# Type 2 Diabetes and Insulin

## **Steps in Insulin Management** 

**Step 1:** Target Fasting Plasma Glucose (FPG) with **basal insulin.**
The target goal for FPG is 70 to 130mg/dL. Start with a bedtime dose of
10 units (0.2 units/kg body weight) of NPH or long acting insulin.
Increase the dose 2 units every 3 days until FPG is between 70 to 130
mg/dL. The dose maybe increased by 4 units every 3 days if FPG is \>
180mg/dL.

**Step 2:** Once the FPG is within target goals, select one pre-meal
elevated glucose level to work on at a time. The target goal for
pre-meal glucose is between 70 to 130mg/dL.

1.  

If pre-lunch glucose is \> 130mg/dL, start 4 units of **bolus insulin**
before breakfast.

If Pre-supper glucose is \> 130mg/L, start 4 units **bolus Insulin**
before lunch **OR** add or increase morning NPH insulin dose.

If Bedtime glucose is \> 140mg/dL, start 4 units **bolus Insulin**
before supper **OR** Increase evening NPH insulin dose.

Increase **bolus Insulin** by 2 units every 3 days.

As insulin doses get larger (over 10 units), begin to change insulin
adjustments by 10 to 20%.

**Step 3:** If A1c is not at the target goal of 6.5 to 7%, start with
the post-prandial glucose level that is above the target goal with bolus
pre-meal insulin. The 2 hour post-prandial glucose target is \< 160mg/dL
and no \> 180mg/dL.

### Table 1 Intermediate and Long Acting Basal Insulin: onset, peak and duration

+---------------------------+-------------+-------------+-------------+
| **Type of Basal Insulin** | **Onset**   | **Peak**    | *           |
|                           |             |             | *Duration** |
+---------------------------+-------------+-------------+-------------+
| **Intermediate Acting**   | 1 to 3      | 6 to 10     | 12 to 20    |
|                           | hours       | hours       | hours       |
| NPH (Humulin N ®,         |             |             |             |
|                           |             |             |             |
| Novolin N ®)              |             |             |             |
+---------------------------+-------------+-------------+-------------+
| **Long Acting**           | 1 hour      | None        | 24 hours    |
|                           |             |             |             |
| \*Glargine (Lantus ®)     |             |             |             |
+---------------------------+-------------+-------------+-------------+
| \*Levemir (Detemir ®)     | 1 hour      | None        | 12 to 24    |
|                           |             |             | hours       |
+---------------------------+-------------+-------------+-------------+

\* Drugs not on IHS National Core Formulary

### Table 2 Rapid and Short Acting Bolus Insulin: onset, peak and duration

  --------------------------- ------------- --------------- ---------------
  **Type of Bolus Insulin**   **Onset**     **Peak**        **Duration**

  \*Lispro (Humalog ®)        15 to 30 min  30 to 90 min    3 to 5 hours

  \*Aspart (Novolog ®)        15 to 30 min  30 to 90 min    3 to 5 hours

  \*Glulisine (Apidra®)       15 to 30 min  30 to 90 min    3 to 5 hours

  Regular (Humulin R®,        30 to 60 min  1 to 2 hours    5 to 8 hours
  Novolin R®)                                               
  --------------------------- ------------- --------------- ---------------

\*Drugs not on IHS National Core Formulary

### Table 3 Premixed Long and Shoirt Acting Insulin: onset, peak and duration

  --------------------------- ------------- ---------------- --------------
  **Insulin**                 **Onset**     **Peak**         **Duration**

  Humulin, Novolin, Novolog   30 min        2 to 4 hours     14 to 24 hours
  70/30                                                      

  \*Humulin 50/50             30 min        2 to 5 hours     18 to 24 hours

  Humalog 75/25               A5 min        ½ to 2 ½ hours   16 to 20 hours
  --------------------------- ------------- ---------------- --------------

\*Drugs not on IHS National Core Formulary

Reference: Nathan, Buse, Davidson, et al. Management of Hyperglycemia in
Type 2 Diabetes: a Consensus Algorithm for the Initiation and Adjustment
of Therapy. (2006). Diabetes Care 28, 1963-1972