15. The ADA Treatment
Algorithm for the Initiation
and Adjustment of Insulin
په عیارولو او دپیل تراپي دانسولین
ادارې منظوردامریکادشکردکنټرول
(ADA)الګوریتم درملیز
17. Initiating and Adjusting Insulin
Continue regimen; check
HbA1c every 3 months
If fasting BG in target range, check BG before lunch, dinner, and bed.
Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
Recheck pre-meal BG levels and if out of range, may need to add another
injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin
If HbA1c ≤7%...
Bedtime intermediate-acting insulin, or
bedtime or morning long-acting insulin
(initiate with 10 units or 0.2 units per kg)
Check FG and increase dose until in target range.
If HbA1c 7%...
Hypoglycemia
or FG >3.89 mmol/l (70 mg/dl):
Reduce bedtime dose by ≥4 units
(or 10% if dose >60 units)
Pre-lunch BG out of range: add
rapid-acting insulin at breakfast
Pre-dinner BG out of range: add NPH insulin at
breakfast or rapid-acting insulin at lunch
Pre-bed BG out of range: add
rapid-acting insulin at dinner
Continue regimen; check
HbA1c every 3 months
Target range:
3.89-7.22 mmol/L
(70-130 mg/dL)
Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.
If HbA1c ≤7%... If HbA1c 7%...
18. Step One…
Continue regimen; check
HbA1c every 3 months
If fasting BG in target range, check BG before lunch, dinner, and bed.
Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
Recheck pre-meal BG levels and if out of range, may need to add another
injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin
If HbA1c ≤7%...
Bedtime intermediate-acting insulin, or
bedtime or morning long-acting insulin
(initiate with 10 units or 0.2 units per kg)
Check FG and increase dose until in target range.
If HbA1c 7%...
Hypoglycemia
or FG >3.89 mmol/l (70 mg/dl):
Reduce bedtime dose by ≥4 units
(or 10% if dose >60 units)
Pre-lunch BG out of range: add
rapid-acting insulin at breakfast
Pre-dinner BG out of range: add NPH insulin at
breakfast or rapid-acting insulin at lunch
Pre-bed BG out of range: add
rapid-acting insulin at dinner
Continue regimen; check
HbA1c every 3 months
Target range:
3.89-7.22 mmol/L
(70-130 mg/dL)
If HbA1c ≤7%... If HbA1c 7%...
Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.
20. ادامــــــــــــــــه...........
•FBGترڅوچې کړی زیات ډوز اودانسولین وګورئ
FBGشي کنټرول:
– Target range: 3.89-7.22 mmol/l (70-130 mg/dl)
– Typical dose increase is 2 units every 3 days, but if
fasting glucose >10 mmol/l (>180 mg/dl), can
increase by large increments (e.g., 4 units every 3
days)
23. Continue regimen; check
HbA1c every 3 months
If fasting BG in target range, check BG before lunch, dinner, and bed.
Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
Recheck pre-meal BG levels and if out of range, may need to add another
injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin
If HbA1c ≤7%...
Bedtime intermediate-acting insulin, or
bedtime or morning long-acting insulin
(initiate with 10 units or 0.2 units per kg)
Check FG and increase dose until in target range.
If HbA1c 7%...
Hypoglycemia
or FG >3.89 mmol/l (70 mg/dl):
Reduce bedtime dose by ≥4 units
(or 10% if dose >60 units)
Pre-lunch BG out of range: add
rapid-acting insulin at breakfast
Pre-dinner BG out of range: add NPH insulin at
breakfast or rapid-acting insulin at lunch
Pre-bed BG out of range: add
rapid-acting insulin at dinner
Continue regimen; check
HbA1c every 3 months
Target range:
3.89-7.22 mmol/L
(70-130 mg/dL)
If HbA1c ≤7%... If HbA1c 7%...
Step Two…
Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.
24. مرحله دویمه:زیاتول دزرقونو دانسولین
چیرې کهFBSخو وي کې لیول مطلوب پهHbA1c7له یا7څخه
نود وي زیاتlunch،Dinnerاوbedtimeدشکر دوینې مخکې څخه
وګورئ اندازه:
• If pre-lunch blood glucose is out of range,
add rapid-acting insulin at breakfast
• If pre-dinner blood glucose is out of range,
add NPH insulin at breakfast or rapid-acting insulin at
lunch
• If pre-bed blood glucose is out of range,
add rapid-acting insulin at dinner
26. • If HbA1c is <7%...
– Continue regimen and check HbA1c every
3 months
• If HbA1c is ≥7%...
– Move to Step Three…
2-3وروسته میاشتې
27. Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.
Continue regimen; check
HbA1c every 3 months
If fasting BG in target range, check BG before lunch, dinner, and bed.
Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
Recheck pre-meal BG levels and if out of range, may need to add another
injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin
If HbA1c ≤7%...
Bedtime intermediate-acting insulin, or
bedtime or morning long-acting insulin
(initiate with 10 units or 0.2 units per kg)
Check FG and increase dose until in target range.
If HbA1c 7%...
Hypoglycemia
or FG >3.89 mmol/l (70 mg/dl):
Reduce bedtime dose by ≥4 units
(or 10% if dose >60 units)
Pre-lunch BG out of range: add
rapid-acting insulin at breakfast
Pre-dinner BG out of range: add NPH insulin at
breakfast or rapid-acting insulin at lunch
Pre-bed BG out of range: add
rapid-acting insulin at dinner
Continue regimen; check
HbA1c every 3 months
Target range:
3.89-7.22 mmol/L
(70-130 mg/dL)
If HbA1c ≤7%... If HbA1c 7%...
Step Three…
30. مجموعي انسولین د لومړی
کړئ محاسبه ډوز
Body weight in kgs / 2
• e.g.; an 80 kg person will require roughly about
40 units / day.
31. محاسبه دډوز........ادامه....
مساوي څلورو په مقدار مجموعي شوی محاسبهs/c
وویشئ زرقونو:
– ¼ of total dose as regular insulin s/c
half-hour ( ½ hr ) before the three main
meals with 6 hrs gap in between.
– ¼ total calculated dose as NPH insulin
s/c at 11:00 p.m. with no food to follow.
32. مثال
For example in an 80-kg diabetic requiring 40 units per day,
start with:
• 08:00 a.m. --- 10 units regular insulin s/c ½ hr before
breakfast.
• 02:00 p.m. --- 10 units regular insulin s/c ½ hr before lunch.
• 08:00 p.m. --- 10 units regular insulin s/c ½ hr before dinner.
• 11:00 p.m. --- 10 units NPH/ lantus insulin s/c
36. مـــثـــــالــــــونـــــــه
• For the following profile:
– Blood sugar fasting = 180
mg/dl
– Blood sugar after breakfast =
250 mg/dl.
– Blood sugar pre lunch = 190
mg/dl
– Blood sugar post lunch 270 =
mg/dl
– Blood sugar pre dinner = 200
mg/dl
– Blood sugar post dinner 260 =
mg/dl
• We need to increase the dose
of NPH at night to bring
down baseline sugar level
(BSF) to around 100 mg/dl
after which the profile should
automatically adjust as
follows:
– Blood sugar fasting = 100
mg/dl
– Blood sugar 02 hrs after
breakfast = 170 mg/dl
– Blood sugar pre-lunch =
110 mg/dl
– Blood sugar 2 hrs. after
lunch = 190 mg/dl
– Blood sugar pre-dinner =
120 mg/dl
– Blood sugar 2 hrs. post
dinner = 180 mg/dl
37. ادامـــــه
• Blood sugar fasting = 130 mg/dl
• Blood sugar after breakfast = 160 mg/dl
• Blood sugar pre-lunch = 130 mg/dl
• Blood sugar post lunch = 240 mg/dl
• Blood sugar pre-dinner = 180 mg/dl
• Blood sugar 2 hrs. post dinner = 200 mg/dl
• This patient needs adjustment of pre-lunch regular
Insulin which will bring down post lunch and pre dinner
readings within normal limits.
• 2 hrs post dinner blood sugar(200 mg/dl) will be
brought down by adjusting pre dinner regular insulin.
39. مثالونه
• e.g-1; If a patient is
stabilized on
• 10U R + 12U R +
10U R + 12U NPH;
• then he may be
shifted to
• 44/2 = 22 units of
70/30 Insulin 12
hourly s/c ½ hr before
meal.
• e.g-2; If the
adjusted Insulin is
• 14U R+16U R+12U
R+8U NPH,
• then split the total
dose:
30 U 70/30 before
breakfast and 20U
70/30 before dinner
to compensate for the
high morning and lunch
Insulin.
40. Combinations………ادامه
• Problem: Remember that BD dosing usually fails to
cover lunch, especially if it is heavy. So:
• Always check for post lunch hyperglycemia when using
this regimen.
• Solution:
1. Patients can be advised to take their lunch (heavier
meal) at breakfast; and breakfast (lighter meal) at
lunch.
2. Adding Glucobay with lunch some times provides a
reasonable control.
3. An alternate combination to overcome the problem is
regular insulin for morning and noon, with premixed
insulin at night.
41. Example
• 10U R before breakfast + 12U R
before lunch + 22U 70/30 before
dinner.