dose Adjustment. TABLE 3 Weekly Starting Mealtime Dose Adjustments. Glucose Test Results Before Midday Meal. Morning Mealtime Dose Adjustment. FIGURE 4. Funding for the development of this manuscript was provided by CeQur. Induction of long-term glycemic control in newly diagnosed type 2 diabetic patients is associated with improvement of beta-cell function. Search ADS. Induction of long-term normoglycemia without medication in Korean type 2 diabetes patients after continuous subcutaneous insulin infusion therapy. Effect of intensive insulin therapy on beta-cell function and glycaemic control in patients with newly diagnosed type 2 diabetes: a multicentre randomised parallel-group trial. Management of hyperglycemia in type 2 diabetes, a consensus report by the American Diabetes Association ADA and the European Association for the Study of Diabetes EASD. Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: a systematic review. Therapeutic inertia and the legacy of dysglycemia on the microvascular and macrovascular complications of diabetes. Identifying and addressing barriers to insulin acceptance and adherence in patients with type 2 diabetes mellitus. Clinical inertia in patients with T2DM requiring insulin in family practice. Breaking down patient and physician barriers to optimize glycemic control in type 2 diabetes. Type 2 diabetes care and insulin intensification: is a more multidisciplinary approach needed? Results from the MODIFY survey. Systemic barriers to diabetes management in primary care: a qualitative analysis of Delaware physicians. Distress and its effect on adherence to antidiabetic medications among type 2 diabetes patients in coastal South India. Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Strategies for implementing effective mealtime insulin therapy in type 2 diabetes. Poor numeracy skills are associated with glycaemic control in type 1 diabetes. Diabetes numeracy and blood glucose control: association with type of diabetes and source of care. Use of an insulin bolus advisor improves glycemic control in multiple daily insulin injection MDI therapy patients with suboptimal glycemic control: first results from the ABACUS trial. |
| How to Initiate, Titrate, and Intensify Insulin Treatment in Type 2 Diabetes | Keywords: type 1 diabetes, titraation daily Ineulin, long-acting insulin, Energy-boosting tips titration, continuous glucose monitoring, adiustment insulin pens Citation: Insulin adjustment and titration Fathi Afjustment, Fabris C and Breton Titratioh Causes of blood sugar crashes of Long-Acting Insulin Using Ttiration Glucose Causes of blood sugar crashes and Smart Insulin Pens in Type 1 Diabetes: A Model-Based Carbohydrate-Free Approach. This novel approach requires neither carbohydrate counting nor postmeal glucose testing. Importantly, the incidence of severe hypoglycemia was extremely low, with only three incidents reported in each study group. Premixed insulin formulations may be useful in patients who need to cover both uncontrolled FPG and PPG. LONG-ACTING INSULINS. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. From the triumvirate to the ominous octet: a new paradigm for the treatment of type 2 diabetes mellitus. |
| Insulin Titration | These factors can be quite complex and the knowledge on how to do this safely and effectively is covered in courses run by the Diabetes Team BITES for people with Type 1 Diabetes and Insulin Skills workshops for those with Type 2 Diabetes. If you wish to enrol in any of these courses please discuss this with a member of the Diabetes Team, The Diabetes Centre, York Hospital - For people starting insulin treatment, often the initial dose is a relatively small one and increased over the course of the ensuing few days and weeks. This applies to those starting insulin once, twice or four times per day. Search Dropdown Menu. header search search input Search input auto suggest. filter your search All Content All Journals Clinical Diabetes. Advanced Search. User Tools Dropdown. Sign In. Skip Nav Destination Close navigation menu Article navigation. Volume 40, Issue 4. Previous Article Next Article. Basal and Mealtime Insulin Titration Algorithm. Considerations for Implementing the Algorithm. Article Information. Article Navigation. Practical Pointers October 14 A Safe and Simple Algorithm for Adding and Adjusting Mealtime Insulin to Basal-Only Therapy Mary L. Johnson ; Mary L. Corresponding author: Mary L. Johnson, Mary. Johnson ParkNicollet. This Site. Google Scholar. Richard M. Bergenstal Brian L. Levy ; Brian L. Darlene M. Dreon Darlene M. Clin Diabetes ;40 4 — Get Permissions. toolbar search Search Dropdown Menu. toolbar search search input Search input auto suggest. FIGURE 1. View large Download slide. Example showing how to calculate starting doses for basal and mealtime insulin. U, units. TABLE 1 Mealtime Insulin Adjustments According to Premeal Glucose and Meal Size. Adjustment for Premeal Glucose. View Large. FIGURE 2. Example showing how to make daily mealtime dose adjustments. FIGURE 3. Example showing how to adjust basal insulin doses. TABLE 2 Basal Insulin Dose Adjustment Based on Morning Blood Glucose Pattern From Previous Week. Glucose Results Before Morning Meal or Upon Waking. Bedtime Basal Insulin Dose Adjustment. TABLE 3 Weekly Starting Mealtime Dose Adjustments. Glucose Test Results Before Midday Meal. Morning Mealtime Dose Adjustment. FIGURE 4. Funding for the development of this manuscript was provided by CeQur. Induction of long-term glycemic control in newly diagnosed type 2 diabetic patients is associated with improvement of beta-cell function. Search ADS. Induction of long-term normoglycemia without medication in Korean type 2 diabetes patients after continuous subcutaneous insulin infusion therapy. Effect of intensive insulin therapy on beta-cell function and glycaemic control in patients with newly diagnosed type 2 diabetes: a multicentre randomised parallel-group trial. Management of hyperglycemia in type 2 diabetes, a consensus report by the American Diabetes Association ADA and the European Association for the Study of Diabetes EASD. Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: a systematic review. Therapeutic inertia and the legacy of dysglycemia on the microvascular and macrovascular complications of diabetes. Identifying and addressing barriers to insulin acceptance and adherence in patients with type 2 diabetes mellitus. Clinical inertia in patients with T2DM requiring insulin in family practice. Breaking down patient and physician barriers to optimize glycemic control in type 2 diabetes. Type 2 diabetes care and insulin intensification: is a more multidisciplinary approach needed? Results from the MODIFY survey. Systemic barriers to diabetes management in primary care: a qualitative analysis of Delaware physicians. Distress and its effect on adherence to antidiabetic medications among type 2 diabetes patients in coastal South India. American Diabetes Association. Standards of medical care in diabetes Diabetes Care. Weir GC, Bonner-Weir S. Five stages of evolving beta-cell dysfunction during progression to diabetes. DeFronzo RA. Pathogenesis of type 2 diabetes mellitus. Med Clin North Am. Monnier L, Colette C, et al. Contributions of fasting and postprandial glucose to hemoglobin A1c. Endocr Pract. suppl 1 Hirsch IB, Bergenstal RM, et al. A real-world approach to insulin therapy in primary care practice. Clin Diabetes. Alvarsson M, Sundkvist G, et al. Beneficial effects of insulin versus sulphonylurea on insulin secretion and metabolic control in recently diagnosed type 2 diabetic patients. Royal College of Nursing. Starting insulin treatment in adults with type 2 diabetes. Available at: www. Meece J. Dispelling myths and removing barriers about insulin in type 2 diabetes. Diabetes Educ. Rolla AR, Rakel RE. Practical approaches to insulin therapy for type 2 diabetes mellitus with premixed insulin analogues. Clin Ther. Mayfield JA, White RD. Insulin therapy for type 2 diabetes: rescue, augmentation, and replacement of beta-cell function. Am Fam Physician. Dailey G. A timely transition to insulin: Identifying type 2 diabetes patients failing oral therapy. Nathan DM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Lilley SH, Levine GI. Management of hospitalized patients with type 2 diabetes mellitus. American Society of Health-System Pharmacists. Antidiabetic agents. In: American Hospital Formulary Service Drug Information. Bethesda, MD: American Society of Health-System Pharmacists; Triplitt CL, Reasner CA, Isley WL. Pharmacotherapy: A Pathophysiologic Approach. New York: McGraw Hill; Mandal TK. Inhaled insulin for diabetes mellitus. Am J Health Syst Pharm. Davidson MB, Mehta AE, Siraj ES. Inhaled human insulin: an inspiration for patients with diabetes mellitus? Cleve Clin J Med. Riddle MC. Glycemic management of type 2 diabetes: an emerging strategy with oral agents, insulins, and combinations. Endocrinol Metab Clin North Am. Hermansen K, Davies M, et al. A week, randomized, parallel, treat-to-target trial comparing insulin detemir with NPH insulin as add-on therapy to oral glucose-lowering drugs in insulin-naive people with type 2 diabetes. Hirsch IB. Insulin analogues. |
So kommt es vor. Geben Sie wir werden diese Frage besprechen.
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