1. Case Studies on Insulin Initiation
Nicole McGrath
2013

2. Case 1 52 year old woman, type 2 diabetes for 10 yrs, BMI 32 (87kg)
On Metformin 850mg mane, 1700mg nocte; Gliclazide 80mg bd
Regularly picks up scripts; assures you she is taking
Not testing BG
HbA1c 70 mmol/mol
What to do?

3. Case 1 Discussion Increase Gliclazide to 160mg bd
Start home BG testing
BG elevated:
Fasting around 10
Before evening meal 12
2 hours after evening meal 13
What next?

4. Case Study 1 - Mrs J Age 52. BMI 32 (87kg). HbA1c: 70mmol/mol
Currently on: Metformin 850mg mane, 1,700mg at dinner, Gliclazide 160mg BD.
Blood glucose (mmol/L)
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How would you start Mrs J. on insulin?

5. Case Study 1 - Mrs J. NZGG: Start Isophane 8-10 units at bedtime.
Continue orals – consider reduction of Gliclazide to 80mg BD.
Give the patient instruction to self-adjust insulin dose.
Likely doses to achieve red line:
Isophane units nocte
Gliclazide 160mg bd
Metformin 850mg mane, 1700mg evening meal
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6. Case Study 2 – Mrs T: Age 74. HbA1c 75mmol/mol (9%)
, Currently on: Prednisone 5mg/day for Rheumatoid Arthritis and maximal OHA therapy.
Blood glucose (mmol/L)
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7. Case Study 2 – Mrs T.
As you can see… high glucose levels rising during the day but dropping over night.
Consider:
10 units of isophane at breakfast and adjust the dose as required.
Good fasting achieved with 15 units but….
Red line still suboptimal so change to
15 units of Pre-mixed insulin breakfast
Penmix 30 / Humulin 30/70
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8. Case 3: 66 yr old male with COPD
On Metformin 1gm bd, Glipizide 5mg bd;
HbA1c 57 mmol/mol
Needs course of Prednisone for exacerbation COPD
Prednisone 40mg daily 5 days then 20mg 5 days
Fasting
Pre-lunch
Pre-dinner
6.8
12.6
17.2
7.1
13.8
18.0

9. PATHWAY FOR MANAGING HYPERGLYCAEMIA SECONDARY TO STEROIDS FOR CLIENTS WITH COPD (on HealthPoint)
Whilst on 40 mg Prednisone
Test BSLs at least tds
OHAs –increase usual mane dose by 100% e.g. usual mane dose Gliclazide 80mg –increase to 160mg
If patient is maximised on OHAs:
transient hyperglycemia can sometimes be tolerated for a short period.
Alternatively, a morning dose of Penmix 30/70 (usually 0.2 units/kg body weight) can be given during steroid treatment.
Some patients may need to be commenced on ongoing insulin

10. Blood glucose (mmol/L)
Case Study 4 - Mr L.
Age 62. BMI 27 (78kg) HbA1c 68mmol/mol. Currently on: maximal OHA therapy.
Blood glucose (mmol/L)
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11. Case Study 4 – Mr L.
High fasting and post-prandial BG: basal insulin with current OHA will treat fasting hyperglycaemia but not post meal BG elevations Suggest Premixed insulin: As lunch not so much of an issue, Novomix 30 or Humalog 25: Start 15 units bd (0.2 units/kg/dose) Stop sulphonylurea
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12. Blood glucose (mmol/L)
Case Study 5 - Mr K.
Age 64. HbA1c 75mmol/mol (9%). Currently on: maximal OHA therapy.
Blood glucose (mmol/L)
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13. Case Study 5 – Mr K.
Mr K’s blood glucose is particularly high after his main meal (dinner).
Consider 10–12 units of pre-mixed insulin (Humalog Mix25 or Novomix30) at dinner.
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14. Case 6: 55 yr old male, BMI 35 (116kg), known diabetes 4 yrs, Hba1c 85
No home BG testing
Long gaps between prescription requests
Prescribed Metformin 1gm bd, Gliclazide 160mg bd
Microalbuminuria, background retinopathy, hypertension

15. Case 6 Option 1 advice on diet, exercise, taking medication
warn of possible adverse consequences;
increase Metformin to 1500mg bd;
Start BG testing and reporting back to nurse

16. Case 6 Option 2: 3 month F/U HbA1c 76:
Has achieved good reduction with compliance but HbA1c still suboptimal and not testing much
Fasting BG 10, Pre-dinner 13
Glargine in addition to Metformin and Gliclazide a reasonable option
Starting dose: 0.2 units / kg / day:
Weight 116kg: start 24 units daily (morning or night)
Insulin self-adjustment in conjunction with weekly contact with nurse

17. Case 6 Option 3: Accept failure of OHA Prescribe pre-mixed insulin bd
He eats 2 meals per day: brunch and dinner
NovoMix 30 or Humalog Mix 25: 24 units bd
Could well need to double that
Stop sulphonylurea, continue Metformin
Provide insulin self-adjustment handout or ask pt to increase each dose by 2 units every 3 days until BG 4-8
Hopefully practice nurse will be able to contact him weekly to support/supervise

18. Case 7: 37 year old female, BMI 45 (weight 128kg); diabetes 3 years
HbA1c 85
Prescribed Metformin 1gm bd; Gliclazide 160mg bd and appears to be taking them
Not testing BG
Sleep Apnoea

19. Case 7 Option 1 Weight loss essential:
Refer to dietitian for consideration of Optifast
Refer for consideration Bariatric Surgery
Pioglitazone in addition to Metformin and Gliclazide
Repeat HbA1c in 3 months

20. Case 7 Option 2 Accept weight loss/exercise not achievable
Consider insulin, although insulin resistance will mean large doses necessary
Eats 3 meals per day and snacks in the evening
Penmix 30 or Humulin 30/70: 26 units bd, stop sulphonylurea
Insulin self-adjustment: may need to increase by > 4 units each time if BG remain very high
Will probably need 60 units bd if she doesn’t change her diet/weight

21. Case 8: 41 yr old male, BMI 27
Diabetes 8 yrs, on Metformin 1500mg bd, Gliclazide 160mg bd, Pioglitazone 45mg daily
Truck driver
HbA1c 62 mmol/mol
Microalbuminuria, erectile dysfunction, retinopathy
BG: fasting 9, pre-dinner 10
Requires heavy traffic licence medical certificate
Patient feels he is doing as much as he can re diet, exercise

22. Case 8 Needs insulin but want to minimise effect on driving
Isophane at night 10 units
Increase by 2-4 units every 3 days to achieve fasting BG < 7
Continue OHA
NB. LTSA do not generally require specialist reports for type 2 patients on insulin