# Insulin Algorithm for Type 2 Diabetes Mellitus in Children and Adults

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4 a. Basal insulin dose: The first step in the conversion is based on the total dose of intermediate-acting insulin. In this case, the person is taking 21 units of NPH or aspart-protamine insulin (70% x 30 units=21 units). So, give 21 units basal glargine (use unit-for-unit conversion for oncedaily intermediate regimens). Remember, do not stop oral agents (+ sulfonylurea) at this time. b. Bolus insulin dose: There are several ways to start the analog. i. See Case 1 (Arbitrary start or Carb-counting) ii. Begin with the previous dose of fast-acting insulin, divide it before meals and titrate every 2 days. In this case, the person was using 30 units of 70/30 or about 9 units of fast-acting insulin (30% x 30 units=9 units). So give 3 units of analog before each meal and titrate every 2 days as per Case 1. C. Conversion from twice-daily premix to intensive/physiologic insulin replacement: Oral therapy failure in an 80 kg person: 70/30 premixed insulin was started and advanced to 60 units per day: 40 units before breakfast and 20 units before dinner. The fasting glucose was at goal, but wide glycemic excursions occurred at other times during the day and night. How do you convert this person to physiologic insulin therapy? There are several approaches. Use which ever method you want. a. Start over and begin insulin at 0.5 units/kg. Give half as basal insulin and half as analog, divided before meals. In this case, the starting dose would be 40 units per day. Start giving 20 units glargine each morning and about 7 units analog before each meal. Titrate the basal and bolus insulins every 2 days to fasting and 2-hr postprandial goals. b. Conversion based on current insulin usage: Basal dose: The first step in the conversion is based on the 80% of the total dose of intermediate-acting insulin. In this case, the person is taking 42 units of NPH or aspart-protamine insulin (70% x 60 units = 42 units). When a person is taking multiple doses of intermediate-acting insulin, we give only 80% as glargine. So, give 34 units basal glargine (80% x 42=~34). Remember, do not stop oral agents (+ sulfonylurea) at this time. Bolus insulin dose: There are several ways to start the analog. i. See Case 1 (Arbitrary start or Carb-counting) ii. Begin with the previous dose of fast-acting insulin, divide it before meals and titrate every 2 days. In this case, the person was using 60 units of 70/30 or 18 units of fast-acting insulin (30% x 60 units = 18 units). So, give 6 units of analog before each meal and titrate every 2 days as per Case 1. c. The 80%-80% rule: Similar to the above method, but yields an ideal ratio of basal:bolus insulin in one step. The dose of basal glargine will be 80% of the total intermediate insulin, and the analog will be 80% of the glargine dose, divided before meals. 4 of 6 Worksheet: Advancing to Intensive/Physiologic Basal: Bolus Insulin Therapy Revised 1/27/10 See disclaimer at

6 References 1. Riddle MC, Rosenstock J, Gerich J. Diabetes Care. 2003; 26: Spellman CW, Renda SM, Davis SN. Realizing the Potential of Insulin Therapy in Type 2 Diabetes: A Case Presentation-Based Monograph. presented at the American College of Osteopathic Internists 64th Annual Convention; Chicago, IL (September 30, 2004) Reviews/Important Articles Abraira C, Colwell J, Nuttall F, et al. Cardiovascular events and correlates in the Veterans Affairs Diabetes Feasibility Trial. Veterans Affairs Cooperative Study on Glycemic Control and Complications in Type II Diabetes. Arch Intern Med. 1997;157(2): Anonymous. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352(9131): DeWitt DE, Dugdale DC. Using new insulin strategies in the outpatient treatment of diabetes: clinical applications. JAMA. 2003;289(17): DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. JAMA. 2003;289(17): Implementation Conference for ACE Outpatient Diabetes Mellitus Consensus Conference Recommendations: Position Statement, February 2, Available online at pub/odimplementation/positionstatement.pdf. Accessed on May 2, Hirsch IB. Insulin analogues. N Engl J Med. 2005;352(2): Once Daily Insulin Morning vs. Bedtime NPH Groop LC, Widen E, Ekstrand A, et al. Morning or bedtime NPH insulin combined with sulfonylurea in treatment of NIDDM. Diabetes Care. 1992;15(7): Morning vs. Bedtime Glargine Fritsche A, Schweitzer MA, Haring HU. Glimepiride combined with morning insulin glargine, bedtime neutral protamine hagedorn insulin, or bedtime insulin glargine in patients with type 2 diabetes. A randomized, controlled trial. Ann Intern Med. 2003;138(12): NPH vs. Glargine Riddle MC, 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): Once Daily vs. Twice Daily Regimen Raskin P, Allen E, Hollander P, et al. Initiating insulin therapy in type 2 diabetes: a comparison of biphasic and basal insulin analogs. Diabetes Care. 2005;28(2): Multiple Dose Insulin Regimens (2-shot Regimens) NPH/Regular vs. NPH/ short acting analogue therapy Vignati L, Anderson JH Jr, Iversen PW. Efficacy of insulin lispro in combination with NPH human insulin twice per day in patients with insulin-dependent or noninsulin-dependent diabetes mellitus. Multicenter Insulin Lispro Study Group. Clin Ther. 1997;19(6): % NPH/ 30% Regular vs. Humalog Mix 75/25 or Novolog Mix 70/30 Roach P, Yue L, Arora V. Improved postprandial glycemic control during treatment with Humalog Mix25, a novel protamine-based insulin lispro formulation. Humalog Mix25 Study Group. Diabetes Care. 1999;22(8): Boehm BO, Home PD, Behrend C, et al. Premixed insulin aspart 30 vs. premixed human insulin 30/70 twice daily: a randomized trial in Type 1 and Type 2 diabetic patients. Diabet Med. 2002;19(5): Multiple Dose Insulin Regimens (3-shot Regimens) Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract. 1995;28(2): Intensive Insulin Therapy Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract. 1995;28(2): Saudek CD, Duckworth WC, Giobbie-Hurder A, et al. Implantable insulin pump vs multiple-dose insulin for non-insulin-dependent diabetes mellitus: a randomized clinical trial. Department of Veterans Affairs Implantable Insulin Pump Study Group. JAMA. 1996;276(16): Raskin P, Bode BW, Marks JB, et al. Continuous subcutaneous insulin infusion and multiple daily injection therapy are equally effective in type 2 diabetes: a randomized, parallel-group, 24-week study. Diabetes Care. 2003;26(9): Bretzel RG, Arnolds S, Medding J, et al. A direct efficacy and safety comparison of insulin aspart, human soluble insulin, and human premix insulin (70/30) in patients with type 2 diabetes. Diabetes Care. 2004;27(5): of 6 Worksheet: Advancing to Intensive/Physiologic Basal: Bolus Insulin Therapy Revised 1/27/10 See disclaimer at

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