II. Indications

III. Protocol: Identify Blood Glucose goals

  1. No predisposition to Hypoglycemia
    1. Pre-meal or Fasting: 70-120
    2. Bedtime: 100-140
    3. Hemoglobin A1C: <7-8% (Normal 4.0 - 6.0%)
    4. Two hour post-prandial Glucose <160 mg/dl
      1. Blood Glucose 20-40 mg/dl above pre-meal Glucose
  2. Predisposition for Hypoglycemia (Comorbid conditions)
    1. Pre-meal/Fasting: 100-150
    2. Hemoglobin A1C: 7-8

IV. Protocol: Starting Basal Insulin (e.g. Lantus) and Bolus Insulin (e.g. Lispro)

  1. Step 0: Adjust oral medications
    1. Stop Insulin Secretagogue (Sulfonylurea, Meglitinide) when on twice daily bolus Insulin
    2. Continue Insulin sensitizers (Metformin, Glitazone)
  2. Step 1: Choose a 24 hour basal Insulin (once daily):
    1. Detemir (Levemir)
    2. Glargine (Lantus)
  3. Step 2: Choose a bolus Insulin (pre-meal Insulin):
    1. Regular Insulin (Novolin R, Humulin R)
    2. Glulisine (Apidra)
    3. Lispro (Humalog)
    4. Aspart (Novolog)
  4. Step 3: Starting dose
    1. Hemoglobin A1C <8
      1. Basal Insulin 0.1 units/kg once daily AND
      2. Bolus Insulin 0.1 units/kg divided equally before meals (start before breakfast and dinner)
    2. Hemoglobin A1C 8-10
      1. Basal Insulin 0.2 units/kg once daily AND
      2. Bolus Insulin 0.2 units/kg divided equally before meals (start before breakfast and dinner)
    3. Hemoglobin A1C >10
      1. Basal Insulin 0.3 units/kg once daily AND
      2. Bolus Insulin 0.3 units/kg divided equally before meals (start before breakfast and dinner)

V. Protocol: Starting Insulin using Premixed Insulin

  1. Step 0: Adjust oral medications
    1. Stop Insulin Secretagogue (Sulfonylurea, Meglitinide)
    2. Continue Insulin sensitizers (Metformin, Glitazone)
  2. Insulin preparations (for twice daily dosing)
    1. Lispro Mix 75/25 or
    2. Aspart Premix 70/30
  3. Starting dose
    1. A1C <8: 0.1 units/kg in AM and 0.1 units/kg in PM
    2. A1C 8-10: 0.2 units/kg in AM and 0.2 units/kg in PM
    3. A1C >10: 0.3 units/kg in AM and 0.3 units/kg in PM

VI. Protocol: Converting from Mixed Insulin to Basal Bolus Insulin

  1. Calculate total Insulin units/kg
    1. Total >1.5 units/kg: Lower total to 1.0 unit/kg
    2. Hemoglobin A1C <9: Decrease total Insulin by 10%
  2. Divide total Insulin Dosing
    1. Insulin Glargine: 50% of total Insulin
    2. Rapid acting: 50% of total divided across meals

VII. Protocol: Advancing Basal/Bolus Dosing in Type II Diabetes

  1. Precautions
    1. Requires regular Blood Glucose Monitoring and compliant, reliable patient and family
    2. Educate on home Hypoglycemia Management (Glucose tablets, Glucagon)
  2. Step 0: 0-0-0-G (Basal Only Protocol)
    1. Basal Insulin
      1. Preparations
        1. Insulin Glargine (G) such as Lantus, Levemir or
        2. NPH (if cost is a concern)
      2. Starting dose options
        1. Basal Insulin 10 units at night OR
        2. Basal Insulin 0.1 to 0.2 units/kg/day (or 50% of total daily sliding scale dose)
      3. Titrate
        1. Increase basal Insulin dose by 1-2 units or 5-10% weekly until Blood Glucose controlled
        2. Go to Step 1 when Blood Glucose not at goal despite basal Insulin >0.5 units/kg/day
    2. Other agents to continue
      1. Oral Insulin sensitizer (e.g. Metformin or Glucophage) and
      2. Oral Insulin Secretagogue (e.g. Glipizide)
        1. Stop when bolus Insulin (e.g. RA) is initiated more than once daily
  3. Step 1: 0-0-RA-G (Basal Plus Protocol)
    1. Add 0.1 units/kg bolus Insulin before largest meal
      1. Lispro or Aspart (rapid acting or RA) or
      2. Regular Insulin (if cost is a concern)
        1. Avoid in Stage IV or Stage V significant Chronic Kidney Disease
        2. Avoid if history of severe Hypoglycemia
    2. Decrease Insulin Glargine by 0.1 units/kg
    3. Continue Insulin sensitizer (e.g. Metformin)
    4. Caution with Insulin Secretagogue (e.g. Glipizide)
      1. May be continued with caution once per day opposite the rapid acting Insulin dose
      2. Consider discontinuing in the elderly or other risks of Hypoglycemia
    5. Check Blood GlucoseFasting, before RA dose, bedtime
  4. Step 2: RA-0-RA-G (Basal-Bolus Protocol)
    1. Add 0.1 units/kg Lispro (RA) before 2nd largest meal
    2. Decrease Insulin Glargine by 0.1 units/kg
    3. Continue Insulin sensitizer (e.g. Metformin)
    4. Stop Insulin Secretagogue (e.g. Glipizide)
    5. Check Blood GlucoseFasting, before RA dose, bedtime
  5. Step 3: RA-RA-RA-G (Basal-Bolus Intensive Protocol)
    1. Add 0.1 units/kg Lispro (RA) before 3rd largest meal
    2. Decrease Insulin Glargine by 0.1 units/kg
    3. Check Blood GlucoseFasting, before RA dose, bedtime
  6. Precautions
    1. Keep Insulin split into 50% basal and 50% bolus

VIII. Protocol: Starting Insulin using NPH

  1. Background
    1. Other regimens less complicated and therefore preferred
    2. However, NPH and Regular Insulin are least expensive Insulin options
  2. Step 0: Adjust oral medications
    1. Stop Insulin Secretagogue (Sulfonylurea, Meglitinide) when on twice daily bolus Insulin
    2. Continue Insulin sensitizers (Metformin, Glitazone)
  3. Step 1: Starting dose
    1. Hemoglobin A1C <8: Total Insulin: 0.1 units/kg in AM and 0.1 units/kg in PM
    2. Hemoglobin A1C 8-10: Total Insulin: 0.2 units/kg in AM and 0.2 units/kg in PM
    3. Hemoglobin A1C >10: Total Insulin: 0.3 units/kg in AM and 0.3 units/kg in PM
  4. Step 2: Divide each Insulin dose into 1/3 bolus (e.g. Regular Insulin) and 2/3 NPH Insulin
  5. Step 3: Schedule 2 doses of bolus Insulin (e.g. regular) and 2 doses of NPH daily
    1. Breakfast (50%): NPH Insulin (2/3) and Regular Insulin (1/3)
    2. Dinner (50%): NPH Insulin (2/3) and Regular Insulin (1/3)

IX. Protocol: Insulin Adjustments

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Ontology: Insulin (C0021641)

Definition (CSP) protein hormone secreted by beta cells of the pancreas; insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose and is also an important regulator of protein and lipid metabolism; insulin is used as a drug to control insulin-dependent diabetes mellitus.
Definition (NCI) A short-acting form of insulin. Regular insulin is obtained from animal or recombinant sources. The onset of action of regular insulin occurs at 30-90 minutes after injection; its effect lasts for 6 to 8 hours. Endogenous human insulin, a pancreatic hormone composed of two polypeptide chains, is important for the normal metabolism of carbohydrates, proteins and fats; it has anabolic effects on many types of tissues. (NCI04)
Definition (NCI) Human insulin protein (110 aa, 12 kDa) is encoded by the human insulin (INS) gene. This cytosolic protein, a heterodimer of disulfide-linked alpha and beta chains, is produced in pancreatic islet beta cells. Binding of insulin to its receptor stimulates glucose uptake, accelerates both glycolysis and the pentose phosphate cycle and increases glycogen synthesis in the liver. Insulin regulates protein and lipid metabolism. It also decreases blood glucose concentration by shuttling molecules into cells to be used for energy. Decreased expression of insulin protein causes familial hyperproinsulinemia.
Definition (MSH) A 51-amino acid pancreatic hormone that plays a major role in the regulation of glucose metabolism, directly by suppressing endogenous glucose production (GLYCOGENOLYSIS; GLUCONEOGENESIS) and indirectly by suppressing GLUCAGON secretion and LIPOLYSIS. Native insulin is a globular protein comprised of a zinc-coordinated hexamer. Each insulin monomer containing two chains, A (21 residues) and B (30 residues), linked by two disulfide bonds. Insulin is used as a drug to control insulin-dependent diabetes mellitus (DIABETES MELLITUS, TYPE 1).
Concepts Amino Acid, Peptide, or Protein (T116) , Pharmacologic Substance(T121) , Hormone(T125)
MSH D007328
SnomedCT 67866001, 39487003, 412222002
English Insulin, insulin, INSULIN PREPARATIONS, Insulin preparation, NOS, Regular Insulin, Regular insulin preparation, Unmodified insulin preparation, Insulin Regular, INSULIN, insulin preparations, insulin preparations (medication), A22 INSULIN PREPARATIONS, insulin regular, Insulin (ox), 8A-L-threonine-10A-L-isoleucine-30B-L-threonine-, Insulin [Chemical/Ingredient], [HS501] INSULIN, Insulin regular, insulin products, insulin preparation, insulin product, regular insulin, insulins, Insulin, Soluble, Soluble Insulin, Insulin, Regular, Insulin product, Insulin (substance), Insulin preparation, Insulin product (product), Regular insulin product, Unmodified insulin product, Insulin preparation (substance), Regular insulin (substance), Regular insulin
Swedish Insulin
Czech insulin, inzulin
Finnish Insuliini
French Insuline ordinaire, Insuline
Russian INSULIN, ИНСУЛИН
Spanish producto con insulina (producto), preparado insulínico, insulina (producto), producto con insulina, insulina (sustancia), insulina, preparado de insulina (producto), preparado de insulina (sustancia), preparado de insulina cristalina de cinc, preparado de insulina cristalina de zinc, preparado de insulina no modificada, preparado de insulina, insulina regular (sustancia), insulina regular, Insulina
Italian Insulina regolare, Insulina
Croatian INZULIN
Polish Insulina
Japanese インスリン, インスリン亜鉛水性懸濁液, インシュリン
German Insulin
Portuguese Insulina