How to adjust the dose of insulin? When to adjust? As a clinician, do you really understand? (one)

The hypoglycemic treatment of patients with type 2 diabetes is a long process
.

Most newly diagnosed patients can be treated with oral hypoglycemic drugs based on lifestyle intervention to achieve good therapeutic effects; if patients have significant clinical symptoms and blood sugar is significantly elevated, short-term insulin intensive therapy can be given

Short-term Intensive Insulin Therapy Individualized Treatment to Relieve High Glucose Toxicity

A, insulin treatment is initiated in four kinds of programs:

A, insulin treatment is initiated in four kinds of programs:

1.
Basal insulin + oral hypoglycemic drugs

1.
Basal insulin + oral hypoglycemic drugs 1.
Basal insulin + oral hypoglycemic drugs

The initial dose of basal insulin (including intermediate and long-acting insulin analogues) is 0.
1-0.
3 U/(kg·d), injected before going to bed, and the amount of insulin is adjusted according to the fasting blood glucose level
.

It can be used in combination with various oral hypoglycemic drugs

0.

2.

The initial dose of insulin once a day is generally 0.
2 U/(kg·d), injected before dinner
.

0.
2 U/(kg·d), injected before dinner

When the glycosylated hemoglobin (HbA1c) is relatively high, use the twice daily injection regimen
.

The starting dose is generally 0.

0.

3.
" three short of a length " of intensive insulin therapy program

3.
" three short of a length " of intensive insulin regimen 3.
" three short of a length " of intensive insulin therapy program

    That is, short-acting insulin is injected before meals, and medium and long-acting insulin are injected before going to bed.
This program is mainly suitable for type 1 diabetes, fasting blood glucose> 11.
1 mmol/L and HbA1c> 9% of newly diagnosed type 2 diabetes patients
.

Using this program, in principle, no longer taking insulin secretagogues

Suitable for newly diagnosed type 2 diabetes patients with type 1 diabetes, fasting blood glucose> 11.

4.

CSII has a lower risk of hypoglycemia and can improve the quality of life of patients, but the medical costs are slightly higher

Today we focus on explaining the "three short and one long" insulin intensive treatment plan
.

2.
Dosage calculation of "three short and one long" insulin intensive program

2.
Dosage calculation of "three short and one long" insulin intensive program

1.
Calculate the daily total: weight (kg) × coefficient

Weight (kg) × coefficient

Coefficient: Type 1 diabetes: 0.
5-1U/kg/d

Type 1 diabetes: 0.
5-1U/kg/d

         Type 2 diabetes: 0.
3-0.
8U/kg/d

         Type 2 diabetes: 0.
3-0.
8U/kg/d

Note: Generally start from the minimum dose ; but the heavier the weight, the heavier the insulin resistance, you can start from the middle value
.

Minimum dose

2.
Calculate the starting dose of basal insulin and short-dose insulin

24h basal insulin dose: 24h meal insulin dose=1:1

24h basal insulin dose: 24h meal insulin dose=1:1

The ratio of basal insulin dose and meal insulin dose varies from person to person, usually a 50/50 ratio, but some people may need a 40/60 ratio
.

After starting treatment, basal insulin can be adjusted every 2-3 days until the fasting blood sugar reaches the control target
.

The basal insulin adjustment plan is as follows:

Adjust every 2-3 days

 

Fasting blood glucose (mmol/L)	Basal insulin dose adjustment (IU)
＜4. 4	-2
4. 4～6. 1	No adjustment
6. 2～7. 8	+2
7. 9～9. 9	+4
＞10. 0	+6

Fasting blood glucose (mmol/L)

Basal insulin dose adjustment (IU)

＜4.
4

-2

4.
4～6.
1

No adjustment

6.
2～7.
8

+2

7.
9～9.
9

+4

＞10.
0

+6

Fasting blood glucose (mmol/L)

Basal insulin dose adjustment (IU)

Fasting blood glucose (mmol/L)

Fasting blood glucose (mmol/L)

Basal insulin dose adjustment (IU)

Basal insulin dose adjustment (IU)

＜4.
4

-2

＜4.
4

＜4.
4

-2

-2

4.
4～6.
1

No adjustment

4.
4～6.
1

4.
4～6.
1

No adjustment

No adjustment

6.
2～7.
8

+2

6.
2～7.
8

6.
2～7.
8

+2

+2

7.
9～9.
9

+4

7.
9～9.
9

7.
9～9.
9

+4

+4

＞10.
0

+6

＞10.
0

＞10.
0

+6

+6

 

3.
Calculate the amount of insulin during meals

3.
Calculate the amount of insulin during meals

(1) Calculate the basic starting dose at meals: insulin dose at meals = 0.
1U/kg/per meal (for example, a 70 kg person may require a 7U quick-acting dose at meals)
.

Meal insulin dose = 0.
1U/kg/per meal

(2) Determine the timing of insulin injection: fast-acting insulin should be injected 15 minutes before meals .
If the blood sugar before meals is already below 4.
5 mmol/L, then insulin should be injected after the first mouthful of meals
.

For example, after 2 hours after a meal, blood glucose> 10mmol/L, insulin will increase by 1 unit for every 2mmol/L increase in blood glucose , but the increase should not exceed 6 units at a time

15 minutes before the meal, the blood sugar before the meal is already lower than 4.
5 mmol/L, then the insulin is injected after the first mouthful of the meal.
After the blood glucose is greater than 10mmol/L 2 hours after the meal, the blood sugar increases by 1 unit for every 2mmol/L increase in insulin.
No more than 6 units

(3) Patients can adjust the insulin dose according to their own food intake.
As with the previous food intake, the pre-meal dose will not be adjusted.
If the meal is larger than the previous meal and there is a dessert after meal, the pre-meal amount will be +3U from the previous basic amount If the meal is larger than the previous meal and there is no dessert, then the previous basic amount before the meal is +1~2U; if it is less than the usual meal, the previous basic amount will be reduced by 1~2U before the meal
.
  

The pre-meal dose will not be adjusted as in the past meal intake.
If it is greater than the past meal intake and there is dessert after meal, the pre-meal amount will be +3U on the previous basis.
If it is greater than the past meal intake and there is no dessert, then the meal The previous basic amount is +1~2U.
If it is less than the usual meal size, the previous basic amount will be reduced by 1~2U before the meal
.
  

(4) Poor blood glucose control after meals should increase the dose of short-acting insulin before meals
.

4.
Further fine-tune the program according to the results of the patient's blood glucose monitoring to find the regularity of insulin usage
.

5.
At the same time, you should strictly pay attention to hypoglycemia and find the cause, especially at night.
When the cause is unknown, reduce the basal insulin dose by 10% to 20%
.

Reduce the basal insulin dose by 10% to 20%
.

6.
If the "three short and one long" insulin regimen is not effective, attention should be paid to: ① diet structure, energy intake and exercise status; ② basic and meal insulin ratio and dosage; ③ accuracy of blood glucose monitoring; ④ whether There is severe insulin resistance; ⑤ For patients with poor pancreatic islet function and large blood glucose fluctuations, care should be taken to exclude adult latent autoimmune diabetes
.
If the "three short and one long" insulin injection regimen still has poor blood glucose control, it is recommended to switch to an insulin pump treatment regimen
.

Note: Before adjusting the insulin treatment plan, what assessments need to be performed on the patient?

Note: Before adjusting the insulin treatment plan, what assessments need to be performed on the patient?

1.
Whether there are reversible factors that cause blood sugar to rise : such as whether there are changes in diet or exercise, stress state, self-adjustment of insulin treatment plan, poor compliance and other reasons
.
If the above situation exists, after correcting the reversible factors, decide whether to adjust the treatment plan
.

Reversible factor

2.
Whether the insulin injection method is correct: For patients who inject insulin subcutaneously, check whether the patient's injection site and injection method are correct
.
If there is an error in the injection method or location, the patient needs to be guided on the correct injection technique and method
.

Injection method

3.
Insufficient dosage : Assess whether the insulin dosage is sufficient, and adjust the treatment plan according to the blood sugar situation
.

Insufficient dosage

4.
Blood glucose : When HbA1c is not up to the standard after insulin treatment, it is necessary to evaluate whether the postprandial blood glucose and fasting blood glucose are up to the standard at the same time, and different plans should be selected according to the blood glucose situation
.

Blood sugar

5.
whether the occurrence of high-risk patients with low blood sugar : long course, aging, etc.
There are a variety of complications are risk factors for hypoglycemia
.
High-risk patients with hypoglycemia should consider adjusting their blood glucose control goals and giving insulin analog therapy
.

High-risk patients with hypoglycemia

6.
Other factors : comprehensively evaluate the diabetic complications and other combination medications, and make individualized conversion plans based on the patient's treatment willingness and compliance
.
Among them, factors such as treatment cost, number of injections, complexity of the plan, and the ability of patients to manage themselves may affect treatment willingness and long-term compliance
.

other factors

Follow-up will continue to update the medication adjustment plan for premixed insulin and insulin pump, remember to follow, like, and favorite!

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