1) Insulin therapy is recommended for type 2 diabetes patients with an HbA1c ≥9%, significant hyperglycemia, or when other treatments fail to control blood glucose levels.
2) There are several options for insulin therapy including basal insulin only, premixed insulin, or basal-bolus regimens. Basal insulin aims to provide background insulin levels while bolus insulin covers mealtime spikes.
3) When initiating insulin, it is important to assess the patient's needs, educate them on self-monitoring, and start at a low dose such as 0.1-0.2 units/kg of basal insulin daily to minimize risks of hypoglycemia and weight gain. The dose is then gradually
Achieving Hba1c targets: Strategies For Initiating and Intensifying Diabetes ...Nemencio Jr
This module highlights the appropriate HbA1c targets that reduce microvascular and macrovascular complications in appropriate populations and how to safely achieve them with current anti-hyperglycemic agents
Insulin Initiation : When We should Start with Basal Insulin?mataharitimoer MT
Insulin Initiation : When We should Start with Basal Insulin?
Dr. Agus Taolin , SpPD, FINASIM | PAPDI CABANG BOGOR
Disampaikan pada acara PIT VI IDI Kota Bogor | 9 Nopember 2013
Achieving Hba1c targets: Strategies For Initiating and Intensifying Diabetes ...Nemencio Jr
This module highlights the appropriate HbA1c targets that reduce microvascular and macrovascular complications in appropriate populations and how to safely achieve them with current anti-hyperglycemic agents
Insulin Initiation : When We should Start with Basal Insulin?mataharitimoer MT
Insulin Initiation : When We should Start with Basal Insulin?
Dr. Agus Taolin , SpPD, FINASIM | PAPDI CABANG BOGOR
Disampaikan pada acara PIT VI IDI Kota Bogor | 9 Nopember 2013
Insulin intensification : the usage of premixed insulin after basal fails mataharitimoer MT
Insulin intensification : the usage of premixed insulin after basal fails
EDDY SUPRIADI, MD | MARZOEKI MAHDI , MD. HOSPITAL.BOGOR
Disampaikan pada acara PIT VI IDI Kota Bogor | 9 Nopember 2013
Optimising glycaemic control and body weightsimplyweight
This Slideshow gives you insight on the Mix50 insulin
For more information please visit
http://www.simplyweight.co.uk
Articles
http://www.simplyweight.co.uk/articles/
Videos
http://www.simplyweight.co.uk/video/
Blogs
http://simplyweight.co.uk/blogs/
Forum
http://www.simplyweight.co.uk/forum/forum.php
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http://www.simplyweight.co.uk/how-to-contact-us/
This presentation is intended to allied health professional to have a overview of different types of insulin. It is meant to be a memory refresh. It was presented as part of continuing medical education session
Insulin intensification : the usage of premixed insulin after basal fails mataharitimoer MT
Insulin intensification : the usage of premixed insulin after basal fails
EDDY SUPRIADI, MD | MARZOEKI MAHDI , MD. HOSPITAL.BOGOR
Disampaikan pada acara PIT VI IDI Kota Bogor | 9 Nopember 2013
Optimising glycaemic control and body weightsimplyweight
This Slideshow gives you insight on the Mix50 insulin
For more information please visit
http://www.simplyweight.co.uk
Articles
http://www.simplyweight.co.uk/articles/
Videos
http://www.simplyweight.co.uk/video/
Blogs
http://simplyweight.co.uk/blogs/
Forum
http://www.simplyweight.co.uk/forum/forum.php
Contact Us
http://www.simplyweight.co.uk/how-to-contact-us/
This presentation is intended to allied health professional to have a overview of different types of insulin. It is meant to be a memory refresh. It was presented as part of continuing medical education session
Approach to case of type 2 DM
lifestyle modificatios
indications to start drug therapy
classification of antidiabetic drugs , mechanism of action , adeverse drug effects , doses , drug interactions , how to add differents class of drugs to give combination therapy . over view insulin therapy
Case studies in the managment of type 2 diabetes NasserAljuhani
Case 1:Poorly controlled type 2 diabetes on triple oral therapies
Case 2:Morning hypoglycemia on premixed InsulinCase 3
Case 3:Newly diagnosed D.M Type1D.M or type 2 D.M ?
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
3. Approach To Starting and Adjusting
Insulin in Type 2 Diabetes
ADA. 7. Approaches to Glycemic Treatment. Diabetes Care 2015;38(suppl 1):S46. Figure 7.2;
adapted with permission from Inzucchi SE, et al. Diabetes Care, 2015;38:140-149
4. Normal Insulin Secretion
Mealtime (bolus)
insulin needs ~ 50%
Background (Basal) Insulin Needs ~ 50%
Kruszynska et al. Diabetologia 30: 16-21, 1987
Polonsky et a. J. Clin. Invest. 81: 442-48, 1988
Time
5. The Role of Insulin Therapy
Relative Insulin
Deficiency
Pre-diabetes and
Type 2 Diabetes
Insulin
Resistance
Incretin Dysfunction
Insulin
Deficiency
Type 1 Diabetes
Critical role in both Type 1 and Type 2 diabetes
• Greatest potency of available therapies
• Demonstrated benefit – multiple clinical trials
6. Insulin Therapy Nomenclature
• Basal insulin – long-acting insulin that is used to provide a background
level of insulin throughout the day and night
• Bolus insulin – short- or rapid-acting insulin that is used to provide an
increased level of insulin for a short period
• Prandial insulin – bolus insulin administered prior to a meal
• Correction insulin - bolus insulin administered to lower a high blood glucose
level
• Pre-mixed (or Biphasic) insulin- combination of short- or rapid-acting and
intermediate or long-acting insulin used to try to cover both fasting and
prandial insulin needs
9. HbA1c ≥ 9%
Insulin as
initial drug
therapy
Insulin is
strongly
considered
Insulin is
mandatory
Significantly
hyperglycemic
symptoms
PG > (300-350
mg/dl)
HbA1c ≥ (10-
12%)
When it is the time for
insulin!!
Catabolic
features are
exhibited
Ketonurea is
demonstrated
American Diabetes Association. Diabetes Care. 2012;35:1364-1379
Insulin as 3rd
drug agent to
two drug
combination
HbA1c ≥ 8.5%
10. INITIATION AND ADVANCEMENT OF
INSULIN THERAPY IN TYPE 2
DIABETES
Objectives:
1. Understand where insulin treatment fits in the current
guidelines of the ADA and EASD
2. Recognize that there are numerous insulin regimens with
various benefits and risks
3. Become familiar with the initiation and advancement of
basal, premixed, and basal/bolus insulin regimens
11. Insulin Therapy Indications
(1) When significant hyperglycemia (metabolic derangement) is
present at diagnosis (e.g., HbA1c ≥10%); or fasting plasma
glucose (FPG) is >13.9 mmol/L (>250 mg/dl) or random glucose is
>16.7 mmol/L (>300 mg/dl)
(2) When symptomatic (e.g., sudden persistent weight loss, ketosis)
(3) When multiple non-insulin therapies fail to achieve individualized
glycemic targets
(4) When rapid achievement of glucose control is desired (e.g., to
induce “clinical remission,” see Module 2)
12. Preparation for Insulin Initiation
Clinicians are required to:
1. Identify the glycemic defect (i.e., periods of hyperglycemia—fasting
hyperglycemia, postprandial hyperglycemia, and overall glycemic
derangement)
2. Address the concerns of the person with diabetes (see Module 6)
3. Select the appropriate insulin regimen and insulin-delivery device
4. Review/adjust non-insulin therapies
5. Assess the risk of hypoglycemia
6. Review diet and activities of daily living (see Module 6)
13. Principles to Follow for Individuals
Concomitantly
Treated with Non-insulin Agents
1) DPP-4 inhibitor, GLP-1 receptor agonist, α-glucosidase inhibitor,
and/or metformin are usually maintained at usual dose although
they need careful monitoring;
2) Insulin secretagogue dose is often reduced or stopped due to
risk of hypoglycemia and/or excessive weight gain;
3) TZD dose is often reduced or stopped due to risk of
hypoglycemia, excessive weight gain, edema, and/or heart
failure.
14. Clinical Efficacy –
Proportion of patients at HbA1c target <7% with eight
classes of
anti-diabetic drugs in type 2 diabetes: systematic review of
218 randomized controlled trials with 78,945 patients
Non-insulin Therapies Insulin Therapies
Esposito et al. Diabetes, Obesity and Metabolism 14: 228–
233, 2012.
15. Clinical Effectiveness-
Glycemic Response and Attainment of A1C Goals Following Newly
Initiated Insulin Therapy for Type 2 Diabetes
Nicholls et al. Diabetes Care 35:495–497,
2012
17. Antihyperglycemic Therapy in
Type 2 Diabetes
ADA. 7. Approaches to Glycemic Treatment. Diabetes Care 2015;38(suppl 1):S43. Figure 7.1;
adapted with permission from Inzucchi SE, et al. Diabetes Care, 2015;38:140-149
18. Sequential Insulin Strategies in T2DM
Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of
print]
Management of Hyperglycemia in Type 2 Diabetes:
Sequential Insulin Strategies
20. Basal insulin in type 2 diabetes
(e.g. LA 0.1-0.2 U/kg or 10U)
Non-insulin therapies
LA = Long-Acting insulin: Glargine, Detemir
Basal Insulin in Type 2 Diabetes
21. Basal Insulin Options
Glargine and Detemir:
• Lasts up to 24 hours; BID dosing may be required (less
common in T2DM vs. T1DM)
• Decreases risk of hypoglycemia (especially nocturnal)
• Less weight gain
• Less variability in effect
Neutral Protamine Hagedorn (NPH):
• Lasts 10–16 hours
• Peaks 8–10 hours
• Less expensive
• May partly cover meal (e.g., breakfast if taken in morning)
but can result in later hypoglycemia (e.g., early afternoon)
Riddle et al. Diabetes Care. 26:3080-3086; 2003
Raskin et al Diabetes Care. 28:260-265; 2005
22. • Most insulin regimens take into account the individual’s weight at
initiation because doing so will help prevent adverse reactions caused by
over-insulinization (most notably hypoglycemia and weight gain).
• Basal insulin is typically begun at a low dose (e.g., 0.1–0.2 units/kg
per day).
• The most convenient strategy is with a single injection of basal insulin
administered before the evening meal or at bedtime, at an initial dose of
0.1units/kg. This will ensure that changes in blood glucose levels will be
gradual.
• Under special conditions, such as significant hyperglycemia (HbA1c
≥9%) and/or obesity, a starting dose of 0.2 units/kg may be used.
• An alternative, non-weight-based option is to start most individuals
empirically with 10 units, or in obesity up to 20 units, of basal insulin
(i.e., long-acting or intermediate-acting).
Initiating Basal
Insulin
23. Advancing Basal Insulin
If most AM fasting BG
>120 mg/dL
(>6.7 mmol/L)
Titrate until fasting glucose at target BG
• Increase 2 units [or 4 units if FBG >180
mg/dl or 10 mmol/L] every 3 days
• If dose reaches ~0.5 units/kg body weight,
consider adding mealtime insulin
If most AM fasting BG
<120 mg/dL
(<6.7 mmol/L) and
A1C remains above target
Test pre–evening meal and bedtime
(or 2-hour post–evening meal) and consider
need for mealtime insulin
If hypoglycemia or FPG
< 70 mg/dL
Reduce insulin dose by 3 units or 10%,
whichever is greater
25. Insulin Analog Mix 75/25 or 70/30
Starting Premixed Insulin Analogue
Regimen
26. Relatively easy to use
Covers insulin requirements
through most of day
Not very physiological
Less flexibility than
basal(±bolus)
Greater likelihood of
hypoglycemia
More weight gain than basal
Emerging evidence supports
better A1C reduction with
basal/bolus
Premixed Insulin Therapy
Supporting Evidence Non-supporting Evidence
27. • Most insulin regimens take into account the individual’s weight at
initiation because doing so will help prevent adverse reactions caused by
over-insulinization (most notably hypoglycemia and weight gain).
• When using premixed insulin, insulin secretagogues are often
discontinued and other non-insulin therapies should be reconsidered.
• The effectiveness of these medications should be reconsidered in light
of the action of the premixed insulin.
• If the HbA1c is ≥9%, the starting dose of premixed insulin is 0.2
units/kg before the morning and evening meals (total daily dose 0.4
units/kg).
• If the HbA1c is <9%, the starting dose is 0.1 units/kg before the
morning and evening meals (total daily dose 0.2 units/kg).
• Based on glucose monitoring, premixed insulin adjustments of 2 units
is typically recommended.
Initiating Premixed
Insulin
29. Rapid-acting insulin at meals Long-acting
insulin at bed
Starting a Basal and Mealtime
(e.g., Basal-bolus) Insulin Regimen
30. Advancing Insulin Therapy from Basal Insulin
Halt or decrease all insulin
secretagogues
TZDs are often reduced or
stopped due to risk of
hypoglycemia, excessive
weight gain, edema, and/or
heart failure
Initiate SMBG before each
meal (injection)
Consider reducing total basal
dose by 0.1 units/kg
Identify highest consistent
post meal glucose or biggest
meal
Start with 0.1 units/kg or 4
units short- or rapid-acting
insulin
The dose can be further
modified by adding 2 units of
short- or rapid-acting insulin
every 3 days until postprandial
glucose is ≤180 mg/dl (10
mmol/l) as per local titration
guidelines.
Titrate to 0.2 units/kg, and if
the target has not been
reached consider dietary
modifications and/or the
addition of a second bolus
injection and subsequent
injection to full basal-bolus
insulin regimen if needed
31. Adapted from Howey DC, et al. Diabetes. 1994;43(3):396-402
Hours
10
8
6
4
2
0
0 1 2 3 4 5 6 7 8 9 10 11 12
InsulinActivity
RHI
Timing of
food
absorbed
Analog Insulin
Rapid-acting Insulin Analogues Versus
Short-acting Insulin
RHI = regular human insulin.
32. • A basal/bolus insulin regimen can be considered at diagnosis when
rapid achievement of glucose control is desired (e.g., symptomatic, or to
induce “clinical remission,” see Module 2).
• Basal/bolus regimens can also be considered when the combination of
basal or premixed insulin and non-insulin therapies are no longer
effective.
• The minimal starting total daily dose is 0.2 units/kg divided as 50%
long- or intermediate-acting and 50% short- or rapid-acting insulin.
• The basal and bolus doses can be titrated separately. Adequate glucose
monitoring should be consistent with clinical needs and safety.
• It is recommended that this intensive insulin regimen should be
initiated and supervised by a specialist with expertise in diabetes.
• An additional option for intensive insulin therapy is premixed insulin 2–
3 times daily (see previous section on starting and adjusting premixed
insulin).
Initiating Basal-Bolus Insulin
Regimen
33. Starting Basal + Bolus (mealtime) Insulin:
A1C <9% A1C ≥9%
Basal-Bolus
insulin
0.2 units/kg/ day
Basal 0.1 units/kg
+
Mealtime 0.1
units/kg
0.4 units/kg/day
Basal 0.2 units/kg
+
Mealtime 0.2
units/kg
• Stop or reduce insulin secretagogue
• TZDs are often reduced or stopped due to risk of hypoglycemia,
excessive weight gain, edema, and/or heart failure
• Select and calculate starting dose
• Divide 50% background, 50% mealtime
Mazze R, et al. Staged Diabetes Management Adult Quick Guide, 5th Edition Revised, 2010
International Diabetes Center
34. Calculating Basal + Mealtime Insulin Dose:
Calculate insulin dose
Weight in kg ______ x units/kg _____ = _____units long-acting
(LA)
(RA) 80 x units/kg _____ = _____units rapid-acting
Example: T2DM Patient (80 kg) with A1C of 9.6% on
metformin and insulin secretagogue
80 0.2 16
Plan Insulin AM Noon PM Bed
LA 16
RA 5 5 6
0.2 16
Total starting dose = 0.2 units/kg
35. Advanced Skills:
CHO Counting and Correction Factor
Determine Insulin: CHO ratio (I:C)
• Amount of insulin covered by 1 units bolus insulin
• Calculated using “450 rule”; start with Total Daily Dose (TDD)
450/TDD = amount of CHO covered by 1 units insulin
Determine Insulin Sensitivity (“Correction”) Factor
• Number of points 1 units insulin will drop BG
• Calculated using “1500 rule” for short-acting insulin
(and “1800 rule” for rapid-acting insulin analog)
• 1500/TDD = expected BG drop covered by 1 units insulin
Mazze R, et al. Staged Diabetes Management Adult Quick Guide, 5th Edition Revised, 2010
International Diabetes Center
36. Principles for Insulin Therapy
• Narrow the gap between guideline and clinical practice
• A timely introduction of insulin therapy in type 2 diabetes could
protect β-cell function and facilitate effective glycemic control.
• Insulin is highly effective but can pose a challenge for both patients
and healthcare practitioners.
• Clinical and psychological insulin resistance are major obstacles to
better glycemic control.
• Basal-insulin-based optimal insulin regimens provide a safer way to
achieve glucose control with fewer episodes of hypoglycemia and less
weight gain.
• Effective patient-centered insulin therapy can be achieved
safely by recognizing and overcoming the various inherent
challenges.
37. An educational program of the International Diabetes Center.
OBJECTIVES
1. Understand where insulin treatment
fits in the current guidelines of the
ADA and EASD.
1. Recognize that there are
numerous insulin regimens with
various benefits and risks.
2. Become familiar with the
initiation and advancement of
basal, premixed, and basal/bolus
insulin regimens.
SUMMARY
1. Insulin may be initiated after failure of
mono or combination non-insulin
therapies, when symptomatic,
glucotoxicity, or at the request of the
individual with diabetes .
2. Basal, basal/bolus, NPH, premixed
insulin regimen can be used safely and
effectively with appropriate education
and glucose monitoring.
3. Basal, premixed, and basal/bolus
insulin can safely be initiated at low
dose and titrated based on SMBG .
Initiation and Advancement of Insulin
Therapy in Type 2 Diabetes
Editor's Notes
Approach to starting and adjusting insulin in type 2 diabetes. FBG, fasting blood glucose; GLP-1-RA, GLP-1 receptor agonist; hypo, hypoglycemia; mod., moderate; PPG, postprandial glucose; #, number. Adapted with permission from Inzucchi et al. Diabetes Care, 2015;38:140-149
This slide summarizes the general recommendations for antihyperglycemic therapy in type 2 diabetes, as outlined in the ADA-European Association for the Study of Diabetes (EASD) position statement
Definitions: DPP-4-i,DPP-4 inhibitor; Fx’s, bone fractures; GI, gastrointestinal; GLP-1-RA, GLP-1 receptor agonist; HF, heart failure; SU, sulfonylurea; TZD, thiazolidinedione
This 2015 position statement is less prescriptive than prior algorithms and discusses advantages/disadvantages of the available medication classes and considerations for use
A patient-centered approach is stressed, including patient preferences, cost and potential side effects of each class, effects on body weight, and hypoglycemia risk
Metformin is reaffirmed as the preferred initial agent, barring contraindication or intolerance, either in addition to lifestyle counseling and support for weight loss and exercise, or when lifestyle efforts alone have not achieved or maintained glycemic goals
The progressive nature of type 2 diabetes and its therapies should be regularly and objectively explained to patients
Equipping patients with an algorithm for self-titration of insulin doses based on SMBG results improves glycemic control in type 2 diabetic patients initiating insulin3
Basal insulin alone is usually the optimal initial regimen, beginning at 0.1-0.2 U/kg body weight, depending on the degree of hyperglycemia. It is usually prescribed in conjunction with 1-2 non-insulin agents. In patients willing to take >1 injection and who have higher A1c levels (≥9.0%), BID pre-mixed insulin or a more advanced basal plus mealtime insulin regimen could also be considered (curved dashed arrow lines).
When basal insulin has been titrated to an acceptable FPG but A1c remains above target, consider proceeding to basal + meal-time insulin, consisting of 1-3 injections of rapid-acting analogues. A less studied alternative—progression from basal insulin to a twice daily pre-mixed insulin—could be also considered (straight dashed arrow line); if this is unsuccessful, move to basal + mealtime insulin.
The figure describes the number of injections required at each stage, together with the relative complexity and flexibility. Once a strategy is initiated, titration of the insulin dose is important, with dose adjustments made based on the prevailing BG levels as reported by the patient.
Non-insulin agents may be continued, although insulin secretagogues (sulfonylureas, meglitinides) are typically stopped once more complex regimens beyond basal insulin are utilized.
Comprehensive education regarding self-monitoring of BG, diet, exercise, and the avoidance of, and response to, hypoglycemia are critical in any patient on insulin therapy.
Titrating background insulin focus on am fasting BG.
Once you reach 0.5 units/kg body weight, explain to the patient that a RA insulin will need to be added
If fasting BG is in target and A1C > 7%, it means that there are other timepoints throughout the day where the patient is having higher blood sugar. Ask them to do some post meal testing. This also helps them see that they're a partner with you in taking care of their diabetes. They provide you with importnat information which in turn helps you to make the best decision for them.
Testing times
Before meals
Post largest meal to see how the insulin is covering the meal