Insulin Initiation

Indications for consideration of insulin

1. Myocardial infarction
2. Marked hyperglycaemic symptoms
3. Weight loss with poor control
4. Suboptimal HbA1c in lean patients
5. Suboptimal HbA1c in obese patients
6. Pregnancy/Pregestational care

Self-monitoring of blood glucose skills should also have been taught.

Is my patient likely to benefit?

• Marked symptoms
• Slim and losing weight
• Well motivated
• Careful with diet
• Established complications and/or long life expectancy

• No Symptoms
• Overweight and gaining
• Poorly motivated
• Not careful with diet
• No complications and limited life expectancy
• Socially isolated.

1. Earlier initiation in younger (Approx: age < 45), lean patients and those with complications.
2. In patients with BMI >28kg/m2, manage other risk factors aggressively especially weight first.
   
   Remember that in an obese individual 5-10% body weight loss gives an HbA1c reduction of 0.7-0.8% and > 10% body weight reduction gives an HbA1c reduction of >1.2%. This weight reduction also has other benefits.
   
   Therefore, in subjects with BMI > 28kg/m2 with an HbA1c within 1% of target, it may well be worth pursuing weight loss aggressively for a trial period first if the clinical situation permits. If there has been no progress with weight loss over a 3 month period then commencing insulin would be appropriate.
   
   Previous assertions that tight glycaemic control does not decrease the risk of development/progression of cardiovascular disease now seem unfounded with the publication of follow up data from the UKPDS/DCCT study. Pursing tight glycaemic control with insulin treatment therefore appears desirable even in those with marked obesity.
3. Individualised targets for patients with limited life-span, high risk of hypoglycaemia or difficulty managing insulin.

Insulin dose initiation and escalation