Personalized Intensification Of Insulin Therapy In Type 2 Diabetes – Does A Basal–bolus Regimen Suit All Patients?
Many patients with type 2 diabetes mellitus (T2DM) require insulin therapy. If basal insulin fails to achieve glycemic control, insulin intensification is one possible treatment intensification strategy. We summarized clinical data from randomized clinical trials designed to compare the efficacy and safety of basal–bolus and premixed insulin intensification regimens. We defined a between-group difference of ≥0.3% in end-of-study glycated hemoglobin (HbA1c) as clinically meaningful. A PubMed database search supplemented by author-identified papers yielded 15 trials which met selection criteria: randomized design, patients with T2DM receiving basal–bolus (bolus injection ≤3 times/day) vs. premixed (≤3 injections/day) insulin regimens, primary/major endpoint(s) HbA1c- and/or hypoglycemia-related, and trial duration ≥12 weeks. Glycemic control improved with both basal–bolus and premixed insulin regimens with – in most cases – acceptable levels of weight gain and hypoglycemia. A clinically meaningful difference between regimens in glycemic control was recorded in only four comparisons, all of which favored basal–bolus therapy. The incidence of hypoglycemia was significantly different between regimens in only three comparisons, one of which favored premixed insulin and two basal–bolus therapy. Of the four trials that reported a significant difference between regimens in bodyweight change, two favored basal–bolus therapy and two favored premixed insulin. Thus, on a population level, neither basal–bolus therapy nor premixed insulin showed a consistent advantage in terms of glycemic control, hypoglycemic risk, or bodyweight gain. It is therefore recommended that clinicians should adopt an individualized approach to insulin intensification – taking int Continue reading >>
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Being A Pancreas: Basal And Bolus Insulin And Juvenile Diabetes
So: as a surrogate pancreas you’ve got to get familiarize yourself with what one does. That’s how you’ll understand the difference between basal and bolus insulin. Typical Pancreatic Activity When we sleep (and are not eating), the liver releases some of its stores of glycogen into the bloodstream, to give the brain the energy it needs. In a normal pancreas, insulin is released slowly and continuously. It does this to keep blood glucose levels in balance. Blood glucose levels would rise without this continuous supply of insulin. When a meal is eaten, the pancreas emits a larger amount of insulin to keep pace with the blood glucose that is being released into the bloodstream from the process of digestion. All of this activity keeps the person without type one diabetes and without insulin resistance at blood glucose levels that range from 65 mg/DL to 150 mg/DL. To Treat Type One Diabetes You’ve got to imitate the pancreas. Your child will have two types of insulin. Basal insulin is like the continuous supply of insulin while bolus is what happens around eating. Basal is “extended release” insulin while bolus is “fast-acting” insulin. Basal insulin starts working within an hour of injection and will has a12 to 24 hour activity duration in the body. Bolus insulin starts to work within 15 minutes of injection and lasts about 4 hours. It is at its peak at around 1 1/2 to 2 hours after injection. Bolus insulin is given when your child has eaten anything with carbohydrates or when his/her insulin level is high. How much? Basal insulin Your endocrinologist will prescribe the amount of basal insulin your child receives based on your child’s age and weight. It will also be based on a week’s worth of multiple night-time blood glucose readings. The basal levels w Continue reading >>
Basal Bolus - Basal Bolus Injection Regimen
Tweet A basal-bolus injection regimen involves taking a number of injections through the day. A basal-bolus regimen, which includes an injection at each meal, attempts to roughly emulate how a non-diabetic person’s body delivers insulin. A basal-bolus regimen may be applicable to people with type 1 and type 2 diabetes. What is a basal-bolus insulin regimen? A basal-bolus routine involves taking a longer acting form of insulin to keep blood glucose levels stable through periods of fasting and separate injections of shorter acting insulin to prevent rises in blood glucose levels resulting from meals. What is basal insulin? The role of basal insulin, also known as background insulin, is to keep blood glucose levels at consistent levels during periods of fasting. When fasting, the body steadily releases glucose into the blood to our cells supplied with energy. Basal insulin is therefore needed to keep blood glucose levels under control, and to allow the cells to take in glucose for energy. Basal insulin is usually taken once or twice a day depending on the insulin. Basal insulin need to act over a relatively long period of time and therefore basal insulin will either be long acting insulin or intermediate insulin. What is bolus insulin? A bolus dose is insulin that is specifically taken at meal times to keep blood glucose levels under control following a meal. Bolus insulin needs to act quickly and so short acting insulin or rapid acting insulin will be used. Bolus insulin is often taken before meals but some people may be advised to take their insulin during or just after a meal if hypoglycemia needs to be prevented. Your doctor will be able to advise you if you have any questions as to when your bolus insulin should be taken. Advantages of a basal-bolus regimen One of t Continue reading >>
Sliding-scale Versus Basal-bolus Insulin In The Management Of Severe Or Acute Hyperglycemia In Type 2 Diabetes Patients: A Retrospective Study
Go to: Introduction Diabetes mellitus is a significant global health disorder. Type 2 diabetes mellitus (T2DM) is becoming more common in almost every population, accounting for approximately 90% of all cases of diabetes in adults in Malaysia in 2008 [1]. Severe or acute hyperglycemia is an acute manifestation of diabetes that commonly occurs in T2DM patients, and requires intensive treatment and hospitalization [2]. According to a prospective cohort study, the causes of admission to hospital in T2DM patients with hyperglycemia include diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state and serious infections [3]. In addition, the concurrent use of blood-glucose altering medications such as corticosteroids, antipsychotics and diuretics tend to worsen severe or acute hyperglycemia by increasing hepatic gluconeogenesis as well as impairing peripheral glucose uptake [2]. Despite the available treatment options for severe or acute hyperglycemia in T2DM patients, glycemic control in this population remains suboptimal [4]. This is partly attributable to the continued use of sliding-scale insulin regimens to manage severe or acute hyperglycemia, despite many treatment guidelines [5], recommending against its use. In addition, there are limited local and global data on the level of glycemic control achieved in T2DM patients with severe or acute hyperglycemia based on the type of insulin regimen used. Therefore, this study was conducted to identify the treatment approach and the achievement of glycemic control among hospitalized T2DM patients with severe or acute hyperglycemia. The specific objectives were twofold: (i) to compare the glycemic control achieved by using sliding-scale (Actrapid or basal-bolus (Actrapid and Insulatard) regimens for the management of severe Continue reading >>
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What Is The Difference Between Basal Insulin And Bolus Insulin?
Basal insulin refers to the insulin required to control your blood sugar in the absence of food intake. A certain amount of insulin is always necessary to keep the blood sugar in the normal range, even in the absence of eating for prolonged periods. Without any insulin in the body, the starch, fat, and protein in the body will break down with severe health consequences, as occurs in people with type 1 diabetes. The amount of insulin that the body requires in the absence of food intake is known as the basal requirement and it is provided by the one or two injections of long-acting insulin that most patients give themselves each day. If a person is using an insulin pump, then it is covered by the basal setting on the pump. Modern insulin pumps offer several basal settings in each 24-hour period, as the basal insulin production in a healthy individual varies over the course of the day, being higher in the 2-to 3-hour period before arising in the morning, for example. Bolus insulin refers to the insulin required to remove the energy derived from a meal from the bloodstream and into the tissues, to replenish energy stores. This is typically provided by the short-acting insulin injection given just prior to eating or by the bolus setting for patients on an insulin pump. Recently developed and marketed forms of insulin very closely match the pattern of insulin production from the pancreas itself in response to food. In this wav, they are able to prevent the blood sugar from rising excessively after a meal, while also preventing the occurrence of low blood sugar after the glucose from the meal has been cleared from the bloodstream. The latest insulin pumps offer different rates and patterns in which this bolus is given, in order to more effectively deal with rapidly or more slo Continue reading >>
The Different Types Of Diabetes And Insulins | Rapid-acting Insulin
What is Fiasp (insulin aspart injection) 100 U/mL? Fiaspis a man-made insulin used to control high blood sugar in adults with diabetes mellitus. It is not known if Fiaspis safe and effective in children. Do not share your Fiaspwith other people, even if the needle has been changed. You may give other people a serious infection, or get a serious infection from them. your blood sugar is too low (hypoglycemia) or you are allergic to any of its ingredients. Before taking Fiasptell your health care provider about all your medical conditions including, if you: are pregnant or breastfeeding or plan to become pregnant or breastfeed. It is not known if Fiasppasses into your breast milk. are taking new prescription or over-the-counter medicines, including supplements. Talk to your health care provider about low blood sugar and how to manage it. Read the Instructions for Useand take Fiaspexactly as your health care provider tells you to. Fiaspstarts acting fast.You should take your dose of Fiaspat the beginning of the meal or within 20 minutes after starting a meal. Know the type and strength of your insulin.Do notchange your insulin type unless your health care provider tells you to. If you miss a dose of Fiaspmonitor your blood sugar levels to decide if an insulin dose is needed. Continue with your regular dosing schedule at the next meal. Check your blood sugar levels.Ask your health care provider what your blood sugar levels should be and when you should check them. Do not reuse or share your needles with other people. You may give other people a serious infection or get a serious infection from them. Do notdrive or operate heavy machinery, until you know how Fiaspaffects you. Do notdrink alcohol or use medicines that contain alcohol. What are the possible side effects of Fia Continue reading >>
Sliding-scale Vs. Basal-bolus Insulin Therapies In Older Adults
Type 2 diabetes is common among nursing home residents and often treated with sliding-scale insulin (SSI) therapy, despite current recommendations that do not support this method. A recent study by Dr. T.S.Dharmarajan and colleagues compared the effectiveness of SSI therapy to basal-bolus insulin (B-BI) therapy to control blood glucose in older nursing home residents with type 2 diabetes. SSI therapy and B-BI therapy share the same medication—insulin—but differ in the timing of administration in relation to meals, dosage, and type(s) of insulin given to patients with type 2 diabetes. SSI regimens administer insulin after demonstrated elevations in blood glucose, a reactive strategy that is not physiological. B-BI therapy takes a more personalized approach, using both a longer acting form of insulin to provide steady regulation of blood sugar (even between meals) and separate injections of shorter-acting insulin throughout the day along with meals. B-BI therapy roughly simulates a non-diabetic body’s delivery of insulin. The B-BI approach is more physiological and mimics pancreatic release of insulin to provide a steady-state regulation, essentially a proactive approach. Dr. Dharmarajan's study, sponsored by the AMDA Foundation and scheduled to appear in the March 2016 print issue of the Journal of the American Medical Directors Association (published online in September 2015), measured levels of fasting blood glucose (FBG) in 64 nursing home residents from 14 long-term care sites randomly assigned to SSI or B-BI therapies over a 21-day clinical intervention trial. Participants treated with B-BI had significantly lower 3-day average FBG levels compared to the SSI participants. The study concluded that switching long-term care patients with type 2 diabetes to B-BI t Continue reading >>
Evidence For Basal–bolus Insulin Versus Slide Scale Insulin
Abstract Greater understanding of hyperglycemia and its control in non-ICU patients has become ever more urgent given the high and increasing prevalence of diabetes in the general population and, hence, in hospitalized patients. It is well accepted that hyperglycemia in hospitalized patients is common and associated with profound medical consequences, longer lengths of stay, high healthcare costs, and adverse outcomes. It is a marker for poor clinical outcome and mortality. Although evidence that supports intensive glycemic control in critically ill patients is strong, glycemic control is often overlooked or insufficient in patients on general medicine and surgery services. In the face of strong evidence that glycemic control helps to improve outcomes in non-ICU patients, it is critical to consider how best to manage hyperglycemia in medical and surgical patients to develop optimum strategies for maintaining glycemic control. Currently available strategies for glycemic control include sliding-scale insulin and basal–bolus regimens. The principal difference between the two strategies is that sliding-scale insulin does not deliver adequate glycemic control to patients and addresses hyperglycemia after it has occurred, whereas a basal–bolus regimen is directed at preventing hyperglycemia. This paper explores the rationale for and implementation of a basal–bolus insulin regimen in non-critically ill hospitalized patients and in addition reviews best practices for transitions of care and discharge planning. Notes Compliance with Ethics Guidelines This paper was underwritten in part by a grant from Sanofi to the Hospital Quality Foundation to support the writing group’s efforts, including travel. All authors report receiving consulting fees from Sanofi. This article d Continue reading >>
Why Basal-bolus Insulin Therapy May Be The Best Choice For Type 2 Diabetes
Many medications, both oral and injectable, exist to manage blood glucose in type 2 diabetes. Even insulin has many different formulations, including fast-acting and long-acting analogs as well as various pre-mixed combinations of faster and slower acting insulins in the same vial. This large selection of treatments is necessary because type 2 diabetes generally progresses over time from insulin resistance to outright beta cell failure. As a result, treatments must frequently be changed or added to one another in order to maintain good control. As the disease progresses, insulin might be combined with one or more oral agents, or different types of insulin might be used together to control glucose. Basal-bolus insulin therapy is one method of using different insulins together to treat diabetes. In order to understand basal-bolus insulin therapy, it is important to understand how the body uses the insulin it produces naturally. Insulin released from the pancreas helps move glucose from the bloodstream into the cells of the body, which then use the sugar for energy. Because the cells need energy all the time, the body must have not only a constant supply of glucose, but also enough insulin to deliver this sugar to the cells. Two important sources of glucose are carbohydrates from foods and glucose made in the liver. The liver supplies the body with glucose primarily during times when a person does not eat, both by breaking down complex sugars stored in the form of glycogen and by creating new sugar from proteins and fats in a process called gluconeogenesis. The combination of glucose from eating and glucose made by the liver provides a supply of sugar 24 hours a day. To move this sugar into the cells that need it for energy, insulin must be present 24 hours a day as well. Continue reading >>
The Difference Between Basal And Bolus Insulin
In order to understand the role of both basal and bolus insulin, it is important to first understand how the body naturally uses glucose and insulin. When food is eaten, it is digested and converted to glucose (sugar) so it can be used for energy. Virtually every cell in the body, including your brain, needs glucose to function properly. The hormone insulin is needed to carry that glucose into cells in all parts of the body so that it can be used for energy. Some of this glucose is stored in the liver as a reserve fuel (called glycogen) that is released when glucose is not available through food. So, between the glucose that is consumed through food and what is gradually released from the liver, the body gets a constant supply of glucose. This also means that there needs to be a constant supply of insulin in the body to keep the amount of glucose in balance. Since more glucose is produced after a meal, the pancreas secretes more insulin. When the amount of glucose is lower, such as between meals or at night, there is less insulin needed -- but there is always at least a small amount of insulin present in the body at all times. Defining Basal and Bolus Insulin Basal insulin is the background insulin that is normally supplied by the pancreas and is present 24 hours a day, whether or not the person eats. Bolus insulin refers to the extra amounts of insulin the pancreas would naturally make in response to glucose taken in through food. The amount of bolus insulin produced depends on the size of the meal. In a person with type 1 diabetes, the pancreas no longer automatically makes insulin regardless of the intake of glucose. The beta cells that produce the insulin have largely shut down. Both the basal, or long-term background insulin, and the bolus, or quick bursts of in Continue reading >>
Being A Pancreas: Basal And Bolus Insulin And Juvenile Diabetes
So: as a surrogate pancreas you’ve got to get familiarize yourself with what one does. That’s how you’ll understand the difference between basal and bolus insulin. Typical Pancreatic Activity When we sleep (and are not eating), the liver releases some of its stores of glycogen into the bloodstream, to give the brain the energy it needs. In a normal pancreas, insulin is released slowly and continuously. It does this to keep blood glucose levels in balance. Blood glucose levels would rise without this continuous supply of insulin. When a meal is eaten, the pancreas emits a larger amount of insulin to keep pace with the blood glucose that is being released into the bloodstream from the process of digestion. All of this activity keeps the person without type one diabetes and without insulin resistance at blood glucose levels that range from 65 mg/DL to 150 mg/DL. To Treat Type One Diabetes You’ve got to imitate the pancreas. Your child will have two types of insulin. Basal insulin is like the continuous supply of insulin while bolus is what happens around eating. Basal is “extended release” insulin while bolus is “fast-acting” insulin. Basal insulin starts working within an hour of injection and will has a12 to 24 hour activity duration in the body. Bolus insulin starts to work within 15 minutes of injection and lasts about 4 hours. It is at its peak at around 1 1/2 to 2 hours after injection. Bolus insulin is given when your child has eaten anything with carbohydrates or when his/her insulin level is high. How much? Basal insulin Your endocrinologist will prescribe the amount of basal insulin your child receives based on your child’s age and weight. It will also be based on a week’s worth of multiple night-time blood glucose readings. The basal levels w Continue reading >>
What's The Difference Between Basal And Bolus Insulin? - Diabetic Nation
Whats the Difference Between Basal and Bolus Insulin? You may have heard the terms basal and bolus insulin in relation to treating type 1 diabetes . For those who are new to an insulin regimen, these terms may be confusing. Here well clear up what these terms mean. People with type 1 diabetes, and even some with type 2 diabetes , have to use insulin throughout the day to manage their diabetes. If you are following a regimen using daily injections, you follow a basal-bolus injection schedule. Basal-bolus therapy is now also called intensive or flexible insulin therapy. The basal-bolus regimen attempts to mimic the way the body would naturally deliver insulin in someone who does not have diabetes. In the routine, a person takes basal insulin one or twice a day in order to regulate blood sugar levels throughout the day. Basal insulin is longer-acting. Examples of basal insulin include glargine, detemir, and degludec. Before eating a meal, the person with diabetes injects bolus, or mealtime, insulin. This works to counteract blood sugar highs brought on by eating. The amount of insulin may need to be adjusted depending on how many carbs are consumed in the meal. Bolus insulin will be rapid-acting or short-acting. Examples of bolus insulin include aspart , lispro , and glulisine. Advantages and disadvantages of basal-bolus therapy With advancements in diabetes treatment, now 30 to 40 percent of people dont use basal-bolus therapy but rather use a continuous glucose monitor and an insulin pump . The advantages of using the basal-bolus regimen versus pump therapy are: More flexibility with how much you eat and when Matches the way the body would naturally release insulin Reduces A1C levels better than other treatments Reduces dangerous blood sugar lows at night The disadvanta Continue reading >>
Understanding Basal And Bolus Insulin
The amount of bolus insulin produced depends on the size of the meal. In a person with type 1 diabetes , the pancreas no longer automatically makes insulin regardless of the intake of glucose. The beta cells that produce the insulin have largely shut down. Both the basal, or long-term background insulin, and the bolus, or quick bursts of insulin needed at mealtimes, must be obtained through injections or an insulin pump in order to process all of the glucose taken in through food or released by the liver. Long-acting basal insulins, such as NPH, Levemir, and Lantus, begin working in 1-2 hours but are released slowly so they can last up to 24 hours, providing that background insulin that is needed around the clock . Fast-acting bolus insulins, such as NovoLog, Apidra, Humalog, and Regular, generally begin working within 15 minutes. The exception is Regular, which has an onset of about 30 minutes. Each of these bolus insulins is designed to be taken just before a meal and have a duration of up to five hours for NovoLog, Apidra, and Humalog, and seven hours for Regular. This means that a person with type 1 diabetes would have to take multiple injections of a bolus insulin each day to cover their meals and snacks, along with a basal dose to keep the background insulin in check. Basal and Bolus Insulin With Insulin Pumps The person using an insulin pump would typically receive a constant low dose of fast-acting insulin that would act as the basal background insulin. Before meals, the pump user would give a larger dose of fast-acting insulin to cover the meal about to be eaten. This satisfies both the basal and bolus needs using the same fast-acting insulin. Whether injecting with a syringe or using an insulin pump, the actual dosing and type of insulin(s) used would be dete Continue reading >>
How To Manage Diabetes With Basal-bolus Insulin Therapy
Diabetes is a disease that affects the way the body produces and uses insulin. Basal-bolus insulin therapy is a way of managing this condition. In type 1 diabetes, the production of insulin is affected. In type 2 diabetes, both the production and use of insulin are affected. In people without diabetes, insulin is produced by the pancreas to keep the body's blood sugar levels under control throughout the day. The pancreas produces enough insulin, whether the body is active, resting, eating, sick, or sleeping. This allows people without diabetes to eat food at any time of the day, without their blood sugar levels changing dramatically. For people with diabetes, this doesn't happen. However, a similar level of blood sugar control can be achieved by injecting insulin. Injections can be used throughout the day to mimic the two types of insulin: basal and bolus. People without diabetes produce these throughout the day and at mealtimes, respectively. What is a basal-bolus insulin regimen? A basal-bolus insulin regimen involves a person with diabetes taking both basal and bolus insulin throughout the day. It offers them a way to control their blood sugar levels. It helps achieve levels similar to a person without diabetes. Advantages There are several advantages to using a basal-bolus insulin regimen. These include: flexibility as to when to have meals control of blood sugar levels overnight they are helpful for people who do shift work they are helpful if travelling across different time zones Disadvantages The downsides to a basal-bolus regimen are that: people may need to take up to 4 injections a day adapting to this routine can be challenging it can be hard to remember to take the injections it can be hard to time the injections it's necessary to keep a supply of insulin w Continue reading >>
A Review Of Basal-bolus Therapy Using Insulin Glargine And Insulin Lispro In The Management Of Diabetes Mellitus
A Review of Basal-Bolus Therapy Using Insulin Glargine and Insulin Lispro in the Management of Diabetes Mellitus 1Diabetes Centre District 3, Azienda Sanitaria Universitaria Integrata di Trieste, Via Puccini 48/50, 34100 Trieste, Italy 2The Ohio State University Wexner Medical Center, Columbus, OH 43210 USA 3Eli Lilly Italia SPA, via A. Gramsci 731/733, 50019 Sesto Fiorentino, Italy Riccardo Candido, Email: ti.oohay@odidnacodraccir . Data sharing is not applicable to this article, as no datasets were generated or analyzed during the current study. Basal-bolus therapy (BBT) refers to the combination of a long-acting basal insulin with a rapid-acting insulin at mealtimes. Basal insulin glargine 100 U/mL and prandial insulin lispro have been available for many years and there is a substantial evidence base to support the efficacy and safety of these agents when they are used in BBT or basal-plus therapy for patients with type 1 or type 2 diabetes mellitus (T1DM, T2DM). With the growing availability of alternative insulins for use in such regimens, it seems timely to review the data regarding BBT with insulin glargine 100 U/mL and insulin lispro. In patients with T1DM, BBT with insulin glargine plus insulin lispro provides similar or better glycemic control and leads to less nocturnal hypoglycemia compared to BBT using human insulin as the basal and/or prandial component, and generally provides similar glycemic control and rates of severe hypoglycemia to those achieved with insulin lispro administered by continuous subcutaneous insulin infusion (CSII). Studies evaluating BBT with insulin glargine plus insulin lispro in patients with T2DM also demonstrate the efficacy and safety of these insulins. Available data suggest that BBT with insulin glargine and insulin lispro prov Continue reading >>
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