insulin initiation and titration for family physicians: case study #2: andy alice y.y. cheng, md...

Insulin Initiation and Titration for Family Physicians: Case Study #2: Andy Alice Y.Y. Cheng, MD FRCPC Peter Lin, MD CCFP

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Insulin Initiation and Titration for Family Physicians:

Case Study #2: Andy

Alice Y.Y. Cheng, MD FRCPC

Peter Lin, MD CCFP

Case Study #2: Andy

Patient history and presentation• 68 years old, retired, regimented lifestyle• Type 2 diabetes for 10 years• A1C = 8.2%• Weight = 90 kg• Maxed out on oral agents• You have been discussing insulin, but he has been

resistant to the idea of injections

Page 3: Insulin Initiation and Titration for Family Physicians: Case Study #2: Andy Alice Y.Y. Cheng, MD FRCPC Peter Lin, MD CCFP

Andy’s SMBG LogbookBreakfast Lunch Dinner

Before After Before After Before After Bedtime

Sunday 8.1 10.2 13.1

Monday 8.2 13.1 9.9 8.4

Tuesday 7.9 10.1 8.1 8.7

Wednesday 8.8 12.8 12.9 8.5

Thursday 10.5

Page 4: Insulin Initiation and Titration for Family Physicians: Case Study #2: Andy Alice Y.Y. Cheng, MD FRCPC Peter Lin, MD CCFP

Type 2 Diabetes: Insulin Choices

1. Basal

2. Basal plus bolus

3. Pre-mixed twice daily

Page 5: Insulin Initiation and Titration for Family Physicians: Case Study #2: Andy Alice Y.Y. Cheng, MD FRCPC Peter Lin, MD CCFP

Why Choose Pre-mixed Insulin?

• Regimented/fixed lifestyle• Fixed meal plan, i.e., 3 meals per day, at the

same time each day• Consistent physical activity regimen• Blood glucose elevations throughout the day,

not just in the fasting state• For those who dislike multiple injections

(basal + bolus regimen)

Page 6: Insulin Initiation and Titration for Family Physicians: Case Study #2: Andy Alice Y.Y. Cheng, MD FRCPC Peter Lin, MD CCFP

DOSINGSEE REVERSE FOR TIPS

CHOOSE AN INSULIN CATEGORY

CHOOSE A BRAND

Page 7: Insulin Initiation and Titration for Family Physicians: Case Study #2: Andy Alice Y.Y. Cheng, MD FRCPC Peter Lin, MD CCFP

Page 8: Insulin Initiation and Titration for Family Physicians: Case Study #2: Andy Alice Y.Y. Cheng, MD FRCPC Peter Lin, MD CCFP

Pre-mixed Insulin Dosingand Titration

14.0 – 7.0

4.0 – 7.0

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