Rajiv Kovil1, Manoj Chawla2, Rajesh Rajput3, A K Singh4, Binayak Sinha5, Samit Ghosal6, Piya Ballani7, Sunil Gupta8, Snehal Tanna9, S M Bandukwala9, Tejas Shah9, Vijay Negalur10, Anil Bhoraskar11, S R Aravind12, Abdul H Zargar13, Jothydev Kesavadev14, Ashok Kumar Das15. 1. Consultant Diabetologist, Kovil Diabetes Center, Mumbai. 2. Consultant Diabetologist, BSES Municipal General Hospital, Mumbai. 3. Senior Professor & Head, Dept of Endocrinology, PGIMS, Rohtak. 4. Consultant Endocrinologist, GD Hospital and Diabetes Institute, Kolkata; Sun Valley Diabetes Research Center, Guwahati. 5. Consultant Endocrinologist, AMRI Hospital, Kolkata. 6. Consultant Endocrinologist ,Nightingale Hospital, Kolkata. 7. Consultant Endocrinologist and Diabetologist, Bombay Hospital and Medical Research Centre, Mumbai. 8. Consultant Endocrinologist, Diabetes Care Center, Nagpur. 9. Consultant Diabetologist Mumbai. 10. Consultant Endocrinologist, Mumbai. 11. Consultant Diabetologist , Asian Heart institute & SL Raheja Hospital Mumbai. 12. Director & Chief Diabetologist, DIACON Hospital, Bangalore. 13. Consultant Endocrinologist, Srinagar. 14. CEO and Director, Jothydev's Diabetes Research Center, Trivandrum. 15. Professor of Medicine and Professor and Head of Endocrinology, Pondicherry Institute of Medical Sciences, Pondicherry.
Abstract
INSTRUCTION: Insulin is the oldest of the currently available treatment options in Type 2 diabetes mellitus (T2DM) and is considered as the most effective glucose lowering agent. Despite this, decision on starting insulin therapy is often delayed in India as well as worldwide due to various barriers at both patient and physician levels. Appropriate insulin dosing and titration is also critical to the successful achievement of tight glycaemic control. OBJECTIVE: To provide simple and easily implementable guidelines to primary care physicians on appropriate insulin dosing and titration of various insulin regimens for both initiation and intensification. METHODOLOGY: Each insulin regimen (once daily [OD] basal, OD, twice daily and thrice daily premixed, basal-plus and basal-bolus) was presented and evaluated for dosing and titration based on established guidelines, data from approved pack inserts, and published scientific literature. These evaluations were then factored into the national context based on the expert committee representatives patient-physician experience in their clinical practice and common therapeutic practices followed in India. RESULTS: Recommendations for dosing and titration of basal, basal-plus, premixed and basal-bolus insulins were developed. The key recommendations are that insulin doses can be adjusted once or twice weekly; adjustment can be based on lowest/mean of three recent self-monitoring of plasma glucose pre-meal/fasting plasma glucose (FPG) values. The titration should be based on FPG or pre-meal value of 80-130 mg/dL and the dose should be reduced by 10-20% for patients reporting hypoglycaemia(<70mg/dL). CONCLUSIONS: The consensus based recommendations mentioned in this paper will be a useful reference tool for health care practitioners, to initiate, optimise and intensify insulin therapy and to successfully achieve optimal glucose control.
INSTRUCTION: Insulin is the oldest of the currently available treatment options in Type 2 diabetes mellitus (T2DM) and is considered as the most effective glucose lowering agent. Despite this, decision on starting insulin therapy is often delayed in India as well as worldwide due to various barriers at both patient and physician levels. Appropriate insulin dosing and titration is also critical to the successful achievement of tight glycaemic control. OBJECTIVE: To provide simple and easily implementable guidelines to primary care physicians on appropriate insulin dosing and titration of various insulin regimens for both initiation and intensification. METHODOLOGY: Each insulin regimen (once daily [OD] basal, OD, twice daily and thrice daily premixed, basal-plus and basal-bolus) was presented and evaluated for dosing and titration based on established guidelines, data from approved pack inserts, and published scientific literature. These evaluations were then factored into the national context based on the expert committee representatives patient-physician experience in their clinical practice and common therapeutic practices followed in India. RESULTS: Recommendations for dosing and titration of basal, basal-plus, premixed and basal-bolus insulins were developed. The key recommendations are that insulin doses can be adjusted once or twice weekly; adjustment can be based on lowest/mean of three recent self-monitoring of plasma glucose pre-meal/fasting plasma glucose (FPG) values. The titration should be based on FPG or pre-meal value of 80-130 mg/dL and the dose should be reduced by 10-20% for patients reporting hypoglycaemia(<70mg/dL). CONCLUSIONS: The consensus based recommendations mentioned in this paper will be a useful reference tool for health care practitioners, to initiate, optimise and intensify insulin therapy and to successfully achieve optimal glucose control.