Detail-Document #241120

This Detail-Document accompanies the related article published in

PHARMACISTS LETTER / PRESCRIBERS LETTER
November 2008 ~Volume 24 ~Number 241120


More. . .
Copyright 2008 by Therapeutic Research Center
Pharmacists Letter / Prescribers Letter ~P.O. Box 8190, Stockton, CA 95208 ~Phone: 209-472-2240 ~Fax: 209-472-2249
www.pharmacistsletter.com ~www.prescribersletter.com

Oral medications controlling
postprandial glucose, but high fasting
glucose. Good for timid insulin users.

Premixed insulin daily or BID (doses harder
to adjust sincefixed combination)

Failure to control blood sugar*

Add rapid-acting insulin before meals where postprandial
hyperglycemia occurs OR premixed insulin daily or BID
Failure to control blood sugar*
Failure to control blood sugar*
Start/intensify insulin therapy

Initiation and Adjustment of Insulin Regimens for Type 2 Diabetes
1,2,3
Note: Insulin therapy should be individualized according to blood sugar values, A1c, diet, medications, lifestyle, etc.

Diagnosis of Type 2 Diabetes

A1c >7% (eAG >154 mg/dL)


Assess current therapy

Lifestyle change Monotherapy usually with metformin

Metformin Add sulfonylurea if A1c <8.5%, add insulin if A1c >8.5%

Combination oral therapy** Failure to control blood sugar*


Motivated patient
Willing to frequently monitor High fasting, high postprandial glucose
blood sugars


Basal insulin with rapid-acting Basal insulin (intermediate
mealtime insulin (~4 doses/day) or long-acting) once daily




Once daily basal insulin with rapid-acting
mealtime insulin mealtime insulin
Example of initial insulin regimen
o 10 units NPH or 0.2 units/kg at bedtime
o 10 units glargine or 0.2 units/kg once daily
o 10 units detemir or 0.2 units/kg once daily
o 10 units premixed insulin once or twice daily
(prebreakfast and/or predinner)
Twice daily provides better glucose control in most patients
Pioglitazone or exenatide +metformin in select patients**
3

Rosiglitazone NOT recommended
3

Consider insulin as initial therapy in severe hyperglycemia
(plasma glucose levels >250 mg/dL), randomglucose levels
consistently >300 mg/dL, or an A1c >10%)
Failure to control blood sugar*=A1c>7%, eAG>154 mg/dL
Stop sulfonylurea, pioglit, or exenatide when start insulin
3

Types of Insulin
Rapid-acting insulin: lispro
(Humalog), aspart (NovoLog),
glulisine (Apidra)
Regular short-acting insulin:
Humulin R, Novolin R
Intermediate-acting (basal) insulin:
NPH (Humulin N, Novolin N)
Long-acting (basal) insulin:
glargine (Lantus),
detemir (Levemir)
Premixed insulin:
Rapid acting: NovoLog Mix 70/30,
Humalog Mix75/25 or 50/50
Short-acting: Humulin 70/30 or 50/50
Novolin 70/30
(Detail-Document #241120: Page 2 of 2)


Users of this document are cautioned to use their own
professional judgment and consult any other necessary
or appropriate sources prior to making clinical
judgments based on the content of this document. Our
editors have researched the information with input from
experts, government agencies, and national
organizations. Information and Internet links in this
article were current as of the date of publication.

Project Leader in preparation of this Detail-
Document: Neeta Bahal OMara, Pharm.D., BCPS


References
1. Hirsch IB, Bergenstal RM, Parkin CG, et al. A real-
world approach to insulin therapy in primary care
practice. Clin Diabetes 2005;23:78-86.
2. Nathan DM, Buse J B, Davidson MB, et al.
Management of hyperglycemia in type 2 diabetes: a
consensus algorithm for the initiation and adjustment
of therapy. Diabetes Care 2006;29:1963-72.
3. Nathan DM, Buse J B, Davidson MB, et al.
Management of hyperglycemia in type 2 diabetes: A
consensus algorithm for the initiation and adjustment
of therapy. Diabetes Care (Dec) 2008;31:1-11.




Cite this Detail-Document as follows: Insulin use in patients with type 2 diabetes. Pharmacists Letter/Prescribers
Letter 2008;24(11):241120.


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Copyright 2008 by Therapeutic Research Center

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