Practical guide to insulin therapy in primary health care. Types of insulin (basal-bolus, pre-mixed) Insulin regimens (augmentation, total replacement) How to convert from one insulin type to another. Some challenging cases.

1. 1
Practical Guide to
INSULIN THERAPY
In Primary Health Care
Dr. Majdi N. Al-Jasim
Consultant Family Medicine
Research Field Coordinator

3. OBJECTIVES
1. To gain knowledge about the main types of insulin therapy:
▪ Basal-bolus
▪ Pre-mixed
2. To understand the main regimen ways (approaches) to initiate insulin
therapy:
▪ Augmentation regimen (only for DM-2):
✓ How to initiate
✓ How to build up
✓ How to monitor using HBGM
▪ Total replacement regimen:
✓ How to calculate total daily insulin requirement (TDI)
✓ How to distribute the insulin doses based on TDI
requirement
✓ How to monitor using HBGM
3. To understand how to convert from basal-bolus type to pre-mixed type
and vise versa
Dr.
Majdi
AlJasim

4. SCENARIO #1
Um Tahseen is 56 year-old woman who has DM-2 for the
past 10 years, came today for follow-up. She is on the
following medications for DM:
▪ Glibenclamide tab 10mg PO BID
▪ Metformin XR tab 1500mg PO OD
▪ Linagliptin tab 5mg PO OD
Her FBS today is 250mg/dl, HbA1C is 12%, weight is 60Kg,
and she is vitally stable.
How will you manage the case?
Dr.
Majdi
AlJasim

5. 1. Failure of oral treatment.
2. High A1C at time of diagnosis (> 10%).
3. Significant symptomatic hyperglycemia (> 250 mg/dl).
4. Pregnancy.
5. Hospitalization.
WHY Insulin?
Dr.
Majdi
AlJasim

6. POWER of oral drugs on A1C
Dr.
Majdi
AlJasim
0.8% to
1.5%
▪ Sulfonylureas
▪ Biguanides
▪ Thiazolidinediones
▪ GLP-1 agonist
0.5% to
0.9%
▪ DPP4 inhibitors
▪ SGLT2 inhibitors
0.7% to
1.0%
▪ α-glucose inhibitors

7. Case analysis:
A1C is 12%
On Glibenclamide 10mg BID, Metformin XR 1500mg OD, Linagliptin 5mg OD
OPTIONS…
① Add Empagliflozin (SGLT2i)→ Max lowering A1C by about 1%
❷ Add Dulaglutide (GLP1a)→ Max lower to A1C by about 1.5%
▪ Adding both may reduce A1C by 2.5% total, and so A1C will be 9.5%
which is still not on target.
Back to our case…
Dr.
Majdi
AlJasim
So the patient needs insulin

8. Insulin Types

9. ▪ NPH (Humulin N®)
▪ Glargine (Lantus®, Basaglar®, Toujeo®)
▪ Detemir (Levemir®)
▪ Degludec (Tresiba®)
Insulin Types
1 Basal-Bolus Type
Dr.
Majdi
AlJasim
Basal Bolus (Meal)
▪ Regular (Humilin R® )
▪ Lispro (Humalog®)
▪ Aspart (Novorapid®)
▪ Glulisine (Apidra®)

10. Insulin Types
1 Basal-Bolus Type
Dr.
Majdi
AlJasim
Basal
Bolus
About 4 hrs

11. Insulin Types
1 Basal-Bolus Type
Dr.
Majdi
AlJasim
Hirsch IB. Insulin analogues. N Engl J Med. 2005;352(2):177

12. Insulin Types
Dr.
Majdi
AlJasim
Resemble the natural way !!
Diabetes Education Online. University of California, San Francisco. http://www.deo.ucsf.edu

13. Insulin Types
1 Basal-Bolus Type
Dr.
Majdi
AlJasim
Basal

14. Insulin Types
1 Basal-Bolus Type
Dr.
Majdi
AlJasim
Bolus

15. It is a mixture of short acting insulin with intermediate acting insulin.
Examples:
▪ Mixtard 30® → Regular 30% + NPH 70%
▪ NovoMix 30® → Aspart 30% + Aspart protamine 70%
▪ Humalog Mix25® → Lispro 25% + Lispro protamine 75%
▪ Humalog Mix50® → Lispro 50% + Lispro protamine 50%
The number in the trade name represent the short acting insulin percentage.
Insulin Types
2 Pre-Mixed Type
Dr.
Majdi
AlJasim

16. Insulin Types
2 Pre-Mixed Type
Dr.
Majdi
AlJasim

17. Insulin Types
2 Pre-Mixed Type
Dr.
Majdi
AlJasim
Endotext.org. insulin pharmacology, types of regimens and adjustment

18. Insulin Types
2 Pre-Mixed Type
Dr.
Majdi
AlJasim

19. Which insulin type to start with?
It is better for these cases to start with
AUGMENTATION approach, starting with basal
insulin alone at first (to break insulin fear).
Back to our case…
Dr.
Majdi
AlJasim
Basal insulin may work alone if A1C < 9.5%

20. Augmentation
Regimen
Insulin Regimens

21. What is pre-prandial fasting state?
It means no calories intake for at least 8 hours except for water.
How to start basal insulin?
Either you start with 10U or 0.1U/Kg
How to adjust basal insulin?
The target pre-prandial FBS is 70 - 130mg/dl. Increase the dose by 2U every 3 days until you reach
the goal. If pre-prandial FBS is < 70mg/dl, decrease the dose by 2U.
Augmentation Regimen
Step 1.
Add basal insulin to current medications. No need to modify or discontinue any medication.
Basal insulin will take care of pre-prandial blood sugar on fasting state.
Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen

22. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim

23. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim

24. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim
▪ The best time to monitor the effect of basal insulin is before breakfast.
▪ If you use before launch and before dinner time, make sure it is in fasting
state (8 hours with no calories intake)

25. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim
Basal insulin curse!
The upper limit to increase the dose of basal
insulin SHOULD NOT exceed 0.7 of patient
weight (Max dose benefit).
Our patient is 60Kg, so the upper limit of basal
insulin increment is (60 x 0.7 = 42 units)

26. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim
 Basal
insulin dose
 Anabolic
effect
( Hunger)
 Food intake
( weight)
 Insulin
resistance
 Blood
sugar
Basal insulin cursed cycle!

27. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim
Patient instructions
▪ Your basal insulin starting dose is 10U (or 0.1U/Kg,
patient weight is 60Kg so 6U).
▪ Check your fasting blood sugar daily before breakfast.
▪ Your target sugar is 70mg/dl - 130mg/dl
✓ insulin by 2 units every 3 days till fasting < 130
✓ If sugar goes < 70,  the dose by 2 units
▪ Whatever happened, do not exceed 42U
▪ When sugar at target, stay on same dose until your
next appointment with your family physician.

28. On 3 months follow-up, patient brought her
blood glucose monitoring chart:
Her new HbA1C is 9.8%
What are you going to do?
Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen
110
115
90
118
She is currently on:
▪ Glibenclamide 10mg BID.
▪ Metformin XR 1500mg OD
▪ Linagliptin 5mg OD
▪ Glargine insulin 16U OD HS

29. Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen
Case analysis:
▪ A1C gets to 9.8%.
▪ The pre-prandial blood sugar is at target
Next step is to check post-prandial glucose

30. Do we need to modify patient medications?
Stop any sulfonylurea that its action time duration (about 14 hrs) overlap with
bolus insulin.
Augmentation Regimen
Step 2.
Add bolus insulin to current medications at the time of patient biggest meal.
Bolus insulin will take care of post-prandial blood sugar of that meal.
Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen
How to start bolus insulin?
Start with 4U
How to adjust bolus insulin?
The target 2 hrs post-prandial is 70 - 180mg/dl. Increase the dose by 2U every 3 days until you
reach the goal. If 2 hrs post-prandial is < 70mg/dl, decrease the dose by 2U.

31. Patient said her biggest meal is on launch. So your current
prescription is:
▪ Glibenclamide tab 5mg PO at dinner only
▪ Metformin XR tab 1500mg PO OD
▪ Linagliptin tab 5mg PO OD
▪ Glargine insulin S/C 16U OD HS
▪ Aspart insulin S/C 4U before launch
Why have you kept Glibenclamide at dinner?
Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen
Aspart will be given
at noon.
Glibenclamide
morning dose
duration will overlap
with aspart, unlike
night dose

32. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim

33. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim
▪ To monitor basal insulin, use before breakfast readings.
▪ To monitor launch bolus insulin, use 2 hours after launch readings.

34. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim
Patient instructions
▪ Your bolus insulin before launch time by 5min is 4U.
▪ Check your blood sugar 2 hours after launch daily
▪ Your target sugar is 70mg/dl - 180mg/dl
✓ insulin by 2 units every 3 days till fasting < 180
✓ If sugar goes < 70,  the dose by 2 units
▪ When sugar at target, stay on same dose until your
next appointment with your family physician.

35. Patient 3 months follow-up chart:
HbA1C is 9.0%.
What are you going to do next?
Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen
100
115
125
108
150
175
155
145
She is currently on:
▪ Glibenclamide 10mg at dinner.
▪ Metformin XR 1500mg OD
▪ Linagliptin 5mg OD
▪ Glargine insulin 16U OD HS
▪ Aspart insulin 10U before launch

36. Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen
Case analysis:
▪ A1C gets to 9.0%.
▪ The pre-prandial blood sugar is at target
▪ The 2-hrs post launch blood sugar is at target
Next step is to check post-prandial glucose of other meals

37. Do we need to modify patient medications?
Stop any sulfonylurea that its action time duration (about 10 hrs) overlap with
bolus insulin.
Augmentation Regimen
Step 3.
Add bolus insulin to current medications at the time of patient second biggest meal.
Bolus insulin will take care of post-prandial blood sugar of that meal.
Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen
How to start bolus insulin?
Start with 4U
How to adjust bolus insulin?
The target 2 hrs post-prandial is 70 - 180mg/dl. Increase the dose by 2U every 3 days until you
reach the goal. If 2 hrs post-prandial is < 70mg/dl, decrease the dose by 2U.

38. Patient said her second biggest meal is at dinner. So your
current prescription is:
▪ Metformin XR tab 1500mg PO OD
▪ Linagliptin tab 5mg PO OD
▪ Glargine insulin S/C 16U OD HS
▪ Aspart insulin S/C 10U before launch
▪ Aspart insulin S/C 4U before dinner
Why did you stop Glibenclamide at dinner?
Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen

39. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim
▪ To monitor basal insulin, use before breakfast readings.
▪ To monitor launch bolus insulin, use 2 hours after launch readings.
▪ To monitor dinner bolus insulin, use 2 hours after dinner readings.

40. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim
Patient instructions
▪ Your bolus insulin before dinner time by 5min is 4U.
▪ Check your blood sugar 2 hours after dinner daily
▪ Your target sugar is 70mg/dl - 180mg/dl
✓ insulin by 2 units every 3 days till fasting < 180
✓ If sugar goes < 70,  the dose by 2 units
▪ When sugar at target, stay on same dose until your
appointment

41. Patient 3 months follow-up chart:
HbA1C is 8.0%.
What are you going to do next?
Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen
105
120
115
118
170
158
164
157
155
149
175
140
She is currently on:
▪ Metformin XR 1500mg OD
▪ Linagliptin 5mg OD
▪ Glargine insulin 16U OD HS
▪ Aspart insulin 10U before launch
▪ Aspart insulin 8U before dinner

42. Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen
Case analysis:
▪ A1C gets to 8.0%.
▪ The pre-prandial blood sugar is at target
▪ The 2-hrs post launch blood sugar is at target
▪ The 2-hrs post dinner blood sugar is at target
Next step is to check post-prandial glucose of other meals

43. Augmentation Regimen
Step 4.
Add bolus insulin to current medications at the time of patient third meal.
Bolus insulin will take care of post-prandial blood sugar of that meal.
Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen

44. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim
Basal
insulin
effect
Breakfast
time
Bolus
insulin
effect
Launch
time
Bolus
insulin
effect
Dinner
time
Bolus
insulin
effect
▪ To monitor basal insulin, use before breakfast readings.
▪ To monitor launch bolus insulin, use 2 hours after launch readings.
▪ To monitor dinner bolus insulin, use 2 hours after dinner readings.
▪ To monitor breakfast bolus insulin, use 2 hours after breakfast readings.

45. Case Approach: Augmentation Regimen
Dr.
Majdi
AlJasim
Home message
▪ Basal insulin acts on pre-meal blood sugar on fasting state.
▪ Bolus insulin acts on post-meal blood sugar.
Golden Rule

46. Why don’t we start patient with bolus insulin at the beginning instead of basal insulin
with augmentation regimen? Why it should be basal insulin first..!!
Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen
■ Pre-prandial
Post-prandial
As A1C gets above 8.5%,
the effect of pre-prandial
hyperglycemia overcomes
the post-prandial one.
Monnier L, et al. Diabetes Care
2003;26(3):881-85.

47. Why don’t doctors do the insulin dose adjustment with augmentation regimen? Why it
should be done by patient at home..!!
Dr.
Majdi
AlJasim
Case Approach: Augmentation Regimen
■ Patient algorithm
Doctor algorithm
- Patient algorithm:  A1C by
1.22%.
- Doctor algorithm:  A1C by
1.08%.
p<0.001
Davies M, et al. Diabetes Care
2005;28(6):1282-8. AT.LANTUS STUDY

48. Replacement
Regimen
Insulin Regimens

49. Dr.
Majdi
AlJasim
Abu Ahmed is 49 year-old man who has DM-2 and
stage 3b CKD, his doctor told him he must shift to
insulin therapy instead of oral hypoglycemic agents
otherwise he will progress to end-stage CKD.
His FBS today is 240mg/dl, HbA1C is 12.5%, weight
is 80Kg, and he is vitally stable.
How will you approach the case?
SCENARIO #2

50. Case analysis:
▪ A1C is 12.5%
▪ Stage-3b CKD, weight is 80Kg
OPTIONS…
Shift him to insulin
Dr.
Majdi
AlJasim
The patient needs insulin (total replacement)
Case Approach: Replacement Regimen

51. Do we need to modify patient medications?
It is better to stop all medications especially sulfonylurea and those with
contraindications.
Replacement Regimen
Step 1.
Calculate Total Daily Insulin (TDI) requirement:
TDI index is a wide range from 0.1 – 1 unit/Kg. As a general rule, start with 0.2 unit/Kg for
DM-1 (insulin sensitive) and 0.5 unit/Kg for DM-2 (insulin resistant).
Dr.
Majdi
AlJasim
Case Approach: Replacement Regimen
How to adjust replacement insulin?
The target pre-prandial is 70 – 130mg/dl and 2 hrs post-prandial is 70 - 180mg/dl.
Increase the dose by 2U every 3 days until you reach the goal. If blood sugar is < 70mg/dl,
decrease the dose by 2U.

52. Calculating TDI requirement:
▪ Patient is DM-2.
▪ Patient weight is 80Kg.
▪ Since he is DM-2, we will use 0.5 unit/Kg TDI index.
▪ So TDI requirement = weight × TDI index
= 80 × 0.5
= 40 units per day
Dr.
Majdi
AlJasim
Case Approach: Replacement Regimen

53. Replacement Regimen
Step 2.
Replacement using Basal-Bolus insulin type:
▪ Use 60% of TDI requirement as Basal insulin.
▪ Use 40% of TDI requirement as total Bolus insulin → distribute third the total for each
meal, then take some units from the lightest meal and add it to the biggest meal.
▪ Same as before but use 50% of TDI for Basal insulin and 50% of TDI for total Bolus insulin.
Dr.
Majdi
AlJasim
Case Approach: Replacement Regimen
OPTION A:
60% to 40% method
50% to 50% method

54. Replacement Regimen
Step 2.
Dr.
Majdi
AlJasim
Case Approach: Replacement Regimen
Replacement using Pre-mixed insulin type:
▪ Distribute ½ of TDI requirement at AM and ½ of TDI requirement at PM.
▪ Put ⅔ of TDI requirement at the part of time when the patient is most likely awake, and
⅓ of TDI requirement at the other part of time.
N.B: Always start with Mix25 or Mix30
OPTION B:
½ to ½ method
⅔ to ⅓ method

55. Using Basal Bolus insulin type as replacement (60% : 40%)
▪ TDI requirement is 40 units per day.
▪ Use 60% of that as basal insulin, and 40% as bolus insulin.
▪ So calculated basal insulin = TDI requirement × 60% = 40 × 60% = 24 units
▪ So calculated total bolus insulin = TDI requirement × 40% = 40 × 40% = 16 units
▪ So bolus dose at each meal = total bolus insulin ÷ 3 meals = 16 ÷ 3 = 6 units in
each meal
➢ Before breakfast 6 units (the lightest meal)
➢ Before launch 6 units (the biggest meal)
➢ Before dinner 6 units
Dr.
Majdi
AlJasim
Case Approach: Replacement Regimen
Basal insulin dose = 24 units
Bolus insulin doses:
Before breakfast 4 units
Before launch 8 units
Before dinner 6 units
OPTION A:

56. Using Basal Bolus insulin type as replacement (50% : 50%)
▪ TDI requirement is 40 units per day.
▪ Use 50% of that as basal insulin, and 50% as bolus insulin.
▪ So calculated basal insulin = TDI requirement × 50% = 40 × 50% = 20 units
▪ So calculated total bolus insulin = TDI requirement × 50% = 40 × 50% = 20 units
▪ So bolus dose at each meal = total bolus insulin ÷ 3 meals = 20 ÷ 3 = about 7
units in each meal
➢ Before breakfast 7 units (the lightest meal)
➢ Before launch 7 units (the biggest meal)
➢ Before dinner 7 units
Dr.
Majdi
AlJasim
Case Approach: Replacement Regimen
Basal insulin dose = 20 units
Bolus insulin doses:
Before breakfast 5 units
Before launch 9 units
Before dinner 7 units
OPTION A:

57. Case Approach: Replacement Regimen
Dr.
Majdi
AlJasim
Basal insulin curse!
The upper limit to increase the dose of basal
insulin SHOULD NOT exceed 0.7 of patient
weight (Max dose benefit).
Our patient is 80Kg, so the upper limit of basal
insulin increment is (80 x 0.7 = 56 units)
Have you
missed
me!!

58. Case Approach: Replacement Regimen
Dr.
Majdi
AlJasim
▪ Pre-prandial goal of blood sugar is 70 – 130 mg/dl.
▪ 2 hours post-prandial goal of blood sugar is 70 – 180 mg/dl.
Basal
insulin
effect
Breakfast
time
Bolus
insulin
effect
Launch
time
Bolus
insulin
effect
Dinner
time
Bolus
insulin
effect

59. Using Pre-mixed insulin type as replacement
Dr.
Majdi
AlJasim
Case Approach: Replacement Regimen
OPTION B:
Method #1 (½ to ½)
Since TDI requirement is 30 units/day, so the dose will be:
▪ AM Pre-mixed 25% insulin = TDI × ½ = 30 × ½ = 15 units
▪ PM Pre-mixed 25% insulin = TDI × ½ = 30 × ½ = 15 units
Method #2 (⅔ to ⅓)
Since TDI requirement is 30 units/day, so the dose will be:
▪ AM Pre-mixed 25% = TDI × ⅔ = 30 × ⅔ = 20 units (assuming
patient is awaked at this time)
▪ PM Pre-mixed 25% insulin = TDI × ⅓ = 30 × ⅓ = 10 units

60. Case Approach: Replacement Regimen
Dr.
Majdi
AlJasim
AM
Pre-mixed
insulin
rapid
part
effect
AM Pre-mixed insulin
intermediate part
effect
PM
Pre-mixed
insulin
rapid
part
effect
▪ Pre-prandial goal of blood sugar is 70 – 130 mg/dl.
▪ 2 hours post-prandial goal of blood sugar is 70 – 180 mg/dl.
PM
Pre-mixed
insulin
intermediate
part
effect
PM
Pre-mixed
insulin
intermediate
part
effect

61. Case Approach: Replacement Regimen
Dr.
Majdi
AlJasim
Home message
Basal-bolus insulin replacement can be titrated by patient at
home until it reaches its goal.
On another hand, Pre-mixed insulin replacement is more
difficult to patient to titrate the dose at home and must be
followed by physician.
Important…

62. Insulin
Conversion

63. After 1 year, Um Tahseen back to the clinic after hearing from her
friends that she was deceived by her physician and there is
another regimen that requires fewer injections instead of 4
injections a day. She insisted to change her insulin regimen. Her
current insulin regimen consists of:
▪ Glargine insulin S/C 20U OD HS
▪ Aspart insulin S/C 8U before breakfast
▪ Aspart insulin S/C 14U before launch
▪ Aspart insulin S/C 12U before dinner
How will change her regimen from basal-bolus insulin type to
pre-mixed insulin type?
Dr.
Majdi
AlJasim
SCENARIO #4

64. Calculate TDI
▪ In already established patient on insulin, TDI is just a summation of insulin
doses the patient is taking daily.
▪ In our case, the patient is taking:
▪ Glargine insulin S/C 20U OD HS
▪ Aspart insulin S/C 8U before breakfast
▪ Aspart insulin S/C 14U before launch
▪ Aspart insulin S/C 12U before dinner
Dr.
Majdi
AlJasim
Insulin Conversion (basal-bolus to pre-mixed)
Step: 1
Calculate Total Daily Insulin (TDI) requirement:
Glargine dose + Aspart dose before breakfast + Aspart dose before launch + Aspart dose
before dinner
TDI = 20 + 8 + 14+ 12 = 54 units/day

65. Basal-bolus TO Pre-mixed TDI conversion ratio
Dr.
Majdi
AlJasim
Step: 2
Basal-bolus TDI = Pre-mixed TDI
Basal-bolus TDI = 20 + 8 + 14+ 12 = 54 units/day
So Pre-mixed TDI = 54 units/day
1:1
CONVERSION
Insulin Conversion (basal-bolus to pre-mixed)

66. Distribution of new doses
▪ ALWAYS, ALWAYS start with Mix25% or Mix30%.
▪ Either you distribute with ½ to ½ OR ⅔ to ⅓ :
Dr.
Majdi
AlJasim
Step: 3
TDI = 54 units/day
▪ So Pre-mixed 25% AM dose = 54 × ½ = 27 units before breakfast
▪ Also Pre-mixed 25% PM dose = 54 × ½ = 27 units before dinner
½ to ½ method
TDI = 54 units/day
▪ So Pre-mixed 25% AM dose = 54 × ⅔ = 36 units before breakfast
assuming this is the time the patient will still awake.
▪ Also Pre-mixed 25% PM dose = 54 × ⅓ = 18 units before dinner
⅔ to ⅓ method
Insulin Conversion (basal-bolus to pre-mixed)

67. Dr.
Majdi
AlJasim
SCENARIO #4
Abu Ahmed picked the pre-mixed insulin type since it is
fewer injections. You tried to explain to him that basal-
bolus is better because he could titrate the dose by
himself, but he insisted on pre-mixed type.
After 1 year, his CKD deteriorated and came to you in
order to change his insulin regimen
He is currently on:
▪ Pre-mixed 25% insulin S/C 40units AM
▪ Pre-mixed 25% insulin S/C 20units PM
How will change his regimen from pre-mixed insulin
type to basal-bolus insulin type?

68. Calculate TDI
▪ In already established patient on insulin, TDI is just a summation of insulin
doses the patient is taking daily.
▪ In our case, the patient is taking:
▪ Pre-mixed 25% insulin S/C 40 units before breakfast
▪ Pre-mixed 25% insulin S/C 20 units before dinner
Dr.
Majdi
AlJasim
Insulin Conversion (pre-mixed to basal-bolus)
Step: 1
Calculate Total Daily Insulin (TDI) requirement:
Pre-mixed 25% dose before breakfast + Pre-mixed 25% dose before dinner
TDI = 40 + 20 = 60 units/day

69. Pre-mixed TO Basal-bolus TDI conversion ratio
Dr.
Majdi
AlJasim
Step: 2
Pre-mixed TDI = Basal-bolus TDI
Pre-mixed TDI = 40 + 20 = 60 units/day
So Basal-bolus TDI = 60 units/day
1:1
CONVERSION
Insulin Conversion (pre-mixed to basal-bolus)

70. Distribution of new doses
▪ Either you distribute with 60% basal to 40% bolus, OR 50% basal to 50% bolus, OR old school way
Dr.
Majdi
AlJasim
Step: 3
TDI = 60 units/day
▪ So Basal dose = 60 × 60% = 36 units
▪ Also total Bolus dose = 60 × 40% = 24 units
▪ Each meal bolus dose = total bolus dose ÷ 3 meals = 24 ÷ 3 = 8
8 units before breakfast 6 units before breakfast
8 units before launch 10 units before launch
8 units before dinner 8 units before dinner
60% to 40% method
Insulin Conversion (pre-mixed to basal-bolus)
Adjustment

71. Distribution of new doses
Dr.
Majdi
AlJasim
Step: 3
TDI = 60 units/day
▪ So Basal dose = 60 × 50% = 30 units
▪ Also total Bolus dose = 60 × 50% = 30 units
▪ Each meal bolus dose = total bolus dose ÷ 3 meals = 30 ÷ 3 = 10
10 units before breakfast 8 units before breakfast
10 units before launch 12 units before launch
10 units before dinner 10 units before dinner
50% to 50% method
Insulin Conversion (pre-mixed to basal-bolus)
Adjustment

72. Distribution of new doses
Dr.
Majdi
AlJasim
Step: 3
TDI = 60 units/day
▪ Since the patient was using Mix25%, it means 25% of the dose is
rapid insulin and 75% of the dose is intermediate insulin.
▪ So total rapid insulin = TDI × 25% = 60 × 25% = 15 units per day
▪ And total intermediate insulin = TDI × 75% = 60 × 75% = 45 units per
day
▪ Total Bolus dose = Total calculated rapid dose = 15 units
▪ Each meal bolus dose = total bolus dose ÷ 3 meals
= 15 ÷ 3 = 5 units in each meal
▪ Total Basal dose = 80% of total calculated intermediate dose
= 45 × 80% = 36 units
Old school way
Insulin Conversion (pre-mixed to basal-bolus)

74. This is home blood sugar monitoring chart of 41 year-old man, weight
is 80 Kg.
What are you going to do?
Dr.
Majdi
AlJasim
105
120
115
118
110
100
105
115
155
149
175
140
He is using:
▪ Pre-mixed 25% insulin 35 units
before breakfast
▪ Pre-mixed 25% insulin 20 units
before dinner
SCENARIO #5
250
230
240
260
85
75
78
88

75. Case analysis:
▪ The patient has ↑ 2hrs after breakfast readings.
▪ The patient has ↓ before launch readings.
▪ The pre-mixed insulin dose responsible for these readings is AM dose.
Dr.
Majdi
AlJasim
Case Approach: Scenario #5
Thinking…
▪ If we ↑ the AM dose, the 2hrs after breakfast readings will be corrected
(rapid part), but the patient will suffer from hypoglycemia before launch
(intermediate part)..!!!
▪ If we ↓ the AM dose, the before launch readings will be fine (intermediate
part), but the patient will suffer from more hyperglycemia 2hrs after
breakfast (rapid part)..!!!

76. Dr.
Majdi
AlJasim
Case Approach: Scenario #5
Is there a way just to ↑ the rapid
part and to ↓ the intermediate
part of AM pre-mixed 25%
insulin?
Did anybody ask for
help?!!

77. Case Approach: Scenario #5
▪ Pre-mixed 50% insulin 35 units before breakfast
▪ Pre-mixed 25% insulin 20 units before dinner
Dr.
Majdi
AlJasim

78. This is home blood sugar monitoring chart of 45 year-old man, weight
is 100 Kg.
What are you going to do?
Dr.
Majdi
AlJasim
200
171
162
189
155
146
169
147
240
234
244
227
He is using:
▪ Pre-mixed 25% insulin 46 units
before breakfast
▪ Pre-mixed 25% insulin 30 units
before dinner
SCENARIO #6
150
130
140
160
72
75
71
72

79. Case analysis:
▪ The patient has ↑ before breakfast readings.
▪ The patient has ↑ after dinner readings.
▪ The patient has ↓ mid-night (3 AM) readings.
▪ The pre-mixed insulin dose responsible for these readings is PM dose.
Dr.
Majdi
AlJasim
Case Approach: Scenario #6
Thinking…
▪ SOMOGYI EFFECT, If the blood sugar level drops too low in the early
morning hours, hormones (such as growth hormone, cortisol, and
catecholamines) are released. These help reverse the low blood sugar level
but may lead to blood sugar levels that are higher than normal in the
morning.
▪ The cause: high PM intermediate part insulin dose.

80. Dr.
Majdi
AlJasim
Case Approach: Scenario #6
I got it, let’s change
PM pre-mixed 25% to
pre-mixed 50%
What a little champ
we have here ☺

81. Case Approach: Scenario #6
▪ Pre-mixed 25% insulin 46 units before breakfast
▪ Pre-mixed 50% insulin 30 units before dinner
Dr.
Majdi
AlJasim

82. This is home blood sugar monitoring chart of 46 year-old man, weight
is 96 Kg.
What are you going to do?
Dr.
Majdi
AlJasim
120
115
100
108
155
140
142
136
130
141
152
142
He is using:
▪ Aspart 12 units before breakfast
▪ Aspart 18 units before launch
▪ Aspart 14 units before dinner
▪ Glargine 24 units OD HS
SCENARIO #7
300
270
223
280
145
136
134
130
240
260
256
238

83. Case analysis:
▪ The patient has ↑ before launch readings.
▪ The patient has ↑ before dinner readings.
▪ The basal insulin is responsible for pre-prandial readings.
Dr.
Majdi
AlJasim
Case Approach: Scenario #7
Thinking…
▪ Glargine effect duration may vary for each individual with a duration of
action as short as 11 hours, causing not enough basal insulin level to
control all pre-prandial blood sugar.
▪ The fix: Add second dose of glargine in AM (start with 8-10 units), or
change basal insulin to more extended-duration analogue like degludec.
(Eldrisi etal, Twice-daily insulin glargine for patients with uncontrolled type 2 diabetes mellitus. J Clin Transl Endocrinol. 2018 Dec 11;15:35-36)

84. Case Approach: Scenario #7
▪ Aspart 12 units before breakfast
▪ Aspart 18 units before launch
▪ Aspart 14 units before dinner
▪ Glargine 24 units at 10:00 PM and 10 units at
10:00 AM
Dr.
Majdi
AlJasim
Option #1

85. Case Approach: Scenario #7
▪ Aspart 12 units before breakfast
▪ Aspart 18 units before launch
▪ Aspart 14 units before dinner
▪ Degludec 24 units OD HS
Dr.
Majdi
AlJasim
Option #2

86. This is home blood sugar monitoring chart of 46 year-old man, weight
is 96 Kg.
What are you going to do?
Dr.
Majdi
AlJasim
70
65
67
68
155
140
142
136
130
141
152
142
He is using:
▪ Aspart 16 units before breakfast
▪ Aspart 20 units before launch
▪ Aspart 18 units before dinner
▪ Glargine 44 units OD HS
SCENARIO #8
300
270
223
280
145
136
134
130
240
260
256
238

87. Case analysis:
▪ The patient has ↓ before breakfast readings.
▪ The patient has ↑ before launch readings.
▪ The patient has ↑ before dinner readings.
▪ The basal insulin is responsible for pre-prandial readings.
Dr.
Majdi
AlJasim
Case Approach: Scenario #8
Thinking…
▪ Glargine dose is ↑ at night that causes hypoglycemia before breakfast.
However, the duration of glargine here seems to be less than 24 hours
causing hyperglycemia before launch and before dinner.
▪ The fix: Split the dose of glargine into PM dose and AM dose. By doing so
we will improve pre-prandial hypo and hyperglycemia.
(Eldrisi etal, Twice-daily insulin glargine for patients with uncontrolled type 2 diabetes mellitus. J Clin Transl Endocrinol. 2018 Dec 11;15:35-36)

88. Case Approach: Scenario #8
▪ Aspart 16 units before breakfast
▪ Aspart 20 units before launch
▪ Aspart 18 units before dinner
▪ Glargine 22 units at 10:00 PM and 22 units at
10:00 AM
Dr.
Majdi
AlJasim

89. This is home blood sugar monitoring chart of 42 year-old man, weight
is 115 Kg.
What are you going to do?
Dr.
Majdi
AlJasim
200
190
205
215
305
270
255
295
300
288
291
289
SCENARIO #9
125
118
128
123
165
156
154
155
200
190
205
195
215
200
220
225
He is using:
▪ Pre-mixed 25% insulin 48 units
before breakfast
▪ Pre-mixed 25% insulin 36 units
before dinner

90. Dr.
Majdi
AlJasim
AM
Pre-mixed
insulin
rapid
part
effect
AM Pre-mixed insulin
intermediate part
effect
PM
Pre-mixed
insulin
rapid
part
effect
PM
Pre-mixed
insulin
intermediate
part
effect
PM
Pre-mixed
insulin
intermediate
part
effect
Case Approach: Scenario #9

91. Dr.
Majdi
AlJasim
Case Approach: Scenario #9
Thinking…
Since the patient has ↑ readings at 3 AM that leads to ↑ readings before breakfast (dawn phenomenon), and
↑ readings 2hrs after dinner, it is safe to ↑ the PM dose using pre-mixed 25%.
The real challenge is AM dose..!!!
▪ If we ↑ the AM dose using pre-mixed 25%, we will have risk of hypoglycemia before launch (75% of
mixture is intermediate part).
▪ If we ↑ the AM dose using pre-mixed 50%, the 2hrs after launch, and before dinner readings will not be
controlled at first (50% of mixture is intermediate part); however, if we try to ↑ the dose even further,
there will be a risk of hypoglycemia 2hrs after breakfast and before launch.
200
190
205
215
305
270
255
295
300
288
291
289
125
118
128
123
165
156
154
155
200
190
205
195
215
200
220
225

92. Dr.
Majdi
AlJasim
Case Approach: Scenario #9
The best approach here is to
convert patient to basal-bolus
regimen.
Another approach is to add 3rd dose
of pre-mixed insulin at noon before
launch.

93. Dr.
Majdi
AlJasim
Case Approach: Scenario #9
Intermediate
dose 3
Rapid
dose 1
Intermediate
dose 1
Intermediate
dose 1
Intermediate
dose 1
Rapid
dose 3
Intermediate
dose 3
Rapid
dose 2
Intermediate
dose 2
Intermediate
dose 2
Intermediate
dose 2
Pre-mixed
dose 1
Pre-mixed
dose 2
Pre-mixed
dose 3

94. Dr.
Majdi
AlJasim
Case Approach: Scenario #9
Advise…!!
This regimen (3 pre-mixed doses) is very hard to adjust and my advise to you
is just to shift patient to basal-bolus regimen.
200
190
205
215
305
270
255
295
300
288
291
289
125
118
128
123
165
156
154
155
200
190
205
195
215
200
220
225

95. At 24 weeks of gestation, a 32 years old lady was
diagnosed to have gestational diabetes. Her weight
is 56Kg. She was consulted on starting insulin since
she has a high risk pregnancy, and she agreed.
How will you approach this case?
Dr.
Majdi
AlJasim
SCENARIO #10

96. Dr.
Majdi
AlJasim
Case Approach: Scenario #10
▪ The approach is as same as with non-pregnant individual, but you will be
more strict.
▪ You will titrate the insulin dose according to HBGM since A1C will not be
accurate indicator during 2nd and 3rd trimester of pregnancy.
▪ It is better to use basal-bolus type instead of pre-mixed type since this is
high risk period and no need to wait for adjusting doses at doctor office.
▪ Pre-prandial goal of blood sugar in pregnancy is 70 – 100 mg/dl.
▪ 2 hours post-prandial goal of blood sugar in pregnancy is 70 – 140 mg/dl.

97. Dr.
Majdi
AlJasim
Case Approach: Scenario #10

98. Dr.
Majdi
AlJasim
Case Approach: Scenario #10
Which insulin to use during pregnancy? Blum AK. Insulin Use in Pregnancy: An Update. Diabetes Spectr. 2016;29(2):92-7

99. Dr.
Majdi
AlJasim
Case Approach: Scenario #10

100. Dr.
Majdi
AlJasim
Case Approach: Scenario #10
Correcting dose with bolus insulin during pregnancy

101. Case Approach: Scenario #10
▪ Aspart 4 units before breakfast
▪ Aspart 6 units before launch
▪ Aspart 4 units before dinner
▪ Detemir 14 units OD HS
Correcting dose
Dr.
Majdi
AlJasim

102. Please, share management with endocrinologist or diabetologist if
you have the following cases in whom insulin is used:
▪ Type-1 DM.
▪ Gestational DM.
▪ Type-2 DM with TDI ≥ 2 units/kg.
▪ Existence of severe DM complications.
Dr.
Majdi
AlJasim
Last message