www.diabeticretinopathy.org.uk

General

Multiple dose insulin in type 2 diabetes

David Kinshuck

 

Introduction

If you have a fair amount of insulin from your pancreas still, you will not need this intensive insulin  regime, and may just need tablets or once daily insulin as opposite.

If your type 2 diabetes is quite severe, and you have very little remaining insulin, then your diabetic control is similar to type 1 diabetes. This page discusses intensive insulin control, and this is taken further in the insulin dose adjustment pages above. You naturally need to speak to your diabetes nurse and doctor for individual advice.

If you have no or very little remaining insulin from you pancreas, and are prone to hypos, then your diabetes is nearly equivalent to the type 1 diabetes patient, and you may benefit from the same intensive insulin 'regime'. This is discussed on this page below and the adjusting insulin dose pages taken from the DAFNE Program.

Complex insulin regimes do lead to better glucose control, fewer hypos, and better weight control than twice daily insulin (NEJM 2009).

 

Controversies

First

The two long acting insulins are Levemir (detemir) or Lantus (glargine). Levemir is shorter acting, with a peak 9-12  hours. Lantus generally has no peak in the first 24 hours, and its action may take 3 days to complete. Therefore anyone with a slightly irregular lifestyle in theory will be better off using twice daily Levemir rather than once daily Lantus. At present, this decision is usually made by diabetes doctors and nurses.

If you do use once daily Lantus, and your glucose levels fluctuate, then you should consider twice daily Levemir instead.

Second

Another controversy is the use of analogue insulins such as lantus and detemir verus older insulins. When first starting insulin there seems to be little difference, but once remaining pancreas insulin levels drop further, analogue insulins seem to give more consistent glucose levels. Analogue insulins are more expensive..

 

How do Levemir/Lantus work

Generally Levemir is used twice in this regime, Lantus is used once a day. These insulins are 'long acting', and provide your body's basal insulin needs just to keep you alive. This enables your body get its energy when you are not eating. Generally twice daily Levemir (detemir) will lead to better diabetic control, and is part of the DAFNE regime, and the adjusting insulin dose pages on this site. The Levemir/Lantus dose will be about 50% of the total insulin dose.

Levemir/Lantus can be given any time of day, but it is best to give it them at the SAME TIME OF DAY each day. If given twice daily, there should be about a 12 hour gap.

 

Quick acting insulin with food

The dose of the quick acting insulin before meals should match the amount of food that you eat. Measuring the amount of food to determine insulin here and here. This insulin regime is called 'basal-bolus' or multiple dose. It is very helpful if you want to achieve very good control. The quick-acting insulins before food are Humalog (lispro) or Novorapid (aspart) or Apidra. The total dose of the quick acting insulin (~3 meals) will be half the total dose, very approximately equal to the total long-acting insulin dose.

The quick-acting insulins are used for meals, and are generally given just as you start (or occasionally during or immediately after) a meal/snack.

 

Insulin pumps

Insulin pump treatment generally achieves even better control than basal bolus insulin as on this page, but these are not generally used in the UK in type 2 patients (not approved by NICE).

 

Insulin resistance, Metformin, exenatide and Lantus

If you are overweight you will be resistant to insulin, and need higher doses than thinner people. In the long term you need to lose weight, but it is still possible to control your diabetes even if you are overweight, though this is not ideal. See reducing weight.
Insulin resistance means that your body needs extra insulin than if you are a normal weight.

Metformin (a tablet) helps reduce insulin resistance and is now recommended for such patients, in addition to insulin. You will need less insulin if you start metformin.

Insulin resistance and the dose of insulin are reduced by exercise . Exercise is critically important in diabetes excellent review.

Similary, exenatide is now licensed for use with insulin (2012). Exenatide makes the body more sensitive to insulin, and when given with insulin (and often metformin as well), less insulin will be needed. The main advantage to the use of exenatide is that there is less weight gain...insulin puts weight on, metformin and exenatide often help to keep weight down.

 

Lantus or Levemir dose if used once daily

 

Adjusting Levemir/Lantus dose once daily

This table explains how to adjust once daily Lantus dose. Levemir would be similar if used once a day. This table is slightly different from the insulin dose adjustment/DAFNE program which discusses this in detail.

 

>
Blood testing time

Blood glucose level

Before breakfast Less than 4mmol/l
(Hypo)
4-6mmol/l 6.1-8.0 mmol/l 8.1-9.9 mmol/l Above 10 mmol/l
Adjust Insulin Reduce insulin by
2 units
Good control Increase insulin by
2 units
Increase insulin by 4 units Increase insulin by 6 units

 

Levemir/Lantus at night

 

Do YOU need Levemir (detemir) once daily or twice daily?

Judging the dose of twice daily Levemir

This is a little more difficult. Using twice daily Levemir adjust the morning dose so your afternoon glucose is about 4.5 - 7.5 (this is pre-evening meal, about 5 hours after lunch).

Usually the total dose of the two Levemir injections will be that same as the long-acting dose used once daily. Generally the once daily dose is split into two doses with 40% about in the morning, and 60% at night.

 

Dose of quick-acting insulin

 

Adjusting your quick acting insulin, table

This table reminds you how to adjust your quick acting insulin, excluding exercise adjustment. Exercise adjustment needs to be included, and is discussed below. This is very approximate...if you only need a low dose of insulin, you may need to make a smaller adjustment. But if you are more insulin resistant and need higher doses, you may need to make larger adjustments (so the percentage change of each dose is similar).

 

>
Blood Testing Time Blood Glucose Level
Less than 4 mmol/l 4-7 mmol/l 7.1-12.0 mmol/l Above 12.0 mmol/l
Before Breakfast Refer to guide on adjustment of slow acting insulin Refer to guide on adjustment of slow acting insulin Refer to guide on adjustment of slow acting insulin Refer to guide on adjustment of slow acting insulin
Before Midday Meal Adjustment needed to breakfast dose of insulin  REDUCE By 2 units GOOD CONTROL No change to insulin INCREASE By 2 units  INCREASE By 4 units
Before evening meal Adjustment needed to lunchtime dose of insulin REDUCE By 2 units GOOD CONTROL  No change to insulin INCREASE By 2 units   INCREASE  By 4 units
Before supper/bedtime Adjustment needed to evening meal dose of insulin REDUCE By 2 units GOOD CONTROL No change to insulin INCREASE By 2 units INCREASE 4 units

Target glucose levels (from DAFNE)

Common problems

 

Levemir/Lantus & quick-acting insulin & exercise

How do you cope with exercise if your diabetes is tightly controlled using Levemir/Lantus and quick-acting insulin?

 

Testing glucose levels

Diabetes education and the XPERT program

If you want good diabetic control, the main type 2 diabetes education course is the XPERT program. This course is very helpful: it helps people come to terms with their diabetes, you learn from others, help others, get to know other similar patients well, learn how to take control of your diabetes, learn how to adjust doses, and are advised by an expert nurse.