This document provides guidelines for initiating and adjusting insulin therapy for type 2 diabetes. It outlines a step-by-step regimen beginning with initiating either bedtime intermediate-acting insulin or bedtime or morning long-acting insulin. It instructs to monitor fasting blood glucose and increase the insulin dose until the target range is achieved. Additional injections of rapid-acting insulin are added before meals if blood glucose levels remain out of range. The regimen is monitored every 3 months by checking HbA1c and adjusting insulin doses up or down based on blood glucose levels and HbA1c targets.

1. ‫درملنه‬ ‫پواسطه‬ ‫انسولین‬ ‫د‬
Insulin Therapy
‫کوونکی‬ ‫وړاندې‬ ‫او‬ ‫ترتیب‬:
‫څپاند‬ ‫هللا‬ ‫عصمت‬ ‫ډاکتر‬
Dr. A s m a t u l l a h S a p a n d

2. ‫انــسـولـیـن‬Insulin
•‫دی‬ ‫جوړښت‬ ‫جوړشوی‬ ‫امینواسیدونوڅخه‬ ‫له‬ ‫انسولین‬
‫د‬ ‫برخې‬ ‫اندوکراین‬ ‫د‬ ‫پانکراس‬ ‫د‬ ‫چې‬Langerhans
‫د‬ ‫جزایرو‬Beta‫افرازیږي‬ ‫او‬ ‫جوړ‬ ‫پواسطه‬ ‫حجراتو‬.
•‫دند‬ ‫مهمه‬ ‫یوه‬ ‫دندوترڅنګ‬ ‫ډیرشمیر‬ ‫دنورو‬ ‫دانسولین‬‫ه‬
‫دی‬ ‫مصرف‬ ‫او‬ ‫کنټرول‬ ‫ګلوکوز‬ ‫د‬ ‫وینې‬ ‫د‬.
•‫د‬ ‫انسولین‬T1DM‫د‬ ‫او‬ ‫ناروغانو‬ ‫ټولو‬ ‫په‬T2DM‫په‬
‫د‬ ‫چې‬ ‫کې‬ ‫ناروغانو‬ ‫ځینو‬Oral agents‫پواسطه‬
‫کیږي‬ ‫کارول‬ ‫نشي‬ ‫کنټرول‬.

3. ‫د‬Basal‫او‬Bolus‫مفکوره‬ ‫انسولین‬
•‫ګلوک‬ ‫اودشپني‬ ‫غذاګانوترمنځ‬ ‫د‬ ‫انسولین‬ ‫نوموړي‬‫وز‬
‫کنټرولوي‬ ‫سویه‬.
•‫لري‬ ‫لیول‬ ‫ثابت‬ ً‫ا‬‫نسبت‬.
•‫ډوز‬ ‫ورځني‬ ‫دمجموعي‬ ‫انسولین‬ ‫د‬50%‫جوړوي‬.
Basal Insulin:
Bolus Insulin:
•‫سویه‬ ‫ګلوکوز‬ ‫وروسته‬ ‫غذاڅخه‬ ‫د‬ ‫انسولین‬ ‫نوموړي‬
‫کنټرولوي‬.
•‫ک‬ ‫یوساعت‬ ‫په‬ ‫او‬ ‫پیلوي‬ ‫اغیزه‬ ‫کې‬ ‫موده‬ ‫دڅودقیقوپه‬‫ې‬
Peak‫رسیږي‬ ‫ته‬.
•‫ډوز‬ ‫ورځني‬ ‫دمحموعي‬ ‫انسولین‬ ‫د‬10-20%‫تشکیلوي‬

4. Bolus insulins (Mealtime or prandial)
Insulin Type Onset of
action
Peak of
action
Duration of
action
Human
regular
Short acting 30-60 minutes 2 hours 6-8 hours
Insulin analogs
(Lispro,Aspart,
Glulisin)
Rapid acting 5-15 minutes 1-1.5 hours 3-4 hours
Inhaled insulin Rapid acting 5-15 minutes 1 hours 3 hours

5. Pre-mixed Insulins
Insulin Composition Examples
NPH-Regular 70% NPH
30% Regular
Humulin 70/30
Dongsulin 70/30
Mixtard 70/30
Insulin Composition Example
Rapid acting
aspart
(Free and soluble)
+
Intermediate acting
aspart(protaminated-
crystallized
30% rapid acting aspart
+70 % intermediate
acting aspart(IAA)
NovoMix 30
Humolog Mix 25
Humolog Mix 50
(25% lispro75%IAA)
(50% lispro 50%IAA)

6. Basal insulins
NPH
• Humulin N (Eli Lilly)
• Insulatard (Novo)
(also available as insulatard Novolet pen)
• Dongsulin N (Highnoon)
• Insuget N (Getz)
===========================================
Analogs
• Glargine (Lantus)
Lantus Solostar Pen (Sanofi Aventis)
• Detemir (Levimir) by Novo
• Degludec (Novo Nordisk)

7. Basal Insulins
Insulin Type Onset of
action
Peak of
action
Duration
of action
NPH Intermediate
acting
2-4 hours 6-7 hours 10-20
hours
Glargine
(Lantus)
Aventis
Long
acting
0.5-1 hours flat ~ 24 hours
Detemir
(Levimir)Novo
Long
acting
0.5-1 hours flat 17 hours
Degludec Long
acting
0.5-1.5
hours
flat More than
42 hours

9. Indications for Insulin Use in Type 2 Diabetes
‫کې‬ ‫دوران‬ ‫په‬ ‫دحمل‬
‫لري‬ ‫اړتیا‬ ‫ته‬ ‫بستر‬ ‫چې‬ ‫ناروغي‬ ‫حاده‬ ‫هغه‬
Perioperative/intensive care unit setting
Postmyocardial infarction
High-dose glucocorticoid therapy
‫چې‬ ‫کله‬oral agents‫ونلري‬ ‫استطباب‬ ‫اویاهم‬ ‫وي‬ ‫وړنه‬ ‫دتحمل‬
Newly diagnosed type 2 diabetes with significantly elevated blood
glucose levels (pts with severe symptoms or DKA)
‫هغه‬T2DM‫د‬ ‫چې‬ ‫ناروغان‬OAD‫د‬combination‫نشي‬ ‫کنټرول‬ ‫هم‬ ‫سره‬ ‫کارونې‬

11. Inadequate
Non pharmacological
therapy
1oral agent
2 oral
agents
3 oral
agents
Add Insulin Earlier in the Algorithm
•Severe symptoms
•Severe
hyperglycaemia
•Ketosis
•pregnancy
Proposed Algorithm of therapy for Type 2
Diabetes

12. ‫لومړی‬ ‫لور‬ ‫په‬ ‫تراپي‬ ‫دانسولین‬
‫ګام‬

13. ‫ګــــټـــــي‬ ‫تـــــراپـــــي‬ ‫دانــسـولـیـن‬
•‫موجوده‬ ‫دټولو‬Antidiabetic‫درمل‬ ‫پخوانی‬ ‫درملو‬.
•‫د‬glycaemia‫اوغوره‬ ‫مخکښ‬ ‫ترټولو‬ ‫کې‬ ‫کنترول‬ ‫په‬
‫درمل‬:
–HbA1c‫راکموي‬ ‫وي‬ ‫چې‬ ‫سویه‬ ‫هره‬ ‫په‬.
–‫چې‬ ‫ډوزنشته‬ ‫اعظمي‬ ‫داسې‬ ‫دانسولین‬
‫مؤثردرملیزتاثیرونلري‬.
•‫په‬triglyceride‫او‬HDLc‫لري‬ ‫اغیزې‬ ‫مثبتې‬.

14. ‫عیبونه‬ ‫تـراپــي‬ ‫دانـسـولـیـن‬
•‫زیاتیدنه‬ ‫وزن‬~2-4 kg
–‫کړي‬ ‫رامنځته‬ ‫ثباتي‬ ‫بې‬ ‫وعایي‬ ‫قلبي‬ ‫ممکن‬.
•Hypoglycemia
–‫په‬ ‫پیښې‬ ‫هایپوګالیسیمیا‬ ‫دشدیدې‬DMT2‫کمې‬ ‫ډیرې‬ ‫کې‬
‫ترسترګوکیږي‬.
Type 1 DM: 61 events per 100 patient-years
Type 2 DM: 1-3 events per 100 patient-years

15. The ADA Treatment
Algorithm for the Initiation
and Adjustment of Insulin
‫په‬ ‫عیارولو‬ ‫او‬ ‫دپیل‬ ‫تراپي‬ ‫دانسولین‬
‫ادارې‬ ‫منظوردامریکادشکردکنټرول‬
(ADA)‫الګوریتم‬ ‫درملیز‬

16. Regimen # 1
‫رژیم‬ ‫لومړی‬

17. Initiating and Adjusting Insulin
Continue regimen; check
HbA1c every 3 months
If fasting BG in target range, check BG before lunch, dinner, and bed.
Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
Recheck pre-meal BG levels and if out of range, may need to add another
injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin
If HbA1c ≤7%...
Bedtime intermediate-acting insulin, or
bedtime or morning long-acting insulin
(initiate with 10 units or 0.2 units per kg)
Check FG and increase dose until in target range.
If HbA1c 7%...
Hypoglycemia
or FG >3.89 mmol/l (70 mg/dl):
Reduce bedtime dose by ≥4 units
(or 10% if dose >60 units)
Pre-lunch BG out of range: add
rapid-acting insulin at breakfast
Pre-dinner BG out of range: add NPH insulin at
breakfast or rapid-acting insulin at lunch
Pre-bed BG out of range: add
rapid-acting insulin at dinner
Continue regimen; check
HbA1c every 3 months
Target range:
3.89-7.22 mmol/L
(70-130 mg/dL)
Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.
If HbA1c ≤7%... If HbA1c 7%...

18. Step One…
Continue regimen; check
HbA1c every 3 months
If fasting BG in target range, check BG before lunch, dinner, and bed.
Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
Recheck pre-meal BG levels and if out of range, may need to add another
injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin
If HbA1c ≤7%...
Bedtime intermediate-acting insulin, or
bedtime or morning long-acting insulin
(initiate with 10 units or 0.2 units per kg)
Check FG and increase dose until in target range.
If HbA1c 7%...
Hypoglycemia
or FG >3.89 mmol/l (70 mg/dl):
Reduce bedtime dose by ≥4 units
(or 10% if dose >60 units)
Pre-lunch BG out of range: add
rapid-acting insulin at breakfast
Pre-dinner BG out of range: add NPH insulin at
breakfast or rapid-acting insulin at lunch
Pre-bed BG out of range: add
rapid-acting insulin at dinner
Continue regimen; check
HbA1c every 3 months
Target range:
3.89-7.22 mmol/L
(70-130 mg/dL)
If HbA1c ≤7%... If HbA1c 7%...
Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.

19. ‫مرحله‬ ‫لومړی‬:‫پیلول‬ ‫دانسولین‬
•‫کړئ‬ ‫پیل‬ ‫یو‬ ‫ډولوڅخه‬ ‫الندې‬ ‫له‬ ‫دانسولین‬:
–Bedtime intermediate-acting insulin or
–Bedtime or morning long-acting insulin
‫او‬ ‫دژونددطریقې‬ ‫دناروغ‬ ‫رژیمونه‬ ‫دانسولین‬
‫عیاریږي‬ ‫نیولوسره‬ ‫نظرکې‬ ‫په‬ ‫غذا‬

20. ‫ادامــــــــــــــــه‬...........
•FBG‫ترڅوچې‬ ‫کړی‬ ‫زیات‬ ‫ډوز‬ ‫اودانسولین‬ ‫وګورئ‬
FBG‫شي‬ ‫کنټرول‬:
– Target range: 3.89-7.22 mmol/l (70-130 mg/dl)
– Typical dose increase is 2 units every 3 days, but if
fasting glucose >10 mmol/l (>180 mg/dl), can
increase by large increments (e.g., 4 units every 3
days)

21. •‫هم‬ ‫اویا‬ ‫شي‬ ‫واقع‬ ‫هایپوګالیسیمیا‬ ‫چیرې‬ ‫که‬fasting
glucose < 3.89 mmol/l (70 mg/dl)…‫نو‬:
–‫د‬ ‫ډوز‬ ‫شپې‬ ‫د‬≥4 units‫یا‬10%‫چیرې‬ ‫که‬ ‫کړئ‬ ‫کم‬ ‫اندازه‬ ‫په‬
‫ډوز‬ ‫مجموعي‬>60 units‫وي‬.
‫ادامـــــــــــــه‬........
‫د‬Postprandial hyperglycemia‫خاطرد‬ ‫دکمولوپه‬
Basal insulin‫او‬ ‫شپې‬ ‫د‬ ‫پواسطه‬Fasting‫هایپرګالیسمیا‬
‫مطلوب‬ ‫زموږ‬ ‫ترڅو‬ ‫کوي‬ ‫بسنه‬ ‫کنټرول‬A1C‫راشي‬ ‫السته‬.
‫چې‬ ‫کله‬Basal insulin‫نو‬ ‫کیږي‬ ‫کارول‬ ‫ډول‬ ‫یوازې‬ ‫په‬OADs‫باید‬ ‫ته‬
‫شي‬ ‫ورکړل‬ ‫ادامه‬.

22. •‫چیرې‬ ‫که‬HbA1c‫له‬7%‫نو‬ ‫وي‬ ‫کم‬ ‫څخه‬:
–‫وروسته‬ ‫میاشتې‬ ‫درې‬ ‫هرې‬ ‫او‬ ‫ورکړئ‬ ‫ادامه‬ ‫ته‬ ‫رژیم‬ ‫نوموړي‬
HbA1c‫کړئ‬ ‫چېک‬.
•‫چیرې‬ ‫که‬HbA1c≥7%‫نو‬ ‫وي‬:
–‫کړئ‬ ‫پیل‬ ‫حرکت‬ ‫ته‬ ‫مرحلې‬ ‫دوهمې‬.
2-3‫وروسته‬ ‫میاشتې‬....

23. Continue regimen; check
HbA1c every 3 months
If fasting BG in target range, check BG before lunch, dinner, and bed.
Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
Recheck pre-meal BG levels and if out of range, may need to add another
injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin
If HbA1c ≤7%...
Bedtime intermediate-acting insulin, or
bedtime or morning long-acting insulin
(initiate with 10 units or 0.2 units per kg)
Check FG and increase dose until in target range.
If HbA1c 7%...
Hypoglycemia
or FG >3.89 mmol/l (70 mg/dl):
Reduce bedtime dose by ≥4 units
(or 10% if dose >60 units)
Pre-lunch BG out of range: add
rapid-acting insulin at breakfast
Pre-dinner BG out of range: add NPH insulin at
breakfast or rapid-acting insulin at lunch
Pre-bed BG out of range: add
rapid-acting insulin at dinner
Continue regimen; check
HbA1c every 3 months
Target range:
3.89-7.22 mmol/L
(70-130 mg/dL)
If HbA1c ≤7%... If HbA1c 7%...
Step Two…
Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.

24. ‫مرحله‬ ‫دویمه‬:‫زیاتول‬ ‫دزرقونو‬ ‫دانسولین‬
‫چیرې‬ ‫که‬FBS‫خو‬ ‫وي‬ ‫کې‬ ‫لیول‬ ‫مطلوب‬ ‫په‬HbA1c7‫له‬ ‫یا‬7‫څخه‬
‫نود‬ ‫وي‬ ‫زیات‬lunch،Dinner‫او‬bedtime‫دشکر‬ ‫دوینې‬ ‫مخکې‬ ‫څخه‬
‫وګورئ‬ ‫اندازه‬:
• If pre-lunch blood glucose is out of range,
add rapid-acting insulin at breakfast
• If pre-dinner blood glucose is out of range,
add NPH insulin at breakfast or rapid-acting insulin at
lunch
• If pre-bed blood glucose is out of range,
add rapid-acting insulin at dinner

25. ‫عیارول‬ ‫ډوز‬ ‫د‬ ‫انسولین‬ ‫د‬
•‫د‬ ً‫ال‬‫معمو‬ ‫انسولین‬ ‫نوموړي‬4units‫پیل‬ ‫شاوخواکې‬ ‫په‬
ً‫ا‬‫تقریب‬ ‫د‬ ‫ورځوکې‬ ‫درو‬ ‫هرو‬ ‫او‬ ‫کیږي‬2 units‫اندازه‬ ‫په‬
‫د‬ ‫څو‬ ‫تر‬ ‫عیاریږي‬ ‫کم‬ ‫اویا‬ ‫زیات‬FBS‫مطلوب‬ ‫اندازه‬
‫ورسیږي‬ ‫ته‬ ‫لیول‬.
‫یادونه‬:‫زرقونه‬ ‫انسولین‬ ‫د‬ ‫چې‬ ‫کله‬1-2‫نو‬ ‫رسیږي‬ ‫ته‬
sulphonylureas‫شي‬ ‫قطع‬ ‫باید‬.

26. • If HbA1c is <7%...
– Continue regimen and check HbA1c every
3 months
• If HbA1c is ≥7%...
– Move to Step Three…
2-3‫وروسته‬ ‫میاشتې‬

27. Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.
Continue regimen; check
HbA1c every 3 months
If fasting BG in target range, check BG before lunch, dinner, and bed.
Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
Recheck pre-meal BG levels and if out of range, may need to add another
injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin
If HbA1c ≤7%...
Bedtime intermediate-acting insulin, or
bedtime or morning long-acting insulin
(initiate with 10 units or 0.2 units per kg)
Check FG and increase dose until in target range.
If HbA1c 7%...
Hypoglycemia
or FG >3.89 mmol/l (70 mg/dl):
Reduce bedtime dose by ≥4 units
(or 10% if dose >60 units)
Pre-lunch BG out of range: add
rapid-acting insulin at breakfast
Pre-dinner BG out of range: add NPH insulin at
breakfast or rapid-acting insulin at lunch
Pre-bed BG out of range: add
rapid-acting insulin at dinner
Continue regimen; check
HbA1c every 3 months
Target range:
3.89-7.22 mmol/L
(70-130 mg/dL)
If HbA1c ≤7%... If HbA1c 7%...
Step Three…

28. ‫مرحله‬ ‫دریمه‬:‫کول‬ ‫نورقوي‬ ‫دانسولین‬
•‫پ‬ ‫دزیاتوالي‬ ،‫وګورئ‬ ‫هم‬ ‫شکربیا‬ ‫دوینې‬ ‫غذامخکې‬ ‫له‬‫ه‬
‫کړئ‬ ‫وراضافه‬ ‫هم‬ ‫زرق‬ ‫دریم‬ ‫دانسولین‬ ‫کې‬ ‫صورت‬.
•‫که‬HbA1c‫الهم‬7‫نو‬ ‫وي‬ ‫زیات‬ ‫اویا‬:
–‫خوړلو‬ ‫غذا‬ ‫له‬2‫وګورئ‬ ‫ګولوز‬ ‫وروسته‬ ‫ساعته‬.
–‫د‬ ‫وړاندې‬ ‫عذا‬ ‫له‬ ‫کې‬ ‫صورت‬ ‫په‬ ‫لوړوالي‬ ‫د‬Rapid‫ډوز‬ ‫انسولین‬
‫کړئ‬ ‫عیار‬.

29. Regimen # 2
‫رژیم‬ ‫دوهم‬

30. ‫مجموعي‬ ‫انسولین‬ ‫د‬ ‫لومړی‬
‫کړئ‬ ‫محاسبه‬ ‫ډوز‬
Body weight in kgs / 2
• e.g.; an 80 kg person will require roughly about
40 units / day.

31. ‫محاسبه‬ ‫دډوز‬........‫ادامه‬....
‫مساوي‬ ‫څلورو‬ ‫په‬ ‫مقدار‬ ‫مجموعي‬ ‫شوی‬ ‫محاسبه‬s/c
‫وویشئ‬ ‫زرقونو‬:
– ¼ of total dose as regular insulin s/c
half-hour ( ½ hr ) before the three main
meals with 6 hrs gap in between.
– ¼ total calculated dose as NPH insulin
s/c at 11:00 p.m. with no food to follow.

32. ‫مثال‬
For example in an 80-kg diabetic requiring 40 units per day,
start with:
• 08:00 a.m. --- 10 units regular insulin s/c ½ hr before
breakfast.
• 02:00 p.m. --- 10 units regular insulin s/c ½ hr before lunch.
• 08:00 p.m. --- 10 units regular insulin s/c ½ hr before dinner.
• 11:00 p.m. --- 10 units NPH/ lantus insulin s/c

33. Dose adjustment
‫عیارونه‬ ‫ډوز‬
•‫سهار‬ ‫په‬ ‫ورځې‬ ‫منظوردراتلونکي‬ ‫دعیارولوپه‬ ‫دډوز‬
FBS‫مهال‬ ‫شپې‬ ‫د‬ ‫مطابق‬ ‫لیول‬ ‫د‬ ‫هغې‬ ‫اود‬ ‫کړئ‬ ‫چېک‬
NPH‫عیارکړئ‬ ‫ډوز‬.
•‫د‬FBS‫مهال‬ ‫شپې‬ ‫د‬ ‫کې‬ ‫صورت‬ ‫په‬ ‫دزیاتوالي‬NPH
‫ډوز‬‫د‬ ‫ورځ‬ ‫هره‬2 units‫کړئ‬ ‫زیات‬ ‫ترهغې‬ ‫اندازه‬ ‫په‬
‫د‬ ‫چې‬FBS‫اندازه‬80-110mg/dl‫ورسیږي‬ ‫ته‬.

34. ‫عیارونه‬ ‫ډوز‬ ‫د‬......‫ادامه‬
•‫د‬FBS‫په‬ ‫ګلوکوز‬ ‫دوینې‬ ‫وروسته‬ ‫ترکنترولیدو‬‫الندې‬
6‫ونیسئ‬ ‫ترنظرالندې‬ ‫نقطوکې‬:
– Fasting.
– 2 hours after breakfast.
– Before lunch (and noon insulin)
– 2 hours after lunch.
– Before dinner (AND EVENING INSULIN)
– 2 hours after dinner

35. RBS‫د‬regular insulin‫په‬ ‫ډوز‬ ‫مخکیني‬ ‫د‬
‫کړئ‬ ‫کنترول‬ ‫سره‬ ‫عیارولو‬

36. ‫مـــثـــــالــــــونـــــــه‬
• For the following profile:
– Blood sugar fasting = 180
mg/dl
– Blood sugar after breakfast =
250 mg/dl.
– Blood sugar pre lunch = 190
mg/dl
– Blood sugar post lunch 270 =
mg/dl
– Blood sugar pre dinner = 200
mg/dl
– Blood sugar post dinner 260 =
mg/dl
• We need to increase the dose
of NPH at night to bring
down baseline sugar level
(BSF) to around 100 mg/dl
after which the profile should
automatically adjust as
follows:
– Blood sugar fasting = 100
mg/dl
– Blood sugar 02 hrs after
breakfast = 170 mg/dl
– Blood sugar pre-lunch =
110 mg/dl
– Blood sugar 2 hrs. after
lunch = 190 mg/dl
– Blood sugar pre-dinner =
120 mg/dl
– Blood sugar 2 hrs. post
dinner = 180 mg/dl

37. ‫ادامـــــه‬
• Blood sugar fasting = 130 mg/dl
• Blood sugar after breakfast = 160 mg/dl
• Blood sugar pre-lunch = 130 mg/dl
• Blood sugar post lunch = 240 mg/dl
• Blood sugar pre-dinner = 180 mg/dl
• Blood sugar 2 hrs. post dinner = 200 mg/dl
• This patient needs adjustment of pre-lunch regular
Insulin which will bring down post lunch and pre dinner
readings within normal limits.
• 2 hrs post dinner blood sugar(200 mg/dl) will be
brought down by adjusting pre dinner regular insulin.

38. Combinations
‫کارونه‬ ‫انسولین‬ ‫څوډوله‬ ‫د‬
•‫شکرپه‬ ‫د‬T2‫دوینې‬ ‫چې‬ ‫کله‬ ‫ناروغانوکې‬
‫فش‬ ‫کوم‬ ‫تر‬ ‫اوناروغ‬ ‫راغی‬ ‫الندې‬ ‫شکرترکنترول‬‫ار‬
‫مجموعي‬ ‫انسولین‬ ‫نود‬ ‫ؤ‬ ‫نه‬ ‫هم‬ ‫الندې‬
‫ډوز‬((‫سهار‬R+‫غرمه‬R+‫ماښام‬R+‫د‬11:00pm
NPH))‫د‬premixed-insulin‫دوه‬ ‫په‬12‫ساعته‬
s/c‫کوو‬ ‫عوض‬ ‫باندې‬ ‫زرقونو‬.

39. ‫مثالونه‬
• e.g-1; If a patient is
stabilized on
• 10U R + 12U R +
10U R + 12U NPH;
• then he may be
shifted to
• 44/2 = 22 units of
70/30 Insulin 12
hourly s/c ½ hr before
meal.
• e.g-2; If the
adjusted Insulin is
• 14U R+16U R+12U
R+8U NPH,
• then split the total
dose:
30 U 70/30 before
breakfast and 20U
70/30 before dinner
to compensate for the
high morning and lunch
Insulin.

40. Combinations………‫ادامه‬
• Problem: Remember that BD dosing usually fails to
cover lunch, especially if it is heavy. So:
• Always check for post lunch hyperglycemia when using
this regimen.
• Solution:
1. Patients can be advised to take their lunch (heavier
meal) at breakfast; and breakfast (lighter meal) at
lunch.
2. Adding Glucobay with lunch some times provides a
reasonable control.
3. An alternate combination to overcome the problem is
regular insulin for morning and noon, with premixed
insulin at night.

41. Example
• 10U R before breakfast + 12U R
before lunch + 22U 70/30 before
dinner.

42. Choice of regimens
‫رژیم‬ ‫کاریدونکي‬ ‫زیات‬ ‫سره‬ ‫ترتیب‬ ‫په‬‫ونه‬
1. R+ R+ R+ L****
2. R+ R+ R+ N ***
3. R+ R+ premixed insulin**
4. BD premixed insulins*

43. Regimen # 3
‫رژیم‬ ‫دریم‬
(Pre mixed)

44. ‫د‬oral‫د‬ ‫سره‬ ‫درملو‬Basal insulin‫په‬ ‫ډول‬ ‫ځانګړي‬ ‫په‬ ‫کول‬ ‫اضافه‬
‫چې‬ ‫ناروغانوکې‬ ‫هغه‬HbA1c‫یې‬7-10%‫تحمل‬ ‫ډول‬ ‫ښه‬ ‫په‬ ‫وي‬ ‫پورې‬
‫کیږي‬.

45. •‫نظر‬FBS‫هر‬ ‫ته‬3-5‫د‬ ‫وروسته‬ ‫ورځې‬
basal insulin‫چې‬ ‫ترهغې‬ ‫عیاریږي‬ ‫ډوز‬
FBS<120mg/dl‫شي‬.
•‫د‬FBS،Post prandial‫دکنترول‬ ‫ګلوکوز‬
‫مطلوب‬ ‫د‬ ‫او‬HbA1c‫د‬ ‫لپاره‬ ‫راوړلو‬ ‫السته‬ ‫د‬
‫مهال‬ ‫شپې‬basal insulin‫پام‬ ‫د‬ ‫کول‬ ‫اضافه‬
‫لري‬ ‫رول‬ ‫وړ‬.

46. The prandial insulins
‫کاریدونکي‬ ‫یوځای‬ ‫سره‬ ‫غذا‬ ‫له‬
‫انسولین‬
Rapid and Regular insulin

47. ‫د‬regular insulin‫محدودیتونه‬ ‫استعمال‬ ‫د‬
•‫باید‬ ‫کبله‬ ‫له‬ ‫کیدلو‬ ‫پیل‬ ‫ځنډ‬ ‫په‬ ‫تاثیر‬ ‫د‬30-45‫شي‬ ‫زرق‬ ‫مخکې‬ ‫غذا‬ ‫له‬ ‫دقیقې‬.
•‫کیږي‬ ‫سبب‬ ‫نارامۍ‬ ‫د‬ ‫دناروغ‬.
•‫تر‬ ‫آن‬ ‫موده‬ ‫اوږده‬ ‫تاثیر‬ ‫د‬12‫غذا‬ ‫له‬ ‫امله‬ ‫دې‬ ‫له‬ ‫چې‬ ‫پورې‬ ‫ساعتونو‬4-6
‫د‬ ‫وروسته‬ ‫ساعته‬hypoglycemia‫کیږي‬ ‫سبب‬.
•‫د‬hyperinsulinemia‫زیاتوي‬ ‫خطر‬.

48. Prandial insulin‫او‬ ‫کوالی‬ ‫پیل‬ ‫څنګه‬
‫شو؟‬ ‫عیاروالی‬
(Starting Insulin in Patients(T2DM) With A1C > 10.0%)

49. Regular insulin and Rapid
acting analogues(Lispro)

50. ‫د‬prandial insulin‫دوه‬ ‫الندې‬ ‫په‬ ‫عیارول‬ ‫ډوز‬
‫لري‬ ‫اړه‬ ‫پورې‬ ‫فکتورونو‬:
.1‫لیول‬ ‫ګلوکوز‬ ‫د‬ ‫مخکې‬ ‫غذا‬ ‫له‬
.2‫مقدار‬ ‫کاربوهایدریت‬ ‫د‬ ‫کې‬ ‫غذا‬ ‫په‬

51. •‫په‬T2DM‫کې‬ ‫ناروغانو‬rapid acting insulin‫په‬
‫عیاریږي‬ ‫ډول‬ ‫الندې‬.
-1 U‫هر‬ ‫د‬10g‫لپاره‬ ‫کاربوهایدریت‬
-1 U‫هر‬ ‫د‬30mg‫له‬ ‫چې‬ ‫لپاره‬ ‫ګلوکوز‬target
100mg/dl‫زیاتیږي‬ ‫څخه‬.
‫لیول‬ ‫ګلوکوز‬ ‫یوناروغ‬ ‫د‬ ‫ډول‬ ‫په‬ ‫دمثال‬160mg/dl‫او‬ ‫دی‬
‫غواړي‬30g‫باید‬ ‫ناروغ‬ ‫نوموړی‬ ،‫واخلي‬ ‫کاربوهایدریت‬5
Urapid insulin‫واخلي‬.

52. ‫اړون‬ ‫نو‬ ‫ټاکلی‬ ‫مقدارنشي‬ ‫دکاربوهایدریت‬ ‫غذا‬ ‫د‬ ‫ناروغ‬ ‫چیرې‬ ‫که‬‫ده‬
‫په‬ ‫ته‬ ‫ډول‬ ‫دغذا‬ ‫نظر‬ ‫ډوز‬ ‫دانسولین‬ ‫چې‬ ‫شي‬ ‫کوالی‬ ‫ډاکتر‬
empirical‫کړي‬ ‫تعین‬ ‫ډول‬.
5 U‫غذا‬ ‫کوچنۍ‬ ‫د‬
‫او‬
8-10 U‫لپاره‬ ‫غذا‬ ‫لویې‬ ‫د‬
‫د‬ ‫نظر‬ ‫انسولین‬ ‫اضافي‬ ‫ورسره‬pre-meal‫ته‬ ‫لیول‬ ‫ګلوکوز‬

53. ‫د‬prandial‫سا‬ ‫لپاره‬ ‫دتعین‬ ‫دډوز‬ ‫انسولین‬‫ده‬
‫زرق‬ ‫انسولین‬ ‫ډوز‬ ‫یو‬ ‫سره‬ ‫غذا‬ ‫دهرې‬ ‫الره‬
‫دي‬ ‫کول‬(5-10)

54. ‫د‬regular‫او‬rapid‫انسولینو‬
‫عیارونه‬

55. ‫د‬ ‫ډوز‬ ‫انسولینو‬ ‫نوموړو‬ ‫د‬20%‫او‬ ‫کم‬ ‫اندازه‬ ‫په‬
‫شئ‬ ‫زیاتوالی‬
‫آخلي‬ ‫ډوز‬ ‫الندې‬ ‫ناروغ‬ ‫یو‬ ‫که‬ ‫توګه‬ ‫په‬ ‫مثال‬ ‫د‬:
1-10 units…………….+/- 2 unit
11-20 units……………+/- 4 units
21-30 units……………+/- 6units
31-40 units……………+/- 8 units…………………..

56. Pre-Mixed (70/30)‫څنګه‬ ‫انسولین‬
‫شو؟‬ ‫کوالی‬ ‫پیل‬

57. For pre mixed insulins(70/30 preparations)
‫مرحله‬ ‫لومړنۍ‬:‫کړئ‬ ‫محاسبه‬ ‫ډوز‬ ‫مجموعي‬ ‫ورځنی‬ ‫انسولین‬:
body weight(kg)/2
‫یوناروغ‬ ‫که‬ ً‫ال‬‫مث‬60kg‫نو‬ ‫ولري‬ ‫وزن‬60/2=30
‫مرحله‬ ‫دوهمه‬:‫په‬ ‫ډوز‬ ‫شوی‬ ‫محاسبه‬3‫وویشئ‬ ‫برخو‬ ‫مساوي‬:30/3
10+10+10
‫مرحله‬ ‫دریمه‬:2/3‫او‬ ‫سهار‬ ‫برخه‬1/3‫کړئ‬ ‫زرق‬ ‫ماښام‬ ‫برخه‬:
Morning=20U Evening=10 U

58. ‫د‬Pre-mixed(70/30)‫عیارونه‬ ‫ډوز‬ ‫انسولین‬

59. ‫د‬Pre-mixed‫د‬ ‫ډوز‬ ‫انسولین‬10%‫یا‬ ‫کم‬ ‫اندازه‬ ‫په‬
‫شئ‬ ‫زیاتوالی‬:
‫آخلي‬ ‫ډوز‬ ‫الندې‬ ‫ناروغ‬ ‫یو‬ ‫که‬ ً‫ال‬‫مث‬:
1-10 units…………….+/- 1 unit
11-20 units……………+/- 2 units
21-30 units……………+/- 3 units
31-40 units……………+/- 4 units…………………..

60. ‫ستونزې‬ ‫عامې‬

61. ‫وشي‬ ‫باید‬ ‫دستونزومخنیوی‬
•‫تړون‬ ‫دناروغ‬ ‫سره‬ ‫ویش‬ ‫مهال‬ ‫منظم‬ ‫له‬
‫هواروي‬ ‫ستونزې‬:
– Regular meals
– Regular injections
– Regular excercise

62. ‫د‬ ‫چې‬ ‫انتخابول‬ ‫انسولین‬ ‫داسې‬ ‫د‬
hypoglycemia‫وي‬ ‫کم‬ ‫یې‬ ‫خطر‬
•‫انسولین‬ ‫هغه‬analogues‫ثابتې‬ ‫او‬ ‫اوږدمهالي‬ ‫چې‬
‫د‬ ‫لري‬ ‫اغیزې‬hypoglycemia‫له‬ ‫خطر‬ ‫کم‬ ‫ډیر‬
‫لري‬ ‫سره‬ ‫ځان‬.

63. ‫چارې‬ ‫الرې‬ ‫ترزیق‬ ‫د‬ ‫دانسولین‬

64. ‫الرې‬ ‫زرق‬ ‫د‬ ‫انسولین‬ ‫د‬
• Arms 
• Legs 
• Buttocks 
• Abdomen 

65. ‫ادامه‬......
•‫جدار‬ ‫دبطن‬ ‫یې‬ ‫ځای‬ ‫غوره‬ ‫ترټولو‬ ‫زرق‬ ‫د‬
‫چې‬ ‫ځکه‬ ‫دی‬:
•‫رسئ‬ ‫الس‬ ‫آسانه‬
•‫موجودیت‬ ‫نسج‬ ‫الجلدی‬ ‫تحت‬ ‫دکافی‬
•‫کیدل‬ ‫مختل‬ ‫نه‬ ‫جذب‬ ‫د‬ ‫سره‬ ‫تمرین‬ ‫په‬

66. ‫طریقه‬ ‫زرق‬ ‫د‬:

67. ‫ادامه‬.....
•‫ونیسئ‬ ‫دګوتوترمنځ‬ ‫پوستکی‬ ‫دبطن‬
•Spirit…. X‫کړئ‬ ‫تطبیق‬
•‫مناسب‬ ‫دزرق‬needle‫وکاروئ‬
•‫په‬90‫کړئ‬ ‫ترسره‬ ‫زرق‬ ‫درجو‬
•‫د‬lypodystrophy‫دزرق‬ ‫لپاره‬ ‫دمخنیوي‬
‫کړئ‬ ‫بدله‬ ‫ځل‬ ‫هر‬ ‫ساحه‬.

68. ‫ادامه‬.......

69. ‫کول‬ ‫ذخیره‬ ‫انسولین‬ ‫د‬
• Injections: refrigerate
• Pens: do not refrigerate

70. Shelf life
• One month
once opened

71. Thank you all
For
Sparing your valuable time
&
Patient listening