CDA Clinical Practice Guidelines indicate that "If individual treatment goals have not been reached by other means, insulin therapy should be initiated to improve glycemic control."

Administration of insulin can reduce glucose production by the liver and lead to normal or improved blood glucose values by decreasing the total glucose load. High glucose values can be directly toxic to the pancreas (the organ that produces the insulin that we need to regulate our blood glucose levels). By using insulin to reduce glucose production we decrease glucose load and decrease glucose toxicity. This may achieve a normal blood glucose level which will in turn allow the pancreas to function to its full potential.

Selecting the type of Insulin

We normally start with a long acting insulin. We may use NPH insulin which is long acting and peaks in effect in 8-12 hrs. Therefore, to get a maximal effect on awakening in the morning, we give the insulin in the evening or at bedtime. In theory, the more insulin we give at bedtime, the lower the Fasting Blood Sugar (FBS) will be. We are trying to achieve a FBS below 7.0 mmol/L (125 mg/dl). Alternatively we can use an extended long acting insulin such as Glargine (Lantus) or Detemir (Levemir), these insulins give an essentially constant insulin level for 24 hours so they can be given at any time of the day (except that the timing should be consistent from one day to the next). The long acting insulin provide 24 hour support, thus giving true basal support and are less likely to cause hypoglycemia as there is less peak activity.

Initial Dose

Start with 10u insulin (if using NPH give the insulin immediately before going to bed, if using long acting analogs give at any time). The insulin may be started by the physician in the office or a prescription given to a Diabetes Education Centre, Diabetes Nurse Educator or Pharmacist to do the actual instruction. The insulin prescription should contain targets and titration instructions.

I recommend giving a few days (or up to a month) of taking the 10u dose to allow the client to get over the barriers of insulin injection and only then start adjusting to achieve glucose targets.

Making Adjustments

Adjustment starts when the client is comfortable with giving the insulin injections. If Fasting Glucose (FBS) remains high (above 7.0 mmol/L) consistently for 3 days in a row, increase bedtime insulin by one or two units at a time. Keep measuring glucose levels in the morning and if the morning glucose (before breakfast) continues to be above 7.0 mmol/L (125 mg/dl) then increase again the insulin dose. We keep on doing this until we achieve a morning (before breakfast) glucose level that is consistently between 4.0 & 7.0 mmol/L (70-125 mg/dl). Some people like to get the glucose level down to normal (less than 6.0 mmol/L (65 mg/dl)).

Follow Up

It is important to follow up frequently until the client is comfortable and has achieved goals. Check A1c in 3 months.

We need to be cautious about nighttime low glucose (see hypoglycemia) and if this occurs, decrease the insulin dose by 2u until reviewed by the health professional.

The usual starting dose is 10u insulin (NPH given at bedtime, Glargine or Detemir given at any time, though the time should be consistent from one day to the next). If FBS is controlled but glucose levels are high at other times of the day we may have to consider more intensive insulin routines.

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Instructions for the patient on how to adjust once daily insulin dose

I have given you a prescription for: ____________________________________

I am giving you a small dose of insulin to prevent your blood glucose (sugar) from going too high, so that you will have a normal blood glucose level. It is safe and rarely causes low blood glucose (hypoglycemia). It is very important to measure your blood glucose with your blood glucose meter. While you are adjusting your insulin, you should measure and record (in your glucose diary) readings in the morning and before lunch and supper as often as possible.

• Start with a dose of 10 units of insulin at bedtime if you are taking NPH, or if you are taking Lantus or Levemir you can take it at anytime as long as it is the same each day.
  
• Measure your blood glucose every morning before breakfast.
  
• If your before-breakfast glucose value is higher than 7.0 for 3 days in a row, you should increase your insulin dose by 2 units (that is, from 10 units to 12 units).
  
• Whenever you have a glucose level higher than 7.0 for 3 days in a row, you will increase your insulin by 2 units.
  
• You should consider testing your blood glucose at 3:00 AM occasionally to ensure you are not having low overnight blood glucose levels.
  
• Do not go above a daily dose of 30 units of insulin without discussing with me. Your goal is to achieve before-breakfast glucose levels between 4.0 and 7.0.
  
• If you have a low blood glucose (hypoglycemic) reaction during the night, decrease the insulin dose by 2 units.
  
• If you have a before-breakfast glucose reading below 4.0 for 2 days in a row, decrease the insulin dose by 2 units.
  

If you have any problems or questions, please call me at: ___________________________

For emergencies outside office hours, call: ________________________________________