Taller de Uso de Insulinas Presenta: Dra. Carmen Ojeda López R2MI Profesor Titular: Dr. Enrique J. Díaz Greene Profesor Adjunto: Dr. Federico Rodríguez Weber

Caso 1 Masculino 43 años, Carga genética: DM, IAM DM2 diagnosticada hace 9 años Educación para manejo de DM hace 9 años, programa de ejercicio Fluctuación de peso en el último año, IMC 29.6 HbA1c 7.3% hace 3 meses, hoy 8.9% Tratamiento Glimepiride 8mg c/24h Metformina 1000mg c/12h Rosiglitazona 8mg c/24h GPA 140-180 mg/dL, postprandial >200

¿Es candidato a iniciar insulina?

Step 1 (initial) involves the lifestyle changes of decreasing weight and increasing activity. These maneuvers are low cost and have other health benefits, but very frequently fail, so the recommendation is to start metformin. Metformin is weight neutral and inexpensive but may result in gastrointestinal (GI) adverse effects and (very rarely) lactic acidosis. The general goal is to keep the HbA1c < 7% (4 standard deviations above normal), although the goal in the individual patient is to keep the A1c as close to normal range as is safe (< 6% = 2 standard deviations above normal) while avoiding serious episodes of hypoglycemia. Step 2 involves adding either basal (intermediate or long-acting) insulin, a sulfonylurea (least expensive, although prone to occasional hypoglycemia) or a thiazolidinedione (also called TZD, glitazone, or "insulin sensitizer"), which avoids hypoglycemia and can improve the lipid profile, but may cause fluid retention and weight gain. Step 3 involves intensifying with a short- or rapid-acting insulin at mealtime if 90-120 minute postmeal glucose is > 180 mg/dL. When A1C is close to goal (< 8.0%), addition of a third oral agent could be considered; however, this approach is relatively more costly and potentially less effective in lowering glycemia when compared to adding or intensifying insulin.

Indicaciones para uso de insulina Falla a tx con hipoglicemiantes orales Intolerancia a hipoglicemiantes orales Comorbilidades que contraindican otros agentes hipoglicemiantes Enfermedad aguda o periodo perioperatorio Consideración por costos Hiperglicemia extrema GPA > 250 ó GPP >300 ó A1C > 10% El paciente persiste sintomático (pérdida de peso, poliuria, polidipsia)

Beneficios de uso de insulina

Caso 1 Masculino 43 años, Carga genética: DM, IAM DM2 diagnosticada hace 9 años Educación para manejo de DM hace 9 años, programa de ejercicio Fluctuación de peso en el último año, IMC 29.6 HbA1c 7.3% hace 3 meses, hoy 8.9% Tratamiento Glimepiride 8mg c/24h Metformina 1000mg c/12h Rosiglitazona 8mg c/24h GPA 140-180 mg/dL, postprandial >200

Barreras del paciente El inicio de insulina indica que la enfermedad ha empeorado y presentan temor de complicaciones severas (deterioro de órganos, ceguera) Creencia de que el iniciar insulina indica que “no se sabe cuidar” Miedo a dolor asociado a la inyecciòn Ansiedad acerca de la técnica de la inyección Inconveniencia de inyecciones diarias Preocupaciòn acerca de hipoglicemia potencial Incertidumbre acerca de los beneficios clínicos de la insulina Concepción de que la insulina es innecesaria ya que otros tratamientos han funcionado en el pasado Miedo a ser estigmatizado entre familia, amigos y trabajo Costo del tratamiento Preocupación por aumento de peso

Barreras del Médico Preocupación sobre la hipoglicemia Aumento en el uso de recursos (visitas al médico, pruebas de laboratorio) Incertidumbre sobre los beneficios potenciales del tratamiento con insulina Preocupación del apego del paciente al régimen prescrito Ganancia de peso Visión de que es el “último recurso” Visión de que el régimen es complejo Creencia de que existe un incremento en el riesgo cardiovascular

¿Qué tipo de insulina iniciar?

INSULINA INICIO PICO DURACIÓN Acción Rápida Insulina Lispro 10-15 min Insulina Aspártica 10-15 min 1-2 h 3-5 h Acción Corta Insulina regular 0.5-1 h 2-4 h 4-8 h Acción Intermedia NPH Lenta 1-3 h 4-10 h 4-12 h 10-18 h 12-20 h Acción Larga Ultralenta Insulina Glargina Insulina Detemir 6-8 h 10-18h Ninguno 24-28 h 20-24 h 12-24 h Premezclada 70/30 (NPH – regular) 50/50 (NPH – regular) 75/25 (NPH – lispro) 2-10 h 10-16 h

Insulina Basal + Prandial Insulina Prandial Insulina Basal + Prandial Insulina Premezclada

Guías generales para iniciar insulina GPA elevada: iniciar insulina de larga duración o insulina basal GPP elevada: iniciar insulina de acción rápida o insulina en bolo que puede usarse para cubrir los alimentos GPA y BPP elevada: más opciones, agentes orales + insulina basal, análogos premezclados, bolos basales en múltiples inyecciones al día o bomba de insulina.

Insulina Basal Insulina NPH Insulina Glargina Insulina Detemir

Guías específicas para iniciar insulina Estudio Treat-to-Target The Treat-to-Target study recommended beginning with long-acting insulin QHs, at 10 units. Titrate once/week using the previous 2 days' FPG: increase by 2 units if FPG between 100-120, by 4 units if FPG 120-140, etc. (3956).

Riddle MC, Rosenstock J, Gerich J, for the Insulin Glargine 4002 Study Investigators. The Treat-to-Target Trial: Randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care. 2003;26:3080–3086. No diferencia significativa en cambio de peso corporal entre glargina y NPH The Treat-to-Target paradigm offers a “simple, standardized way to initiate basal insulin in routine practice for an important group of patients, those overweight patients with type 2 diabetes who have HbA1c between 7.5% and 10% despite using 1 or 2 oral agents. The proportion of patients in whom target HbA1c was achieved was significantly greater in the insulin glargine group versus the NPH insulin group (33.2% vs 26.7%; P < 0.05) (Figure 1). HbA1c level was improved to target in both treatment groups (means: insulin glargine, 6.96%; NPH insulin, 6.97%), and ~60% of patients in both groups achieved HbA1c levels <7% (insulin glargine, 58.0%; NPH insulin, 57.3%). In both groups, mean FPG levels decreased from baseline to end point (insulin glargine, from 11.0 to 6.5 mmol/L [from 198 to 117 mg/dL]; NPH insulin, from 10.8 to 6.7 mmol/L [from 195 to 120 mg/dL]), and the proportion of patients in whom FPG target was achieved without hypoglycemia was significantly greater with insulin glargine versus NPH insulin (22.1% vs 15.9%; P < 0.03). In addition, the mean deviation from the median FPG value, a marker of within-patient variability in day-to-day glycemic control, in individual patients was lower with insulin glargine versus NPH insulin (1.02 vs 1.13 mmol/L [18.4 vs 20.4 mg/dL]; P = 0.013); however, the difference in the change from baseline in body weight with insulin glargine versus NPH insulin was not statistically significant (+3.0 vs +2.8 kg). Furthermore, a high compliance rate (>90%) was observed, as estimated according to the amount of insulin returned to the investigators at each visit. Together, these results suggest that not only was the forced Treat-to-Target titration algorithm effective but also that the patients adhered to the regimen

Mayor incidencia de hipoglicemia con NPH en las primeras 12 semanas Yki-Jarvinen H, Kauppinen-Makelin R, Tiikkainen M, et al. Insulin glargine or NPH combined with metformin in type 2 diabetes: The LANMET study. Diabetologia. 2006;49:442– 451. Mayor incidencia de hipoglicemia con NPH en las primeras 12 semanas The LANMET study,38 a 36-week, randomized, open-label, parallel-group study in 110 patients (aged 35–75 years) with suboptimally controlled type 2 diabetes (HbA1c ≥8.0%; mean, 9.5%) used a patient self-titration treat-to-target algorithm to compare bedtime regimens of insulin glargine versus NPH insulin. Patients were instructed to increase their daily insulin dose by 2 IU every 3 days if their FPG levels were above the target range of 4.0 to 5.6 mmol/L (72–100 mg/dL); dose escalation was stopped if ≥1 hy-poglycemic episode occurred

Guías específicas para iniciar insulina The AT.LANTUS (A Trial comparing LANTUS Algorithms to achieve Normal blood glucose Targets in subjects with Uncontrolled blood Sugar) study39 compared an algorithm based on the treat-to-target algorithm with a self-titration algorithm in a large (n = 4961), multinational (59 countries), 24-week, randomized, open-label study in patients (aged ≥18 years) with suboptimally controlled (HbA1c >7.0% and <12%) type 2 diabetes. Patients using the self-titration algorithm titrated insulin glargine in incremental doses of 2 IU every 3 days

No diferencia en incidencia de hipoglicemia nocturna o severa Davies M, Storms F, Shutler S, et al, for the ATLANTUS Study Group. Improvement of glycemic control in subjects with poorly controlled type 2 diabetes: Comparison of two treatment algorithms using insulin glargine. Diabetes Care. 2005;28: 1282–1288. No diferencia en incidencia de hipoglicemia nocturna o severa In this study, significant reductions in mean HbA1c were observed with both treatment algorithms. Significantly greater mean reductions in HbA1c and FBG (Figure 3) were observed with the self-titration algorithm versus the treat-to-target algorithm (HbA1c, –1.22% vs –1.08%; FBG, –3.4 vs –3.2 mmol/L [–62 vs –57 mg/dL]; both, P < 0.001), which relied on weekly contact with the investigational site for insulin glargine dose titration. The pattern of insulin glargine titration in relation to the corresponding reduction in FBG over the course of the 24-week study (Figure 3) shows how maximal dosing was achieved when the FBG approached 6.7 mmol/L (120 mg/dL), after which point further insulin glargine titration was optional and at the discretion of the investigator in this particular study Differences in symptomatic hypoglycemia between the patient self-titration algorithm versus the treat-to-target algorithm were statistically significant, but probably not clinically relevant (29.7% vs 26.3%; Δ, 3.4% [90% CI, 1.2%–5.5%]).39 Statistically significant changes in mean (SD) body weight were observed from baseline to end of study with the patient self-titration algorithm (from 79.8 [16.2] kg to 81.1 [16.5] kg; P < 0.001) and the treatto- target algorithm (from 79.8 [15.8] kg to 80.8 [16.0] kg; P < 0.001).

Tratamiento intensivo 1. Cambio a insulina 2 veces al día (generalmente aún en combinación con metformina) 2. Avance a tratamiento basal + bolo Introducir análogos de acción rápida para controlar GPP Bolos de 4-10UI antes de alimento con mayor incremento en GPP (>162mg/dL), agregar antes de desayuno, comida, cena como sea necesario A randomized, open-label comparison of insulin glargine with NPH insulin as the basal insulin in basal–bolus regimens in 518 patients with type 2 diabetes33 found similar glycemic control with the 2 regimens (mean change from baseline in HbA1c: –0.41 vs –0.59; 95% CI for the difference between treatments: 0.00–0.35). However, a lower incidence of nocturnal hypoglycemia (31.3% vs 40.2% of patients reported ≥1 episode of nocturnal hypoglycemia; P = 0.015) and less weight gain (0.4 vs 1.4 kg; P < 0.001) were observed with insulin glargine versus NPH insulin.

Adición progresiva de insulina prandial a insulina basal Optimice la dosis de insulina basal Identifique la comida principal del día Introduzca la insulina prandial una vez al día en la comida principal Discontinúe los secretagogos de insulina concomitantes Titule la dosis de insulina prandial para alcanzar la meta de glucosa sanguínea Añada más inyecciones de insulina prandial, conforme se requiera Nathan D y cols. Diabetes Care 2008;31:1−11.

Guías específicas para iniciar insulina Estudio 1-2-3 Iniciar con dosis diaria de BiAsp 70/30 6UI 41% de los pacientes consiguió A1c objetivo con esa dosis 70% de los pacientes con una segunda dosis de 6UI con desayuno 77% de los pacientes con 3a dosis con la comida

Janka HU, Plewe G, Riddle MC, et al Janka HU, Plewe G, Riddle MC, et al. Comparison of basal insulin added to oral agents versus twicedaily premixed insulin as initial insulin therapy for type 2 diabetes. Diabetes Care. 2005;28:254–259. Menor hipoglicemia con glargina 49.4% de px con HbA1C <7% vs 39% con insulina premezclada (70/30R) The LAPTOP (LANTUS plus Amaryl plus metformin versus premixed insulin in Patients with Type 2 diabetes mellitus after failing Oral treatment Pathways) study40 was a 24-week, randomized, open-label trial that compared treatment with oncedaily insulin glargine plus glimepiride with twice-daily 30% regular human insulin/70% NPH insulin (30/70) in 371 insulin-naive patients (aged 35–75 years) with suboptimally controlled type 2 diabetes (HbA1c 7.5%– 10.5%) while receiving a sulfonylurea plus metformin. The study involved a forced insulin titration to target FBG ≤5.5 mmol/L (≤100 mg/dL) for both insulins and an additional predinner blood glucose target ≤5.5 mmol/L (≤100 mg/dL) for the 30/70 premixed insulin. With this study design, the insulin glargine plus OADs regimen was associated with greater reductions from baseline in HbA1c compared with premixed insulin (insulin glargine plus OADs: from 8.85% to 7.15%; premixed insulin: from 8.83% to 7.49%; adjusted mean Δ: –1.64% vs –1.31%; P < 0.001) and FBG (insulin glargine plus OADs: from 9.5 to 6.4 mmol/L [from 171 to 115 mg/dL]; premixed insulin: from 9.6 to 7.4 mmol/L [from 172 to 133 mg/dL]; adjusted mean Δ: –0.9 mmol/L [–17 mg/dL]; P < 0.001) levels. Overall, 49.4% of patients in the insulin glargine–treated group achieved HbA1c ≤7% versus 39.0% in the premixed insulin group (P = NS)

No diferencia en cambio de peso, hipoglicemia similar Heller S, et al. Comparison of Insulin Detemir and Insulin Glargine in a Basal–Bolus Regimen, With Insulin Aspart as the Mealtime Insulin, in Patients With Type 1 Diabetes: A 52-Week, Multinational, Randomized, Open-Label, Parallel-Group, Treat-to-Target Noninferiority Trial. Clinical Therapeutics/Volume 31, Number 10, 2009 No diferencia en cambio de peso, hipoglicemia similar This multinational, open-label, parallelgroup, treat-to-target, noninferiority trial enrolled patients aged ≥18 years who had had T1DM for at least 12 months, had been taking a basal–bolus insulin regimen for at least 3 months, and had a glycosylated hemoglobin (HbA1c) value ≤11.0% at screening. Patients were randomized in a 2:1 ratio to receive either detemir or glargine for 52 weeks. The basal insulin was initially administered once daily (in the evening) in both groups; if patients in the detemir group were achieving the plasma glucose (PG) target before breakfast but not before dinner, they were switched to twice-daily administration. Glargine was administered once daily throughout the trial, according to its approved labeling. Each patient attended 13 study visits and received 16 scheduled telephone calls from the trial site. The primary efficacy end point was glycemic control (HbA1c) after 52 weeks of treatment. Secondary end points included the number of patients achieving an HbA1c value ≤7.0%, with or without a major hypoglycemic episode in the last month of treatment; fasting PG (FPG); within-patient variation in self-monitored plasma glucose (SMPG) before breakfast and dinner; and 10-point SMPG profiles. The noninferiority margin was 0.4%, consistent with US Food and Drug Administration guidelines

In the studies in insulin-naive patients, 17a8 more episodes of hypoglycemia were noted in those treated with twice-daily premixed insulin analogues compared with a basal insulin analogue; in the study in which patients had previously received insulin, 19 the incidence of hypoglycemia was similar between treatments (Table I). In one of the studies in insulin-naïve patients, is there was no difference in mean (SD) rates of nocturnal hypoglycemia between insulin lispro 75/25 and insulin glargine (0.14 [0.43] vs 0.24 [1.10] episode/ patient/30 d, respectively) when both were used in conjunction with metformin, and there were no episodes of severe hypoglycemia (defined as requiring third-party assistance) during the study. In the study by Raskin et al, 17 minor hypoglycemia (BG <56 mg/dL, with or without symptoms that were self-treated) was reported by 43% of patients treated with insulin aspart 70/30 and by 16% of patients treated with insulin glargine (P < 0.05); major hypoglycemia (an episode with neurologic symptoms consistent with hypoglycemia that required assistance) occurred only once, in a patient treated with insulin glargine.

BIAsp 70/30 + HGO vs Glargina +HGO Raskin P, Allen E, Hollander P, et al, for the INITIATE Study Group. Initiating insulin therapy in type 2 diabetes: A comparison of biphasic and basal insulin analogs. Diabetes Care. 2005;28:260–265. INITIATE BIAsp 70/30 + HGO vs Glargina +HGO (metformina + pioglitazona) 6UI de BiAsp 2 veces al día si GPA >= 180 5UI de BiAsp 2 veces al día si GPA < 180 Titulación de acuerdo a GPA (de 2 en 2 UI como para Treat-to-Target) HbA1C menor en premix (6.91% vs 7.41%; P < 0.01) The INITIATE (INITiate Insulin by Aggressive Titration and Education) study41 was a 28-week, randomized, open-label trial that compared the efficacy and tolerability of biphasic insulin aspart 70/30 (BIAsp 70/30, prebreakfast and presupper) plus OADs with those of once-daily insulin glargine plus OADs in 233 insulin-naive patients with type 2 diabetes inadequately controlled (HbA1c ≥8%) with OADs alone. In that study, insulin doses were titrated weekly for the first 12 weeks and every 2 weeks thereafter to achieve target FPG and presupper glucose values of 4.4 to 6.1 mmol/L (80–110 mg/dL). Presupper BIAsp 70/30 and bedtime glargine doses were titrated based on FPG. The prebreakfast BIAsp 70/30 dose was titrated based on presupper plasma glucose values. In contrast to the LAPTOP study,40 INITIATE41 reported that the mean HbA1c was significantly lower at end point in the BIAsp 70/30 group than in the insulin glargine group (6.91% vs 7.41%; P < 0.01). The mean HbA1c reduction was greater in the BIAsp 70/30 group than in the insulin glargine group (–2.79% vs –2.36%; P < 0.01), especially in patients with baseline HbA1c >8.5% (–3.13% vs –2.60%; P < 0.05)

Tratamiento intensivo Debe evitarse el tratamiento intensivo en los pacientes: Incapaces de monitorizarse frecuentemente Propensos a desarrollar hipoglicemia severa Aquellos en quienes la hipoglicemia es potencialmente fatal Insuficiencia suprarrenal Insuficiencia hipofisiaria Insuficiencia contrarregulatoria Insuficiencia autonómica Uso concomitante de betabloqueadores Enfermedad coronaria o EVC Pacientes potencialmente con mal apego (abuso de alcohol o drogas,trastornos psiquiátricos)

Caso 2 Masculino de 18 años No antecedentes, peso 60kg IMC 20.5 Hospitalizado por cetoacidosis diabética una semana previa Egresa con diagnóstico de DM1

¿Qué tratamiento iniciar?

Guías para tratamiento DM1 Paso 1. – Establecer dosis total de insulina Dosis total diaria= peso (kg) x 0.7 (UI) Adolescentes 1 – 2 U/kg/d > 65 años 0.5 a 0.7 U/kg/d The total daily dose (TDD) is equal to the weight in kg 0.7; for example, a 70-kg patient would require 70 0.7 ¼ 49 U of insulin daily. Note that adolescents may require 1 to 2 U/kg/d, and patients older than age 65 may require 0.5 to 0.7 U/kg/d. TDDs may be rounded off for easier management; that is, 49 U/d can be changed to 50 U/d

Guías para tratamiento DM1 Paso 2. – Determinar la dosis de inicio aproximada de insulina basal a usar Insulina basal= dosis total diaria / 2 El resto se asigna a insulina prandial Step 2: determine the approximate starting dose of basal insulin to be used (glargine or detemir) The basal insulin requirement is equal to TDD divided by 2. Thus, a patient requiring 50 U of insulin/d would be prescribed 25 units of basal insulin. The remaining 25 units could be allotted to prandial insulin dosing.

Guías para tratamiento DM1 Paso 3.- Determinar insulina prandial basal La dosis de insulina rápida para alimentos es igual a 0.1 U/kg Step 3: simplified formula for determining baseline prandial insulin dosing The baseline meal time rapid-acting insulin dose is equal to 0.1 U/Kg; for example, a 70 kg patient would require 70 0.1 ¼ 7 U prior to each meal.

Guías para tratamiento DM1 Paso 4.- Permitir que el paciente ajuste la dosis prandial de insulina de acuerdo a la cantidad de comida Step 4: allow the patient to adjust the prandial dose of insulin based on the size of the meal This amount of insulin (Table 3) could be added or subtracted from the original baseline amount of insulin prescribed for the patient

Guías para tratamiento DM1 Paso 5.- Establecer el factor de sensibilidad a insulina ISF= 1700/TDD Si TDD= 50 ; 1UI disminuirá 34mg/dL La meta de corrección nunca debe ser menor a 150mg/dL Step 5: establish the insulin sensitivity factor The insulin sensitivity factor (ISF) determines how much one unit of insulin is likely to reduce one’s baseline glucose level. ISF is equal to 1700/ TDD of insulin; for example, if one’s TDD ¼ 50 units, 1700/50 ¼ 34. This means that 1 unit of any rapid acting insulin analogue will lower one’s glucose level from baseline by 34 mg/dL. The correction target should never be set below 150 mg/dL. In this example, if one’s premeal glucose level is 220 mg/dL and the target is 150 mg/dL, the patient would add an additional 2 units to his standard mealtime dose. Therefore, if he normally takes 7 units before lunch, but his prelunch glucose is 220 mg/dL, he would now take 7 þ 2 ¼ 9 units. In addition, if the patient is planning to consume a large amount of food for this particular meal, he could always add an additional 2 units for 11 units taken 10 minutes before lunch.

Paso 6.- Permitir que el paciente ajuste su insulina basal Opción A Paso 6.- Permitir que el paciente ajuste su insulina basal standard basal treat-to-target protocol 1. Iniciar Domingo por la noche usando ___ unidades de glargina o detemir. 2. Monitorizar glicemia en ayuno (en la mañana y al dormir cada dìa) 3. Usar el esquema de titulación de dosis fija cada Lunes para ajustar la dosis de insulina por la noche. Step 5: establish the insulin sensitivity factor The insulin sensitivity factor (ISF) determines how much one unit of insulin is likely to reduce one’s baseline glucose level. ISF is equal to 1700/ TDD of insulin; for example, if one’s TDD ¼ 50 units, 1700/50 ¼ 34. This means that 1 unit of any rapid acting insulin analogue will lower one’s glucose level from baseline by 34 mg/dL. The correction target should never be set below 150 mg/dL. In this example, if one’s premeal glucose level is 220 mg/dL and the target is 150 mg/dL, the patient would add an additional 2 units to his standard mealtime dose. Therefore, if he normally takes 7 units before lunch, but his prelunch glucose is 220 mg/dL, he would now take 7 þ 2 ¼ 9 units. In addition, if the patient is planning to consume a large amount of food for this particular meal, he could always add an additional 2 units for 11 units taken 10 minutes before lunch.

Paso 6.- Permitir que el paciente ajuste su insulina basal Opción B Paso 6.- Permitir que el paciente ajuste su insulina basal customized 3- and 7-day treat-to-target protocol 1. Iniciar usando __ unidades de glargina o detemir a las _PM 2. Monitorizar glicemia en ayuno (en la mañana y al dormir cada dìa) 3. Aumentar la dosis de insulina basal cada 3 o 7 días hasta que la glucosa en ayuno de los últimos 3 a 7 días sea en promedio de 110 m/dL No aumentar más si presenta glicemia menor a 60mg/dL y reducir dosis de insulina basal 2 UI. 1. Begin using ___ units of glargine or detemir at ___ PM each evening. 2. Monitor blood glucose levels fasting in the morning and at bedtime each day. 3. Increase dose of basal insulin by units each 3 days or 7 days until the previous 3- or 7-day fasting glucose readings average is !110 mg/dl. Do not increase dose any further if you experience a single blood glucose value below 60 mg/dL, and reduce your bedtime dose of basal insulin by 2 units. For example, if your nighttime dose was 26 units when you noted a blood glucose value of 56 mg/dL, decrease your bedtime dose to 24 units until you are seen by the doctor.

Paso 6.- Permitir que el paciente ajuste su insulina basal Opción C Paso 6.- Permitir que el paciente ajuste su insulina basal customized treat-to-target protocol 1. Iniciar usando __ unidades de glargina o detemir a las _PM 2. Monitorizar glicemia en ayuno (en la mañana y al dormir cada dìa) 3. Aumentar __ unidades de insulina basal cada __ días hasta que la glucosa en ayuno de los últimos 7 días sea en promedio de 110 mg/dL Si presenta glicemia menor a 60mg/dL reducir dosis de insulina basal 2 UI. 1. Begin using ___ units of glargine or detemir at ___ PM each evening. 2. Monitor blood glucose levels fasting in the morning and at bedtime each day. 3. Increase dose of basal insulin by units each 3 days or 7 days until the previous 3- or 7-day fasting glucose readings average is !110 mg/dl. Do not increase dose any further if you experience a single blood glucose value below 60 mg/dL, and reduce your bedtime dose of basal insulin by 2 units. For example, if your nighttime dose was 26 units when you noted a blood glucose value of 56 mg/dL, decrease your bedtime dose to 24 units until you are seen by the doctor.

Paso 6.- Permitir que el paciente ajuste su insulina basal Opción D Paso 6.- Permitir que el paciente ajuste su insulina basal predictive 303 protocol 1. Iniciar por la noche usando ___ unidades de glargina o detemir. 2. Monitorizar glicemia en ayuno en forma diaria 3. Ajustar insulina basal de acuerdo a la tabla basado en la glicemia promedio de los últimos 3 días. 1. Begin using this dose of basal insulin (levemir/glargine) at ___ PM/AM. 2. Make certain to check your fasting glucose levels daily. 3. Adjust your basal insulin dose at ___PM/AM as shown in Table 5, based on the average blood glucose levels over the previous 3 days;

Caso 3 Masculino de 48 años con DM 2 dx hace 7 años. IMC 29 HbA1C 10.9% Tratamiento Metformina 1000mg c/12h Pioglitazona 45mg c/24h Glimepiride 4mg c/24h Inició insulina NPH 70/30 con mejora en GPA a 140-180mg/dL pero con hipoglicemia ocasional a mitad del día y por la noche. Disminuyó dosis de sulfonilurea e insulina para disminuir episodios de hipoglicemia. Su HbA1c disminuyó a través de este periodo aproximadamente a 8%, sin embargo los eventos de hipoglicemia persistieron y ahora él y su familia prefieren que su glicemia se mantenga en 200mg/dL

¿Qué modificación le realiza al tratamiento?