Yes
Fasting Glucose Targets Achieved But HbA1c Target not Achieved
Can swap Insulatard to Glargine if tea higher than breakfast readings but below 10mmol/l . If not look at glucose readings pre meals and bed and switch to BD Insulin mixture if appropriate.
Premixed BD insulin dose titration: Novomix 30, Humalog Mix 25, Mixtard 30, Humulin M3.
Premixed insulin 10 units twice daily in addition to metformin if applicable.
Monitor capillary glucose (CG) pre meals and pre bed in the titration period. Titrate dose after every 3 days.
Target glucose values
Fasting glucose: 4.0-7.0 mmol/L
Premeal glucose: 4.0-7.0 mmol/L
Pre bed glucose: 6.0-10 mmol/L
These targets may need to be modified according to individual circumstances and target HbA1c.
Titrate:
Give patient written advice regarding dose adjustment.
Morning insulin dose adjustment:
If before lunch and before evening meal glucose readings both > 11.0 mmo/L then increase pre breakfast insulin by 4 units
NB: Once insulin dose at this time > 30 units then increase by 20% rather than 4 units
If before lunch and before evening meal glucose readings are both above target but < 10.9 mmol/L then increase pre breakfast insulin by 2 units.
NB: Once insulin dose at this time > 30 units then increase by 10% rather than 2 units.
If one of this pair of readings is in target and the other above/below target then clinical judgement/specialist advice may be required and consideration may be given to alternative insulin mixture.
Evening insulin dose adjustment
If before bed and before breakfast glucose readings both > 11.0 mmo/L then increase pre evening meal insulin 4 units.
NB: Once insulin dose at this time > 30 units then increase by 20% rather than 4 units
If before bed and before breakfast glucose readings are both above target but < 10.9 mmol/L then increase pre evening meal insulin by 2 units.
NB: Once insulin dose at this time > 30 units then increase by 10% rather than 2 units.
If one of this pair of readings is in target and the other above/below target then clinical judgement/specialist advice may be required and consideration may be given to alternative insulin mixture.
Hypos
If glucose < 3.9 mmol/L before bed or before breakfast then look for cause. If recurs/no good cause then reduce evening meal insulin by 4 units.
If glucose < 3.9mmol/L before lunch or before evening meal then look for cause. If recurs/no good cause then reduce breakfast insulin by 4 units.
