Wandell PE, Tovi J. principal concept of diabetes therapy ought to be to obtain euglycemia, without leading to hypoglycemia. Appropriate usage of contemporary insulins and dental drugs, including incretin mimetics shall help doctors accomplish that target. = 0.011).[61] Such a sensation is not very surprising as the top activity of NPH, which occurs at 6-8 hours following shot usually, might coincide with insulin private amount of the entire time, i actually.e. midnight. Low cortisol may be the most important adding factor. As the best efficiency of NPH weans off, BAY-1251152 we.e. dawn toward, insulin resistance goes up because of surge of cortisol, resulting in hyperglycemia. Such elements necessitate the shot of NPH as past due as possible, before midnight preferably. Technically, it really is quite disadvantageous for older people who might would rather retire early. Insulin analogues like detemir and glargine, being virtually peakless can be given even early, and hence have been emerging as natural choices in the elderly. Initiation with basal bolus: Ideal but too complexA combination of long-acting insulin once a day and preprandial rapid-acting insulin is considered an ideal regimen since it mimics basal and prandial endogenous insulin secretion. However, it is usually a very intense and complex regimen. It may require four to five injections daily and frequent monitoring of blood glucose levels at least three times daily, and it requires special skills in carbohydrate counting and in adding insulin correction doses for preprandial hyperglycemia. It may be a necessity in type 1 diabetics and in very special situations such as pregnancy, preoperative patients or patients hospitalized for other medical morbidities. Because of the complexity of this regimen, it may not be appealing to older adults for domiciliary use on long-term basis. The initial starting total daily dose of insulin is usually estimated to be 0.6 U/kg. The insulin regimen should subsequently be modified on the basis of the individual’s response to therapy.[47] In the Treating to Target in Type 2 diabetes (4-T) study, up to 81.6% of patients who were initiated on basal analogue detemir required additional prandial insulin during 3 years of follow-up when titrations were done to achieve a tight glycemic control.[62] The South Asian Consensus group recommends that in patients already undergoing treatment with adequate doses of two or more oral anti-diabetic drugs (OADs), addition of bedtime basal insulin may be considered when FPG is 150 mg/dL and PPPG is 200 mg/dL and/or HbA1c is 8.5%. Long-acting analogues are favored over NPH basal insulin. The best time to inject both analogues and NPH is usually in the evening; however, the former can be given at any time of the day depending on the patients (or attendants) convenience. The physician may continue the ongoing secretagogues, but nighttime SUs ESR1 are to be avoided. Metformin should be continued along with basal insulin therapy. The panel prefers a conservative initial starting dose of 0.1 U/kg/day. After initiation, the dose should be titrated once or twice every week on the basis of glucose monitoring results, targeting FBG. If HbA1c targets are not achieved, it may be due to hidden rise in postprandial blood sugar which has to be recognized and treated according to a pre-set protocol [Table 7]. Table 7 Protocol of intensification of basal insulin therapy in elderly diabetic patients Open in a separate windows Using insulin in elderly diabetics: Role of premixed insulin Conventionally, premixed insulins are used twice daily, with breakfast and supper. Premixed insulin preparations are more convenient and less prone to errors in dosing, two relevant points in the elderly; but they limit the flexibility in diet and lifestyle. Among the patients who have round the clock hyperglycemia, i.e. fasting/pre-meal and post-meal hyperglycemia, premixed insulin can be used especially in those not preferring multiple injections and those who cannot perform frequent self-monitoring of blood glucose, thus making the prescription of the basal bolus regimen redundant (observe above). Premix insulin is the favored insulin in the interpersonal situation prevailing in the South Asian countries because of the following reasons: simple.If HbA1c targets are not achieved, it may be due to hidden rise in postprandial blood sugar which has to be identified and treated according to a pre-set protocol [Table 7]. Table 7 Protocol of intensification of basal insulin therapy in elderly diabetic patients Open in a separate window Using insulin in elderly diabetics: Role of premixed insulin Conventionally, premixed insulins are used twice daily, with breakfast and supper. to achieve euglycemia, without causing hypoglycemia. Appropriate use of modern insulins and oral drugs, including incretin mimetics will help physicians achieve this aim. = 0.011).[61] Such a phenomenon is not at all surprising because the peak activity of NPH, which usually occurs at 6-8 hours following the injection, might coincide with the most insulin sensitive period of the day, i.e. midnight. Low cortisol is the most important contributing factor. As the greatest efficacy of NPH weans off, i.e. toward dawn, insulin resistance rises due to surge of cortisol, leading to hyperglycemia. Such factors necessitate the injection of NPH as late as possible, preferably before midnight. Technically, it is quite disadvantageous for the elderly who might prefer to retire early. Insulin analogues like glargine and detemir, being virtually peakless can be given even early, and hence have been emerging as natural choices in the elderly. Initiation with basal bolus: Ideal but too complexA combination of long-acting insulin once a day and preprandial rapid-acting insulin is considered an ideal regimen since it mimics basal and prandial endogenous insulin secretion. However, it is a very intense and complex regimen. It may require four to five injections daily and frequent monitoring of blood glucose levels at least three times daily, and it requires special skills in carbohydrate counting and in adding insulin correction doses for preprandial hyperglycemia. It may be a necessity in type 1 diabetics and in very special situations such as pregnancy, preoperative patients or patients hospitalized for other medical morbidities. Because of the complexity of this regimen, it may not be appealing to older adults for domiciliary use on long-term basis. The initial starting total daily dose of insulin is usually estimated to be 0.6 U/kg. The insulin regimen should subsequently be modified on the basis of the individual’s response to therapy.[47] In the Treating to Target in Type 2 diabetes (4-T) study, up to 81.6% of patients who were initiated BAY-1251152 on basal analogue detemir required additional prandial insulin during 3 years of follow-up when titrations were done to achieve a tight glycemic control.[62] The South Asian Consensus group recommends that in patients already undergoing treatment with adequate doses of two or more oral anti-diabetic drugs (OADs), addition of bedtime basal insulin may be considered when FPG is 150 mg/dL and PPPG is 200 mg/dL and/or HbA1c is 8.5%. Long-acting analogues are favored over NPH basal insulin. The best time to inject both analogues and NPH is usually in the evening; however, the former can be given at any time of the day depending on the patients (or attendants) convenience. The physician may continue the ongoing secretagogues, but nighttime SUs are to be avoided. Metformin should be continued along with basal insulin therapy. The panel prefers a conservative initial starting dose of 0.1 U/kg/day. After initiation, the BAY-1251152 dose should be titrated once or twice every week on the basis of glucose monitoring results, targeting FBG. If HbA1c targets are not achieved, it may be due to hidden rise in postprandial blood sugar which has to be recognized and treated according to a pre-set protocol [Table 7]. Table 7 Protocol of intensification of basal insulin therapy in elderly diabetic patients Open in a separate windows Using insulin in elderly diabetics: Role of premixed insulin Conventionally, premixed insulins are used twice daily, with breakfast and supper. Premixed insulin preparations are more convenient and less prone to errors in dosing, two relevant points in the.