Building Competency in Diabetes Education THE ESSENTIALS
BASAL-BOLUS INSULIN THERAPY | 12-37
47% of the 4,352 participants with type 1 and type 2 diabetes had lipohypertrophy, of whom 28% did not recall ever having their injection sites checked (37). A 10:00 PM administration time (with a one-hour leeway) is recommended to match peak absorption with the counterregulatory hormone surge during the dawn hours (the dawn phenomenon/effect between 4:00 AM and 7:00 AM). The importance of the dawn phenomenon has been debated in past years, but research by Bolli (36) and the introduction of rtCGM and flash glucose monitoring (isCGM) have demonstrated the importance of this phenomenon and nocturnal glucose control. The individual must be aware that taking intermediate-acting insulin at widely varying times or after midnight will impact nocturnal BG control and the following daytime glycemia. Instructing patients to take their intermediate-acting insulin at “bedtime” may result in wide variation of administration times. Wake and sleep times need to be identified to suggest a tailored regimen, especially if the person works night shifts. Consider splitting the dose of basal insulin for people working night shifts, travel through more than three time zones frequently or with variable schedules. Twice daily NPH/N: Splitting the basal dose of NPH/N has demonstrated success in many clinical case reports. Clinicians may prescribe NPH/N twice daily for basal replacement, especially in type 1 diabetes. A second dose of NPH/N (20-30% of the bedtime dose) can be added at breakfast or lunch to provide daytime basal insulin (673). • Consider splitting the dose when total basal dose is more than 40 units (74). • Switching from NPH/N to glargine U100, basaglar or detemir o Once-daily dosing: Substitute unit for unit (63,64). Consider reducing the dose if there is nocturnal hypoglycemia or hypoglycemic unawareness. o Twice-daily NPH/N to once daily glargine U100 or detemir: reduce total basal by 20% (75,76). 2. Long-acting insulin analogues An ideal basal insulin replacement would provide a low, constant, reproducible but variable plasma insulin, with a long duration of action that would be convenient and affordable for the individual. The deficiencies of NPH in meeting these criteria have led to the development of LAAs: Glargine U100, detemir and more recently glargine U300, degludec
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