1. Basal and Meal Time Insulin Case Study
Davida F. Kruger, MSN,APN-BC,BC-ADM
Certified Nurse Practitioner
Division of Endocrinology, Diabetes, Bone and Mineral Disorders
Henry Ford Health System
Detroit, Michigan
What I plan to do in this presentation is share our experiences in developing a different model of diabetes care delivery, using diabetes educators as care providers to a population of pts w/ poorly controlled type 2 diabetes.
This is not necessarily a new or unique process, as we will discover during the presentation.
This model gave diabetes educators the opportunity and responsibility of managing the care of pts under delegated prescribing authority from supervising senior staff physicians in our System. 1

2. Betty 56 years old Weight 182 lbs, b/p 136/82 Metformin 100omg BID
glyburide 10 mg BID
MNT, working on portion size and learning carb counting
SMBG, usually twice daily but has been checking when feels low or high
Wants to improve her A1c which has been running between 7.8 and 8.4.

3. Fix The Fasting First B L S HS Saturday 198 156 Sunday 176 168 199
Monday
184
170
179

4. Basal Insulin Replacement Therapy
Normal Insulin Secretion
at Meal Time
Insulin Glargine/Detemir
NPH Insulin
Change in Serum insulin .
s.c. injection
Time (hours) 4

5. Start a Basal Insulin “Treat to Target”
Continue oral agent(s) at same dosage
Do NOT stop insulin secreting agent
Add single, evening insulin dose ( U/kg)
units
Glargine, Detemir or NPH (bedtime)
Increase insulin dose every 3-4 days as needed
Increase U if FBG >150 mg/dL
Increase U if FBG = >110,<150 mg/dL
Treat to target FBG (usually <120 mg/dL)
Determine maximum insulin increase till call clinic
6-59 5

6. Starting Basal Insulin
Started Betty on 10 units at 10 PM of Glargine.
Focus on fasting blood glucose
Increase 1-2 units every 3 days until FBS at target with out hypoglycemia
Can us 3/0/3 rule
Ask patient their comfort level
Call clinic when patient taking XX units

7. Glargine Started… Is Premeal Coverage Needed?B
pre
2 hr
post L S M
16u G
109
188
142
200
155
189 Tu
116
135
118
177
179
202 W
120
154
132
167
162
190 Th 97
127
122
211

8. Betty Taking 30 units of glargine No issues with low blood glucose
Working on learning carbohydrate counting and portion sizes
Blood glucose monitoring increased to look at 2 hr post prandial blood glucose
A1c 8.2 %

9. PPG Contributes to 50% or More of Overall A1C When A1C Is 8.4 or Below
The choice of an initial insulin needs to be based on the pt’s curent state of glucose control.
This slides illustarates that when glycemic control is poor, correcting the fasting blood glucose would be the bettr strategy.
However, as A1c’s improve, and fall below 8.4%, then PPG becomes more significant
PPG Contributes to 50% or More of Overall A1C When A1C Is 8.4 or Below
In the past, the belief was that A1C levels were primarily dependent on FPG
However, postprandial hyperglycemia also is an important component of generating A1C
Postprandial glycemic excursions become more predominant in patients with good control of fasting plasma glucose. Therefore, treatment should focus on both FPG and PPG excursions to reach and maintain A1C targets.
Key words:
Diagnosis
Total glucose control
A1C
FPG
PPG
Postprandial glucose
Adapted from Monnier L, Lapinski H, Collette C. Contributions of fasting and postprandial plasma glucose increments to the overall diurnal hyperglycemia of Type 2 diabetic patients: variations with increasing levels of HBA(1c). Diabetes Care. 2003;26:881–885. 9

10. Bolus Insulin Replacement Therapy
Normal Insulin Secretion
at Meal Time
Rapid-acting Analogue
Regular insulin
Change in Serum insulin .
s.c. injection
Time (hours)
Apidra
Humalog
Novolog 10

11. Basal-Bolus Insulin Therapy: Insulin Glargine at HS and Mealtime Lispro or Aspart
Insulin Effect
Slide 61
Basal-Bolus Insulin Therapy: Insulin Glargine at HS and Mealtime Lispro or Aspart
The slide depicts the profile of a “basal-bolus insulin” regimen, with insulin glargine at bedtime (HS) providing the basal component and prandial insulin lispro or insulin aspart providing the bolus component
This regimen affords the following advantages:
Provides flexibility for varying dietary habits
Less risk of nocturnal hypoglycemia due to the 24-hour near-constant effect of insulin glargine, making it an ideal basal insulin
Less risk of between-meal hypoglycemic episodes due to the short duration of the rapid-acting insulin analogs, which may also provide insulin coverage for snacks or extra meals with additional injections
Avoidance of mixing different insulin preparations in the same syringe as single insulins are administered with each injection. Insulin pens are suggested for maximal convenience and accuracy in dosing
1. Leahy J. In: Leahy J, Cefalu W, eds. Insulin Therapy. New York, NY: Marcel Dekker, Inc.; 2002:87 B L D HS
Insulin lispro or aspart
Insulin glargine
Adapted with permission from Leahy J. In: Leahy J, Cefalu W, eds. Insulin Therapy. New York, NY: Marcel Dekker Inc.; 2002:87 11

12. Traditional “Sliding Scale”
An arbitrary insulin dosing algorithm based only on pre-meal blood glucose values
Pre-Meal BG (mg/dl)
Insulin Dose (units)
Less than 151 2 4 6 8 10 12

13. Adjusting meal insulin
Sliding scale not specific to patient needs
Not flexible for carbohydrate in meals
Breakfast meal may need more insulin –hormonal influence
No meal insulin if less than 100mg/dl??
Use of correction insulin??

14. Starting Meal Time Insulin
Stop insulin secreting agent
Add Bolus insulin before meals (REG or analog). Do not need to do all meals at once, look at patterns, fix what is broken first
For all meals
Add 10 units and redistribute total dose 50/50
Pt taking 30 units Lantus already
Add 10 units to a new total dose of 40 units
50% will be new basal (20 units)
50% in divided doses will be the meal time bolus (i.e. 7/6/7)
Carb counting and correction factors
BG checks a must! Do not know where going
SAFETY 14

15. Total Daily Insulin
Total daily insulin requirement is calculated by body weight
T1: need about 0.6 units/kg (range )
T2: need about 1.2 units/kg (range 1 – 1.4)
BGs at goal without hypoglycemia.
40-50% basal (background)
50-60% bolus (meal doses) 15

16. Calculating “Basal–Bolus” Insulin
Calculate TDD
T1: need about 0.6 units/kg (range )
T2: need about 1.2 units/kg (range 1 – 1.4)
Basal dose: 40 – 50% of TDD
Bolus dose: 50-60% of TDD:
Divide equally for three meals OR
Sensitivity Factor = 1700/TDD
1 unit will drop BG by XX points
Carbohydrate Ratio = 500/TDD
1 unit for every XX gm carbs
(Pt BG – target) / (SF) = CORRECTION
Now add carb ratio for meal. 16

17. For Example 250 pound T2DM (114 kg)
Calculated TDD: 114 x 1.2 = 137 u/day
Basal Dose: 68 units a day (50% of TDD)
Bolus Dose: (other 50% of TDD)
Isocaloric meals:
68/3 = 23 units before each meal
Carbohydrate ratio: 500/137 = 3
1 unit for every 3 grams of carbs
Insulin Sensitivity: 1700/137 = 12
1 unit will lower BG 12 mg/dL 17

18. What’s the dose range? Type 2: 0.3 to 1.2 units/kg
“Thin type 2’s” are more insulin deficient
“Heavy type 2’s” are more insulin resistant
Most pts with T2DM need insulin doses of
1 to 1.2 units/kg to achieve an A1c <7%
(basal dose of 0.5 to 0.6 units/kg per day) 18

19. Hypoglycemia Most common side effect of insulin therapy
Glucose levels less than 70 mg/dl are treated
Symptoms of hypo are treated regardless of glucose level
Usual treatment is 15 gm glucose/ wait 15 min and repeat if needed ( Rule of 15/15)

20. Hypo Treatment Liquid glucose preferred to solid
Orange juice is better than a piece of cake
Simpler forms of sugar are better than sugars with fat
Jelly beans are better than chocolate
All patients need to carry on them a hypoglycemic treatment at all times

21. Know What Insulin is Working
Testing Times
AM (fasting) indicates action of evening basal or intermediate insulin
Pre- lunch indicates action of AM short acting
Pre-supper ………………….pre lunch short acting
HS……………………pre-supper short acting

22. Carb Counting Referral to dietitian Flexible and adaptable
Meal specific
Provide web sites and carb counting books
Read labels

23. Betty: Book knowledge and the patient before you
Weight 182 lbs/83 kg
Will need up to units per kg/body weight
Go low and slow, use blood glucose to direct
Figure dose needed then decide on which meal (s)
Look at A1c to help guide
Basal Insulin now30 units at 10 PM, FBS are well controlled, concentrate on 2 hour pp
Prevent hypoglycemia

24. Betty: Continued Basal insulin 30 units
1 unit per kg/body weight is 83 units TDD
53 units/3 meals is 18 units per meal
Start with breakfast and dinner, add lunch as needed, if no breakfast, add at lunch and dinner OR
Carb counting and sensitivity factor:
500 ./. 83 = unit to cover 6 grams carb
1700 ./. 83 = unit of insulin to drop 20mg/dl
Blood glucose goal is 100mg/dl before meals

25. Example Insulin Sensitivity Blood glucose before meal is 180mg/dl
Goal is 100mg/dl
= 80 (correct for)
80 ./. 20 = 4 units (insulin sensitivity)
Carb Coverage
Dinner meal: 2 Hambugers, 2 rolls, ½ cup applesauce, ½ cup green beans, ½ cup corn
Approx 60 grams of carb
1 unit covers 6 grams of carb = 6 units of meal time unsulin
Total for this meal: 10 units meal time insulin

26. Pearls
Once insulin sensitivity and carb ratios determined not as difficulty as it may appear
When patients consume less and blood glucose improve less risk of hypoglycemia
Blood glucose monitoring is key
Consider Continuous Blood Glucose Monitoring as an aid
Lack of understanding of Nutrition is often what prevents patients from getting to treatment goals
Insulin dosing is a moving target……..