Use of Insulin in Outpatient Diabetes Management

Abstract

Dosing insulin is like a dance. The insulin dose is initially calculated, and then the blood glucose levels must be evaluated 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 enough that self-monitoring of blood glucose (SMBG) or continuous glucose monitoring (CGM) and recording is key for a successful insulin therapy.

Appendix: Initial Doses for Each Regimen

Basal insulin :

0.2 units/kg/day or 10 Units (Usually in the Evening)

Conventional Insulin Regimen:

0.5 units/kg/day

Divide

Option A

2/3 in a.m. (2/3 NPH, 1/3 rapid or fast acting).

1/3 in p.m. (1/2 NPH, 1/2 rapid or fast acting).

Option B

1/3 before every meal (1/2 NPH, 1/2 rapid or fast acting).

Basal Bolus Insulin Regimen :

Fixed basal-bolus

0.5 units/kg/day

−50% for basal doses.

−50% for prandial doses, divided in three equal doses. One for each meal.

Flexible basal-bolus.

0.5 units/kg/day (Total Daily Dose: TDD)

−50% for basal doses.

−50% for prandial doses.

Insulin to Carbohydrate Ratio (I:CHO ratio).

I:CHO ratio = 450/TDD.

Prandial bolus: Total of carbohydrate grams/I:CHO ratio.

Correction Factor:

mg/dL: Correction Factor = 2000/TDD.

mmol/L: Correction Factor = 100/TDD.

Pre meal target glucose: Initially 150 mg/dL (~8 mmol/L), later on 120 mg/dL (~7 mmol/L). If the patient is stable and is able to identify hypoglycemia, target glucose could be lowered to 100 mg/dL (5.55 mmol/L).

Post meal target glucose: 180 mg/dL (10 mmol/L).

Correction bolus = (Current glucose – Target glucose)/Correction factor.

Total Bolus: Prandial Bolus + Correction Bolus.