Use of Insulin in Outpatient Diabetes Management

  • Raquel N. Faradji
  • Ana Paula Díaz Barriga-Menchaca
  • María Elena Sainz de la Maza Viadero


Dosing insulin is like a dance. The insulin dose is initially calculated, and then the blood glucose levels must be evaluated, in order to increase or decrease the insulin dose responsible for that blood glucose value. The goal is not to go chasing after the blood glucose has risen but to prevent its rise. For this, one must carefully take into account the quality and quantity of a given meal (and its carbohydrate content), the activity level, the patient’s health status, and how other medications could affect the blood glucose levels.

In this chapter, we describe the different insulin types and their action times, the clinical indications for insulin initiation, the different insulin regimens, and the adverse effects. We also give insulin storage and injection recommendations.

Having a multidisciplinary team (diabetes educator, dietitian, physician, patient, family support) is key for insulin initiation and adjustment. Starting insulin in the office (first injection) will increase treatment adherence. Having a close follow-up is important. In addition, one must be careful to educate the patient in hypoglycemia prevention, detection, and treatment. It cannot be stressed out enough that self-monitoring of blood glucose (SMBG) and records are keys for a successful insulin therapy.


Insulin Fast-acting insulin Rapid-acting insulin Intermediate-acting insulin Long-acting insulin Ultra-long-acting insulin Premixed insulin Insulin regimen Basal regimen Basal-plus regimen Basal-bolus regimen 


  1. 1.
    Bethel MA, Feinglos MN. Basal insulin therapy in type 2 diabetes. J Am Board Fam Pract. 2005;18(3):199–204. Available from: Scholar
  2. 2.
    American Diabetes Association (ADA). Standard of medical care in diabetes - 2017. Diabetes Care. 2017;40(Supplement 1):S4–128.CrossRefGoogle Scholar
  3. 3.
    Garber AJ, Abrahamson MJ, Barzilay JI, Blonde L, Bloomgarden ZT, Bush MA, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm – 2017 executive Summary. Endocr Pract. 2017;23(2):207–38. Available from: Scholar
  4. 4.
    Tibaldi JM. Evolution of insulin: from human to analog. Am J Med. Elsevier Inc. 2014;127(10):S25–38. Available from:
  5. 5.
    Holman RR, Thorne KI, Farmer AJ, Davies MJ, Keenan JF, Paul S, et al. Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes. N Engl J Med. 2007;357(17):1716–30.CrossRefGoogle Scholar
  6. 6.
    Holman RR, Farmer AJ, Davies MJ, Levy JC, Darbyshire JL, Keenan JF, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes. N Engl J Med. 2009;361(18):1736–47. Available from: Scholar
  7. 7.
    Riddle M, Rosenstock J, Gerich J. The treat-to-target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care. 2003;26(11):3080–6.CrossRefGoogle Scholar
  8. 8.
    Heise T, Pieber TR, Danne T, Erichsen L, Haahr H. A pooled analysis of clinical pharmacology trials investigating the pharmacokinetic and pharmacodynamic characteristics of fast-acting insulin aspart in adults with type 1 diabetes. Clin Pharmacokinet. Springer International Publishing;. 2017;56(5):551–9.CrossRefGoogle Scholar
  9. 9.
    Origin T, Investigators T. Basal insulin and cardiovascular and other outcomes in dysglycemia. N Engl J Med. 2012;367(4):319–28. Available from: Scholar
  10. 10.
    Marso SP, McGuire DK, Zinman B, Poulter NR, Emerson SS, Pieber TR, et al. Efficacy and safety of degludec versus glargine in type 2 diabetes. N Engl J Med. 2017; NEJMoa1615692. Available from:
  11. 11.
    Becker RHA, Dahmen R, Bergmann K, Lehmann A, Jax T, Heise T. New insulin glargine 300 units z mL 21 provides a more even activity profile and prolonged glycemic control at steady state compared with insulin glargine 100 Units z mL 21. Diabetes Care. 2015;38(4):637–43.PubMedGoogle Scholar
  12. 12.
    Bailey T, Dahmen R, Pettus J, Roussel R, Bergmann K, Maroccia M, Nassr N, Klein O, Bolli G, Heise T. Insulin glargine 300 u/ml (gla-300) provides more stable and more evenly distributed steady-state pharmacodynamic/pharmacokinetic profiles compared with insulin degludec in type 1 diabetes (T1DM). Endocr Pract. 2017;23(1):48A. Available from: Scholar
  13. 13.
    Heise T, Nørskov M, Nosek L, Kaplan K, Famulla S, Haahr HL. Insulin degludec: lower day-to-day and within-day variability in pharmacodynamic response compared with insulin glargine 300 U/mL in type 1 diabetes. Diabetes Obes Metab. 2017;19(7):1032–9.CrossRefGoogle Scholar
  14. 14.
    Sorli C. New developments in insulin therapy for type 2 diabetes. Am J Med. Elsevier Inc. 2014;127(10):S39–48. Available from:
  15. 15.
    Klonoff DC. Afrezza inhaled insulin. J Diabetes Sci Technol. 2014;8(6):1071–3. Available from: Scholar
  16. 16.
    Weiss S, Cheng S. Inhaled insulin provides improved glycemic control in patients with type 2 diabetes mellitus inadequately controlled with oral agents: a randomized controlled. Arch Intern Med. 2003;163:2277–82. Available from: Scholar
  17. 17.
    Arnolds S, Heise T. Inhaled insulin. Best Pract Res Clin Endocrinol Metab. 2007;21(4):555–71. Available from: Scholar
  18. 18.
    Mohanty RR, Das S. Inhaled insulin - current direction of insulin research. J Clin Diagn Res. 2017;11(4):OE01–2.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Meneghini L, Mersebach H, Kumar S, Svendsen A, Hermansen K. Comparison of 2 intensification regimens with rapid-acting insulin aspart in type 2 diabetes mellitus inadequately controlled by once-daily insulin detemir and oral antidiabetes drugs: the step-wise randomized study. Endocr Pract. 2011;17(5):727–36. Available from: Scholar
  20. 20.
    Meneghini LF. Stepwise addition of prandial insulin. Lancet Diabetes Endocrinol. Elsevier Ltd. 2014;2(1):3–4. Available from:
  21. 21.
    Bode, Bruce; Kyllo, Jennifer; Kaufman FR. Pumping Protocl. A Guide to Insulin Pump Therapy Initiation [Internet]. 2007. Available from: Protocol - a Guide to Insulin Pump Therapy Initiation.pdf.
  22. 22.
    Walsh J, Roberts R, Bailey T. Guidelines for optimal bolus calculator settings in adults. J Diabetes Sci Technol. 2011;5(1):129–35.CrossRefGoogle Scholar
  23. 23.
    Walsh J, Roberts R, Bailey T. Guidelines for insulin dosing in continuous subcutaneous insulin infusion using new formulas from a retrospective study of individuals with optimal glucose levels. J Diabetes Sci Technol. 2010;4(5):1174–81.CrossRefGoogle Scholar
  24. 24.
    Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977–86. Available from: Scholar

Suggested/Further Reading

  1. American Diabetes Association (ADA). Practical insulin: a handbook for prescribing providers. 3rd ed. Alexandria, VA: American Diabetes Association; 2011.Google Scholar
  2. Faradji Hazán RN. Indicar un Esquema Convencional e Intensivo de Insulina. In: Sociedad Mexicana de Nutrición y Endocrinología: Taller de Atención Integral para Pacientes con Diabetes. Manual para Profesores y Manual para Alumnos. Chapter 14. 1st ed. Editorial Permanyer; 2014.Google Scholar
  3. Faradji Hazán RN, Díaz Barriga Menchaca AP, Antillón Ferreira, CA. Diabetes en la Población Pediátrica. In: Dorantes y Martínez, SMNE: Endocrinología Clínica. 5th ed. Editorial Manual Moderno; 2016. ISBN 9786074485554.Google Scholar
  4. Faradji Hazán RN, E Sainz de la Maza Viadero, Hazán de Jacob y Levy E, Morales Alvarado E, Díaz Barriga Menchaca AP. Chapter 11. Tratamiento integral de la Diabetes Tipo 1. In: Ochoa Martínez C, Madero Fernández del Castillo MA y González Chávez A, SMNE, CMMI: Manual práctico del manejo de la diabetes mellitus y sus complicaciones. 1st ed. Editorial Alfil; 2016. ISBN 9786077411673.Google Scholar
  5. Phillips P. Insulin and type 2 diabetes: a simple guide to prevent’stuff ups’. Aust Fam Physician. 2006;35(12):975–8.PubMedGoogle Scholar
  6. To access useful information and resources about the topic in Spanish consult:

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Raquel N. Faradji
    • 1
    • 2
    • 3
    • 4
  • Ana Paula Díaz Barriga-Menchaca
    • 5
  • María Elena Sainz de la Maza Viadero
    • 1
    • 2
    • 6
  1. 1.Clinica EnDiMexico CityMexico
  2. 2.RENACED Diabetes Tipo 1Mexico CityMexico
  3. 3.Pathophysiology of the Endocrine System, Escuela de Medicina TEC-ABC, Tecnologico de Monterrey, Centro Medico ABCMexico CityMexico
  4. 4.Sociedad Mexicana de Nutrición y Endocrinología, MexicoMexico CityMexico
  5. 5.Instituto Nacional de Ciencias Médias y Nutrición “Salvador Zubirán”Mexico CityMexico
  6. 6.Didactic Resources for Nutrition, Escuela de Dietetica y Nutricion ISSSTEMexico CityMexico

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