Insulin Dosing in Type 2 Diabetes

1. See Also
   1. Insulin
   2. Insulin Simulation
   3. Insulin Dosing
   4. Insulin Dosing in Type I Diabetes
   5. Carbohydrate Counting
   6. Insulin Adjustment with Carbohydrate Counting
2. Protocol: Identify Blood Glucose goals
   1. No predisposition to Hypoglycemia
      1. Pre-meal or fasting: 70-120
      2. Bedtime: 100-140
      3. Hemoglobin A1C: <7% (Normal 4.0 - 6.0%)
      4. Two hour post-prandial glucose <160 mg/dl
         1. Blood Glucose 20-40 mg/dl above pre-meal glucose
   2. Predisposition for Hypoglycemia (Comorbid conditions)
      1. Pre-meal/fasting: 100-150
      2. Hemoglobin A1C: 7-8
3. Protocol: Starting Basal Insulin (e.g. Lantus) and Bolus Insulin (e.g. Lispro)
   1. Step 0: Adjust oral medications
      1. Stop Insulin Secretagogue (Sulfonylurea, Meglitinide) when on twice daily bolus Insulin
      2. Continue Insulin sensitizers (Metformin, Glitazone)
   2. Step 1: Choose a 24 hour basal Insulin (once daily):
      1. Detemir (Levemir)
      2. Glargine (Lantus)
   3. Step 2: Choose a bolus Insulin (pre-meal Insulin):
      1. Regular Insulin (Novolin R, Humulin R)
      2. Glulisine (Apidra)
      3. Lispro (Humalog)
      4. Aspart (Novolog)
   4. Step 3: Starting dose
      1. Hemoglobin A1C <8
         1. Basal Insulin 0.1 units/kg once daily AND
         2. Bolus Insulin 0.1 units/kg divided equally before meals (start before breakfast and dinner)
      2. Hemoglobin A1C 8-10
         1. Basal Insulin 0.2 units/kg once daily AND
         2. Bolus Insulin 0.2 units/kg divided equally before meals (start before breakfast and dinner)
      3. Hemoglobin A1C >10
         1. Basal Insulin 0.3 units/kg once daily AND
         2. Bolus Insulin 0.3 units/kg divided equally before meals (start before breakfast and dinner)
4. Protocol: Starting Insulin using Premixed Insulin
   1. Step 0: Adjust oral medications
      1. Stop Insulin Secretagogue (Sulfonylurea, Meglitinide)
      2. Continue Insulin sensitizers (Metformin, Glitazone)
   2. Insulin preparations (for twice daily dosing)
      1. Lispro Mix 75/25 or
      2. Aspart Premix 70/30
   3. Starting dose
      1. A1C <8: 0.1 units/kg in AM and 0.1 units/kg in PM
      2. A1C 8-10: 0.2 units/kg in AM and 0.2 units/kg in PM
      3. A1C >10: 0.3 units/kg in AM and 0.3 units/kg in PM
5. Protocol: Converting from Mixed Insulin to Basal Bolus Insulin
   1. Calculate total Insulin units/kg
      1. Total >1.5 units/kg: Lower total to 1.0 unit/kg
      2. Hemoglobin A1C <9: Decrease total Insulin by 10%
   2. Divide total Insulin Dosing
      1. Insulin Glargine: 50% of total Insulin
      2. Rapid acting: 50% of total divided across meals
6. Protocol: Advancing Basal/Bolus Dosing in Type II Diabetes
   1. Starting point
      1. Insulin Glargine (G) once daily and
      2. Oral Insulin Secretagogue and
      3. Oral Insulin sensitizer
      4. Protocol below, adds rapid acting Insulin (RA)
         1. Insulin Lispro or Aspart
   2. Step 1: 0-0-RA-G
      1. Add 0.1 units/kg Lispro (RA) before largest meal
      2. Decrease Insulin Glargine by 0.1 units/kg
      3. Continue Insulin Secretagogue and sensitizer
      4. Check Blood Glucose fasting, before RA dose, bedtime
   3. Step 2: RA-0-RA-G
      1. Add 0.1 units/kg Lispro (RA) before 2nd largest meal
      2. Decrease Insulin Glargine by 0.1 units/kg
      3. Stop Insulin Secretagogue, continue sensitizer
      4. Check Blood Glucose fasting, before RA dose, bedtime
   4. Step 3: RA-RA-RA-G
      1. Add 0.1 units/kg Lispro (RA) before 3rd largest meal
      2. Decrease Insulin Glargine by 0.1 units/kg
      3. Check Blood Glucose fasting, before RA dose, bedtime
   5. Precautions
      1. Keep Insulin split into 50% basal and 50% bolus
7. Protocol: Starting Insulin using NPH
   1. Background
      1. Other regimens less complicated and therefore preferred
      2. However, NPH and Regular Insulin are least expensive Insulin options
   2. Step 0: Adjust oral medications
      1. Stop Insulin Secretagogue (Sulfonylurea, Meglitinide) when on twice daily bolus Insulin
      2. Continue Insulin sensitizers (Metformin, Glitazone)
   3. Step 1: Starting dose
      1. Hemoglobin A1C <8: Total Insulin: 0.1 units/kg in AM and 0.1 units/kg in PM
      2. Hemoglobin A1C 8-10: Total Insulin: 0.2 units/kg in AM and 0.2 units/kg in PM
      3. Hemoglobin A1C >10: Total Insulin: 0.3 units/kg in AM and 0.3 units/kg in PM
   4. Step 2: Divide each Insulin dose into 1/3 bolus (e.g. Regular Insulin) and 2/3 NPH Insulin
   5. Step 3: Schedule 2 doses of bolus Insulin (e.g. regular) and 2 doses of NPH daily
      1. Breakfast (50%): NPH Insulin (2/3) and Regular Insulin (1/3)
      2. Dinner (50%): NPH Insulin (2/3) and Regular Insulin (1/3)
8. Protocol: Insulin Adjustments
   1. See Insulin Dosing
   2. See Insulin Adjustment with Carbohydrate Counting

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