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Toronto Notes 2019 Disorders of Glucose Metabolism Endocrinology E11 Insulin Dose Schedules
Table 12. Insulin Titration and Titration Suggestions for Type 2 Diabetes (as per Diabetes Canada 2018 Clinical Practice Guidelines)
Basal Insulin Only – Add-on to Anti-hyperglycemic Agents
See above summary for A1C, BG targets
Most patients will need 40-50 units/d to achieve target but there is no maximum dose
Start at a low dose of 10U at bedtime (lower for lean patients <50 kg)
Titrate dose accordingly until fasting BG target is achieved (see CDA guidelines for appropriate titration)
If fasting hypoglycemia, dose of bedtime basal should be reduced
If daytime hypoglycemia, reduce dose of oral anti-hyperglycemic agents (especially secretagogues)
Basal-Bolus Insulins
When addition of basal insulin to anti-hyperglycemic agents is insufficient to reach target BG, bolus (prandial) insulin should be added before meals
Option exists to only add bolus insulin to the meal with the highest postprandial BH as a starting point
Insulin secretagogues typically stopped when bolus (prandial) insulin added; metformin is continued
Maintain the basal dose and add bolus insulin with each meal at a dose equivalent to 10% of basal dose
Total Daily Insulin (TDI) = 0.3-0.5 U/kg; 40% TDI = basal, 20% TDI = prandial (bolus) prior to each meal
Adjust basal insulin to achieve target fasting BG, bolus insulin to achieve postprandial BG levels (5-10 mmol/L) or pre-prandial BG levels for subsequent meal (4-7 mmol/L)
Premixed Insulin Before Breakfast and Before Dinner
Target fasting and pre-dinner BG levels of 4-7 mmol/L
Most patients with T2DM need 40-50 U BID to achieve target, but no maximum dose
Start at a low dose of 5-10 U BID (before breakfast and before dinner)
Patients can self-titrate by increasing insulin dose by 1 U/d until pre-dinner (breakfast dose) or fasting BG (dinner dose) at target Continue metformin and consider stopping secretagogue
Dosing and Titration Example
Starting dose – 10 U at bedtime
Increase dose by 1 U every 1 night until fasting BG has reached target of 4-7 mmol/L
Dosing and Titration Example
TDI = 0.5 U/kg: 0.5 x 100 kg = 50 U
Basal insulin = 40% of TDI
40% x 50 U = 20 U; basal bedtime = 20 U
Bolus insulin = 60% of TDI
60% x 50 U = 30 U; 10 U dosed with each meal
Dosing and Titration Example
10 U ac breakfast, 10 U ac dinner
Increase breakfast dose by 1 U/d until pre-dinner BG has reached target
Increase dinner dose by 1 U/d until fasting BG has reached target
• CorrectionFactor(CF)=100/TotalDailyDoseofinsulin(TDD)=changeinbloodglucoseperunitinsulin ■ BG <4: call MD and give 15 g carbohydrates
■ BG between 4 to 8: no additional insulin
■ BG between 8 to (8 + CF): give one additional unit
■ BG between (8 + CF) to (8 + 2CF): give two additional units
■ BG between (8 + 2CF) to (8 + 3CF): give three additional units
Insulin Pump Therapy: Continuous Subcutaneous Insulin Infusion (CSII)
• externalbattery-operateddeviceprovidescontinuousbasaldoseofrapid-actinginsulinanalogue (aspart, glulisine, or lispro) through small subcutaneous catheter
• atmeals,patientprogramspumptodeliverinsulinbolus
• providesimprovedqualityoflifeandflexibility
• riskofDKAifpumpisinadvertentlydisconnected
• coverageavailableforinsulinpumpsforindividualswithType1DMvariesbyprovince