DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

Version 4.0
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
J-3. INSULIN THERAPY
Insulin requirements vary widely among people with diabetes, even when other factors are similar. Types,
frequency, and dosages of insulin must be individualized, considering the following factors:
• Type of diabetes
• Age
• Weight (presence or absence of obesity)
• Co-morbid conditions
• Presence of autonomic neuropathy
• Concomitant medications (specifically beta-blockers)
• Patient’s ability to perform self-glucose monitoring and accurately inject insulin
• Complexity of management strategy (number of injections, variable dosing based on carbohydrate intake
and pre-prandial glycemia)
• Risks and benefits of hypoglycemia, including psychosocial factors
• Magnitude and pattern of hyperglycemia
Many patients with type 2 DM can achieve their glycemic target with a single bedtime injection of long-acting
insulin or pre-meal split-mixed insulin, often in combination with an oral agent. Some patients will require
intensified regimens to achieve their target glycemic range. Early use of insulin should be considered in any patient
with extreme hyperglycemia, even if transition to therapy with oral agents is intended as hyperglycemia improves.
Other insulin options include: Adding basal insulin (NPH or long-acting analog) and continuing therapy with one or
two oral agents, adding a premixed insulin while continuing insulin sensitizers (e.g., metformin), and discontinuing
secretagogues, or adding rapid-acting insulin at mealtimes and continuing therapy with one or two oral agents.
(Adapted from: White, 2007)
The care of patients with type 1 or type 2 DM (needing insulin) should be individualized, in consultation with a
multidisciplinary diabetes care team. If expeditious consultation is not possible, the primary care provider should
institute “survival” insulin therapy. The degree of insulin resistance determines the starting dosing; for example:
• Newly diagnosed, lean, T1DM; total daily insulin (TDI) 0.5 units/kg/d; half as basal insulin
• Long standing, obese, T2DM; TDI 0.8. to 1 units/kg/d; half as basal insulin
RECOMMENDATIONS
1. Use of insulin therapy should be individualized, and managed by a healthcare team experienced in
managing complex insulin therapy for patients with type 1 DM. [I]
2. Use intermediate- or long-acting insulin to provide basal insulin coverage. [B]
3. Insulin glargine or detemir may be considered in the NPH insulin-treated patient with frequent or severe
nocturnal hypoglycemia. [B]
4. Use regular insulin or short-acting insulin analogues for patients who require mealtime coverage.
5. Alternatives to regular insulin (aspart, lispro, or glulisine) should be considered in the following settings:
[B]
RATIONALE
• Demonstrated requirement for pre-meal insulin coverage due to postprandial hyperglycemia AND
concurrent frequent hypoglycemia
• Patients using insulin pump.
Patients with type 1 DM have an absolute insulin deficiency and require lifelong insulin replacement. In most
patients with type 2 DM, blood glucose control deteriorates over a period of years, due to declining insulin
production. In these circumstances oral therapies can no longer maintain blood glucose control to targets and insulin
replacement therapy becomes inevitable.
Module G: Glycemic Control Page 61