DIAGNOSIS AND MANAGEMENT OF DIABETES MELLITUS Ezekiel Arteta, M.D. Charlene Bularan, M.D.
Department of Family and Community Medicine Ospital ng Maynila Medical Center OUTLINE Definition of Diabetes Mellitus Classification Spectrum Summary of the Clinical Practice Guidelines for each Specialty: Pediatrics (AAP) Medicine (ADA and PSEM) Obstetrics (POGS) Pharmacology of Anti-Diabetic Drugs DIABETES MELLITUS Complex metabolic disorder characterized by persistent hyperglycemia resulting from: o Reduced insulin secretion o Decreased glucose utilization o Increased glucose production CLASSIFICATION OF DIABETES MELLITUS Type 1 Diabetes (insulin-dependent/ Juvenile DM) o Complete or near-total insulin deficiency o Caused by the autoimmune destruction of - cells of the pancreatic islets o May be idiopathic Type 2 Diabetes (noninsulin-dependent DM) o Variable degrees of insulin resistance, impaired insulin secretion, and increased glucose production Gestational Diabetes Mellitus (Type 4) o DM that is diagnosed for the first time in pregnancy
DIFFERENTIATION BETWEEN TYPE 1 AND TYPE 2 DM
DEFINITION OF DIABETES MELLITUS
TEST WHO ADA Philippine CPG AACE IDF Fasting Plasma Glucose 126 mg/dL (7.0 mmol/L) 2-h Plasma Glucose after 75-g OGTT 200 mg/dL (11.1 mmol/L) HbA1c 6.5% Random Plasma Glucose 200 mg/dL (11.1 mmol/L) + symptoms PRE-DIABETES Impaired Fasting Glucose o FPG of 100125 mg/dL (5.66.9 mmol/L) ADA, AACE, Phil. CPG o FPG of 110125 mg/dL (6.16.9 mmol/L) WHO: Impaired Glucose Tolerance o 2h 75-g OGTT of 140199 mg/dL (7.8 11.0 mmol/L) ADA, WHO, AACE, Phil. CPG Increased HbA1c (ADA) o HbA1c level of 5.7 6.4% ADA, WHO, Phil. CPG o HbA1c level of 5.5 6.4% AACE
DIABETES MELLITUS IN THE PEDIATRIC AGE GROUP
Sources: American Academy of Pediatrics CPG on DMT2 American Diabetes Association CPG on DM UNITE Philippines CPG on DM SCREENING FOR DIABETES MELLITUS Screening for Type 1 diabetes among children is NOT recommended because the disease appears to be of low prevalence; screening tests using serologic markers are not readily available and do not appear to be cost-effective; and there are as yet no clearly effective preventive approaches.
SCREENING FOR DIABETES MELLITUS Screening for pre-diabetes and Type 2 DM is recommended among asymptomatic children commencing at age10 years or at onset of puberty , if puberty occurs at a younger age (ADA) with the following risk factors: (Grade C, Level 4): o Overweight (BMI > 85 th percentile for age and sex, weight-for-height > 85 th percentile, or weight > 120% of ideal for height) OR o Obese: BMI >95th centile or > +2SD SCREENING FOR DIABETES MELLITUS Screening for pre-diabetes and Type 2 DM is recommended among asymptomatic children commencing at age10 years or at onset of puberty , if puberty occurs at a younger age (ADA) with the following risk factors: (Grade C, Level 4): o Plus any 2 of the following risk factors Family history (especially parents and grandparents) of Type 2 DM Signs of insulin resistance (Acanthosis nigricans, hypertension, dyslipidemia, PCOS, or small for gestational age birth weight) Maternal history of diabetes or GDM during the childs gestation SCREENING FOR DIABETES MELLITUS Should screening for Type 2 DM be done in children? o Screening for pre-diabetes and Type 2 DM is recommended among asymptomatic children commencing at age10 years or at onset of puberty, if puberty occurs at a younger age (ADA) with the following risk factors: (Grade C, Level 4):
SCREENING FOR DIABETES MELLITUS
DIABETES MELLITUS IN THE ADULT AND THE ELDERLY
Sources: American Diabetes Association CPG on DM, 2013 UNITE Philippines CPG on DM SCREENING All individuals being seen at any physicians clinic or by any healthcare provider should be evaluated annually for risk factors for type 2 diabetes and pre- diabetes. (Table 2) (Grade D, Level 5) Obesity, pre-diabetes, components of the metabolic syndrome, PCOS, previous GDM, family history and schizophrenia are some of the risk factors for DM. Universal screening using laboratory tests is not recommended as it would identify very few individuals who are at risk. (Grade D, Consensus) SCREENING Laboratory testing for diabetes and prediabetes is recommended for individuals with any of the risk factors for Type 2 diabetes mellitus. (Table 2) (Level 3-4, Grade B)
SCREENING Testing should ideally be carried out within the health \care setting (clinics, hospitals, local health centers) because of the need for follow-up and discussion of abnormal results by qualified health care professionals (nurse, diabetes educator, physician). (Grade B, Level 3) Testing at any setting should be supervised by a qualified health care professional. (Grade D, Level 5)
SCREENING If initial test/s are negative for diabetes, repeat testing should ideally be done annually. (Grade D, Level 5) DIAGNOSIS The diagnosis of Diabetes Mellitus can be made based on the following criteria*: (Grade B, Level 2) o Plasma glucose > 126 mg/dL (7.0 mmol/L) after an overnight fast o Two-hour plasma glucose > 200 mg/dl (11.1 mmol/l) during an Oral Glucose Tolerance Test o A random plasma glucose > 200 mg/dl (11.1 mmol/l) in a patient with classic symptoms of hyperglycemia (weight loss, polyuria, polyphagia, polydipsia) or with signs and symptoms of hyperglycaemic crisis.
DIAGNOSIS *Among ASYMPTOMATIC individuals with positive results, any of the three tests should be REPEATED within two weeks for confirmation. (Grade C, Level 4) DIAGNOSIS A 75-gram OGTT is preferred as the first test in the following individuals who have: (Grade B, Level 3) A previous FBS showing Impaired Fasting Glucose (100 to 125 mg/dL or 5.6 to 6.9 mmol/L) Previous diagnosis of Cardiovascular Disease (Coronary Artery Disease, Stroke, Peripheral Arteriovascular Disease) or who are at high risk for cardiovascular disease. A diagnosis of Metabolic Syndrome
DIAGNOSIS At the present time, we cannot recommend the routine use of the following tests for the diagnosis of diabetes: (Grade C, Level 3) o HBA1c (because of poor access and lack of standardiazation) o Capillary Blood Glucose o Fructosamine
However, if a result is available upon consultation due to prior testing, it should be interpreted with caution and should be confirmed by any of the 3 tests that are considered standard: fasting plasma glucose, oral glucose tolerance test or random plasma glucose. (Grade B, Level 2)
DIAGNOSIS We do not recommend the following tests for the diagnosis of diabetes (Grade B, Level 3): o Urine glucose o Plasma Insulin MANAGEMENT AND MONITORING Initial evaluation - comprehensive medical history and PE o Coronary heart disease risk assessment o Foot evaluation: assess risk for foot ulcer (identify high-risk feet) o Eye exam: fundoscopy on diagnosis o Dental history or oral health history MANAGEMENT AND MONITORING Minimal initial tests to be requested Fasting blood glucose, complete lipid profile HbA1c Liver function tests Urinalysis; spot urine albumin-to-creatinine ratio Serum creatinine and calculated GFR
Optional tests ECG and TET TSH in type 1 diabetes, dyslipidemia or women over age 50 y GLUCOSE CONTROL
IDF AACE ADA HBA1c 6.5% 6.5% < 7% Preprandial plasma glucose < 110 mg/dL < 110 mg/dL 70-130 mg/dL Peak postprandial glucose NA < 140 mg/dL < 180 mg/dL Bedtime plasma glucose NA NA 110-150 mg/dL *Goals should be individualized *Certain populations require special considerations *Less intensive glycemic goals may be individualized in patients with frequent or severe hypoglycemia MANAGEMENT AND MONITORING Glycemic targets should be achieved within 6 months of diagnosis or first prescription. MANAGEMENT The major components of the treatment of diabetes are:
Diet and Exercise A Oral hypoglycaemic therapy B Insulin Therapy C MANAGEMENT Diet is a basic part of management in every case. Treatment cannot be effective unless adequate attention is given to ensuring appropriate nutrition. Dietary treatment should aim at: Ensuring weight control Providing nutritional requirements Allowing good glycaemic control with blood glucose levels as close to normal as possible Correcting any associated blood lipid abnormalities Controlling of blood pressure
MANAGEMENT Protein: o Intake can range between 10-15% total energy (0.8-1 g/kg of desirable body weight) o Should be derived from both animal and vegetable sources. Recommended: One serving of protein from animal sources every other day
MANAGEMENT Carbohydrates: Should be 50-60% of total caloric content of the diet Has the greatest effect on blood glucose Enough Glucose available throughout the day (not so much not little) Consistent timing and composition of meals and snacks from day to day Evening snack helps prevent nocturnal hypoglycemia
Whole grain bread Cereals Legumes Fruits and Vegetables GI can raise Blood glucose faster GI can raise Blood glucose slower
MANAGEMENT Fats: o Should provide 25-35% of total intake of calories o Saturated fat intake should not exceed 10% of total energy. o Cholesterol consumption should be restricted and limited to 300 mg or less daily o With elevated LDL and overweight Saturated fat: limit to 7% Cholesterol: limit to less than 200 mg daily
MANAGEMENT Fats: o Low intake of unsaturated fat + high carbohydrate + low total fat + energy intake = help lower LDL and cholesterol o High monounsaturated fat diet Lower postprandial rise in blood glucose, insulin, and triglycerides Does not improve fasting blood glucose
MANAGEMENT Salt o Excessive salt intake is to be avoided, particularly in people with hypertension and those with nephropathy.
MANAGEMENT AND MONITORING Initiate treatment with metformin for monotherapy unless with contraindications or intolerance of its ADEs o Diarrhea o Severe nausea o Abdominal pain MANAGEMENT AND MONITORING When optimization of therapy is needed, choose the second drug according to the following - o Degree of HbA1c lowering o Hypoglycemia risk o Weight gain/loss o Patient profile (dosing complexity, renal/hepatic problems, other contraindications and age)
Sequence of Antihyperglycemic Therapy (ADA, 2012) MANAGEMENT AND MONITORING Since HbA1c reduction is the overriding goal, the precise combination used may not be as important as the glucose level achieved. There is no evidence that a specific combination is any more effective in lowering glucose levels or preventing complications than another. o SU + Pio = SU + Metformin (Hanefield et al, 2004 & Nagasaka et al, 2004) o SU + Met = SU + DPP-IV inhibitors (?) MANAGEMENT AND MONITORING The goal BP for most persons with diabetes is <140/90 mm Hg. o Lifestyle therapy alone for 3 months if pre- hypertensive (SBP 130-139 mm Hg or DBP 80- 89 mm Hg) o Pharmacologic + lifestyle therapy if SBP>140 mm Hg or DBP >90 mm Hg, or pre- hypertensive uncontrolled with lifestyle therapy alone MANAGEMENT AND MONITORING ACE inhibitors & ARBs are generally recommended as initial therapy. If one class is not tolerated, the other should be substituted. Multiple drug therapy (>2 agents at maximal doses) is generally required to achieve BP targets. Thiazide-type diuretics, calcium channel blockers and B- blockers may be given as additional agents. MANAGEMENT AND MONITORING Recommendations are consistent with Philippine Practice Guidelines for the Treatment of Dyslipidemia. LDL is the primary target for dyslipidemia management in persons with diabetes MANAGEMENT AND MONITORING Statin therapy should be added to lifestyle therapy, regardless of baseline levels for diabetics o With overt CVD (A) o Without CVD who are >40 y and have 1 more other CVD risk factors (A) For patients at lower risk (e.g. without overt CVD and <40 y), statin therapy should be considered in addition to lifestyle therapy if LDL-C remains >100 mg/dL Those with multiple risk factors (hypertension, familial hypercholesterolemia, LVH, smoking, family history of premature CAD, male sex, age >55 y, proteinuria, albuminuria, BMI>25) MANAGEMENT AND MONITORING
The 100-70 rule Without overt CVD, goal is LDL-C <100 mg/dL (2.6 mmol/L) [A] With overt CVD, goal is LDL-C <70 mg/dl (1.8 mmol/L). Use of high dose statin is an option. [B] MANAGEMENT AND MONITORING Insufficient evidence to recommend aspirin for primary prevention in lower risk individuals o Men < 50 y o Women <60 y
Clinical judgment if with multiple risk factors MANAGEMENT AND MONITORING Use aspirin therapy for secondary prevention strategy in those with DM and a history of CVD [A]. For patients with CVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used.
Combination therapy of ASA (75-162 mg/day) and clopidogrel (75 mg/day) is reasonable up to a year after an acute coronary syndrome [B]. LIPID PROFILE, BLOOD PRESSURE AND BMI TARGET
Parameter Ideal Acceptable Bad TG <1.5 mmol/L (150 mg/dl) <2.2mmol/L > 2.2 mmol/L TC < 4.5mmol/L (200 mg/dl) >4.5 mmol/L > 6.0 mmol/L LDL < 2.5 mmol/L (100 mg/dl) < 4.4mmol/L > 4.4 mmol/L HDL > 1.1 mmol/L (40 mg/dl in men; 50 mg/dl in women) 0.9-1.1mmol/L < 0.9 mmol/L BP < 130/80mmHg >130/80- <140/90 > 140/90 BMI (Males) < 25 <27 27 BMI (Females) < 24 <26 26 MANAGEMENT AND MONITORING The following patients must be referred to internists or diabetes specialists (endocrinologists or diabetologists) - o Type 1 diabetes o Moderate to severe hyperglycemia o Co-morbid conditions (infections, acute CV events i.e. CHF or acute MI) o Significant hepatic and renal impairment o Women with diabetes who are pregnant CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF DIABETES MELLITUS Ezekiel Arteta, M.D. Charlene Bularan, M.D.
Department of Family and Community Medicine Ospital ng Maynila Medical Center CASE 3 A 29 y/o G1P0 26 weeks AOG by LMP, NIL came in for pre-natal check-up.
VS: 140/90 (done twice) 89 20 37.0C
Patients FBS = 91 mg/dl at 26 weeks AOG. Test was repeated at 32 weeks AOG which revealed 114 mg/dl. UA revealed +1 albumin, +1 sugar.
Diagnosis? DIABETES MELLITUS IN PREGNANCY
Source: Philippine Obstetrics and Gynecology Society CPG on DM EPIDEMIOLOGY 7% of all pregnancies are complicated with GDM worldwide In PH, 1.9% of pregnant women admitted have GDM 5.1% of Filipinas had DMT2 or GDM according to POGS, Inc. RISK FACTORS Increase overall and abdominal obesity Sedentary lifestyle and change in diet (caloric diet) Cigarette smoking Inadequate cell response as seen among Japanese population LBW and undernutrition in utero Genes (SEA descent) Chronic infections (HBV and PTB) Exposure to environmental irritants Moderate Fe ++ overload i.e., hemoglobinopathies
SCREENING AND DETECTION Recommendations for Filipino Pregnant Women DM recognized during pregnancy may be classified as either GDM or overt DM based on plasma glucose levels (Level III, Grade C) Universal screening for GDM is recommended among Filipino Gravidas (Level III, Grade B) At 1 st PNCU determine if gravida is high risk accdg to history and risk factors (Level III, Grade B) If low risk, with normal intial test (FBS, HBA1c or RBS), screening should be done at 24-28 weeks AOG using 2 hr 75g OGTT
SCREENING AND DETECTION Recommendations for Filipino Pregnant Women If OGTT is normal at 24-28 weeks AOG, re-test at 32 wks AOG or earlier if there are sx of hyperglycemia (3 Ps, plus polyhydramnios, accelerated fetal growth) OGTT should be performed in the morning after an overnight fasting of 8-14 hours. o Have an unrestricted diet 3 days or more prior to testing, i.e., >/ 150 g of CHO per day o Do not smoke and remain seated during the test
GDM WHO ADA POGS FBS >125 mg/dL (6.9 mmol/L) >92 mg/dL (5.1 mmol/dL) >92 mg/dL (5.1 mmol/dL)
TREATMENT DIET! Medical Nutrition therapy o For normal-weight women (BMI: 20-25 kg/m 2 ) 30 kcal/kg should be prescribed; o For overweight and obese women (BMI > 24-34 kg/m 2 ) calories should be restricted to 25 kcal/kg, o For morbidly obese women (BMI > 34 kg/m 2 ) calories should be restricted to 20 kcal/kg or less
TREATMENT Weight Management weight gain recommendations for women with GDM who had normal weight or were underweight prepregnancy is the same as for those without GDM
Energy intake for overweight or obese women with GDM may be modestly restricted as long as weight gain is appropriate while minimizing risk of ketosis.
TREATMENT Lifestyle changes cessation of smoking and counseling about alcohol consumption.
The most important thing in the reduction of complications among women with GDM is glycemic control GOALS OF MANAGEMENT OUTPATIENT GLUCOSE TRAGETS FOR PREGNANT WOMEN
For GDM treatment goals are: - Pre-prandial glucose concentration of 95mg/dL (5.3 mmol/L) - 1-hour postmeal glucose value of 140mg/dL (7.8 mmol/L) - 2-hour post meal glucose value of 120mg/dL (6.7 mmol/L)
GOALS OF MANAGEMENT For women with pre-existing DM type I or II who become pregnant, goals are: - Premeal, bedtime, and overnight glucose values of 60-99mg/dL (3.3-5.4 mmol/L) - Peak post prandial glucose value of 100- 129mg/dL (5.4- 7.1 mmol/L) - HbA1c of 6%
TREATMENT
The optimal treatment for women with GDM or type 2 DM who are not able to maintain normoglycemia with CHO restricted diet INSULIN TREATMENT Dosages: - 0.7-0.8 U/kg BW on 1 st trimester - 1.0 U/kg BW on 2 nd trimester - 1.2 U/kg BW on 3 rd trimester
- 2/3 given before breakfast, 1/3 given before dinner (NPH insulin) - Regular insulin and rapid acting insulin are best dosed with each meal
TREATMENT Oral Hypoglycemic Agents use? o ACOG and the ADA do not currently recommend oral hypoglycemic agents.
PHARMACOLOGY OF ANTI-DIABETIC DRUGS
Source: Pharmacotherapy 101 by Dr. Agnes Cruz
Sequence of Antihyperglycemic Therapy (ADA, 2012) ORAL HYPOGLYCEMIC AGENTS
Source: Pharmacotherapy 101 by Dr. Agnes Cruz There are currently six classes of oral anti- diabetic agents: Biguanides Insulin Secretagogues Sulphonylureas Insulin Secretagogues Non-sulphonylureas -glucosidase inhibitors Thiazolidinediones (TZDs) DPP-IV Inhibitors
Biguanide: METFORMIN Primary effects are to decrease hepatic glucose production and increase insulin- mediated peripheral glucose uptake Efficacy: HbA1c 1-2% 11-22 mmol/mol FPG 40-70 mg/dl 2.2-3.9 mmol/mol METFORMIN SIDE EFFECTS CONTRAINDICATIONS DRUG INTERACTION Preparation Lactic acidosis (rare; in patients with CHF) Diarrhea and abdominal discomfort Weight loss Kidney failure Liver disease Lactic acidosis Cimetidine Furosemide Nifedipine Tablets: 500, 850, and 1000 mg. Tablets (extended release): 500, 750, and 1000 mg. Solution: 500 mg/5 ml Usual dose: o 500 mg BID to TID Max dose: o 850 mg TID to 3g/day Max effective dose: o 1000 mg BID METFORMIN BRAND NAME STOCK DOSE PRICE RiteMed 500 3.09 Gludin 500 3.20 Neoform 500 3.35 Diamet 500 500 3.50 Pharex 500 3.75 Nidcor 500 4.32 Winthrop 500 4.50 Diafat 500 5.19 Glucoform 500 5.60 I-Max 500 5.60 BRAND NAME STOCK DOSE PRICE Melta-SE 500 6.00 Neomet 500 6.00 Panfor SR 500 6.50 Ansures MR 500 7.00 Glumet 500 7.22 Fornidd 500 7.40 Euform Retard 850 8.90 Humamet 500 9.40 Glucophage 500, 750, 850
Secretagogues These medications try to replace the natural stimulus for beta cells to secrete insulin. SULFONYLUREAS Efficacy: HbA1c 1-2% 11-22 mmol/mol FPG 40-70 mg/dl 2.2-3.9 mmol/mol Short-acting: o Tolbutamide Intermediate-acting: o Tolazamide o Glipizide o Glyburide/ Glibenclamide Long-acting: o Chloropropamide o Glimepiride SULFONYLUREAS SIDE EFFECTS CONTRAINDICATIONS DRUG INTERACTION Hypoglycemia Weight gain IDDM DKA Diabetic Coma Pregnancy, Lactation (next slide) Short-acting: o Tolbutamide: not available Intermediate-acting: o Tolazamide: not available o Glipizide: Minidiab 5,10mg OD max: 40mg/d o Glyburide/ Glibenclamide: Daonil 5mg Maintenance: 5-10 mg/day Long-acting: o Chloropropamide: not available o Glimepiride: Aforglim 2, 3 mg OD o Glicazide: Diamicron 30, 80mg OD
is an insulin secretagogue, with glucoregulatory effects.
for patients whose diabetes was not well- controlled on other oral medications. GLUCAGON-LIKE PEPTIDE 1 AGONISTS Efficacy: HbA1c 1-2% 11-22 mmol/mol FPG 5.76-11.7 mg/dl 0.32-0.65 mmol/mol PPG 6.12-17.28 mg/dl 0.34-0.96 mmol/mol GLUCAGON-LIKE PEPTIDE 1 AGONISTS SIDE EFFECTS CONTRAINDICATIONS DRUG INTERACTION Moderate and transient nausea, vomiting and diarrhea Low risk of hypoglycemia and no evidence of increased CV risk Not for type 1 DM or diabetic ketoacidosis. Do not use in end-stage renal disease or severe renal impairment (<30 mL/min), severe GI disease May increase hypoglycemia when used w/ a sulfonylurea. OC, antibiotics, warfarin Exenatide (Byetta): 250mcg/mL 5mcg/dose bid SC Liraglutide (Victoza): 6mg/mL , 3mL 0.6ml SC daily
Insulin Therapy Characteristics Onset is the length of time before insulin reaches the bloodstream and begins lowering blood glucose.
Peaktime is the time during which insulin is at maximum strength in terms of lowering blood glucose.
Duration is how long insulin continues to lower blood glucose. INSULIN Insulin Therapy Indications o Short-Term Use: Acute illness, surgery, stress and emergencies Pregnancy Breast-feeding Insulin may be used as initial therapy in type 2 diabetes in marked hyperglycaemia Severe metabolic decompensation (diabetic ketoacidosis, hyperosmolar nonketotic coma, lactic acidosis, severe hypertriglyceridaemia)
INSULIN Insulin Therapy o Long-Term Use: If targets have not been reached after optimal dose of combination therapy or BIDS, consider change to multi-dose insulin therapy. When initiating this, insulin secretagogues should be stopped and insulin sensitisers e.g. Metformin or TZDs, can be continued.
Dosing: 0.3 1.5/kg BW Rapid-acting Insulin: Lispro 100IU/ml 3mL (P705.00/cartridge or pen); aspart 100IU/ml 3mL (P724.00/pen): immediately before meals
Short-acting: Humulin-R 100IU/mL, 3mL vial (P1,200): 30 mins before meals
Intermediate-acting: Humulin-N 100IU/mL, 3mL (P526.00/cartridge): AM and PM
Pre-mixed Humulin 70/30 (70% NPH 30% regular insulin) Combination of int. acting + SA
Novomix 30 (70% aspart protamine 30% aspart )
Humalog mix 25 (75% lispro protamine, 25% lispro) Insulin Regimen To augment beta cell function (0.3 U/kg) prevents gluconeogenesis during bedtime - BIDS (Bedtime Insulin dailytime SU) - Example: Gliclazide 80mg OD + Humulin N 10U SC at bedtime
To replace beta cell function (0.6-1.0 U/kg) basal and meal-related (bolus) requirements - Split dose 2/3 1/3 rule given before breakfast/dinner respectively - Split-mixed: Insulatard (int.) 20U + Actrapid (S.A) 6U before breakfast then Insulatard (int.) 10U + Actrapid (S.A) 6U before dinner
- Modified split-mixed: Humulin N 16U (intermediate acting) + Humulin R 4 U (short acting) before breakfast then Humulin R 6 U at lunch then Humulin N 8U (intermediate acting) + Humulin R 4 U (short acting) before dinner
- Basal plus Regimen: Lantus 20U (basal insulin) OD + Humalog (S.A) 10U before lunch - Basal Bolus Regimen: Pre-meal SA + basal insulin i.e., Actrapid 10U SC premeals TID + Humulin N 20U at bedtime TREATMENT ALGORITHM FOR PEOPLE WITH T2DM (IDF)