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Type 2 Diabetes Management Guidelines

Bolus insulin

  • Clear instructions for patients on how to administer and self-titrate bolus insulin
  • Essential particularly if concerns over cognitive impairment (medication oversight may be required)
  • Ideally administer injections of bolus insulin before meals
  • Patients should be advised not to administer meal bolus if they are skipping that meal
  • Patients should have different coloured pens for their different types of insulin
  • Use BD fine 4 or 5 mm needles as associated with better absorption and less pain/trauma
  • Encourage rotation of injection sites
  • Insulin pens that use ½ unit increments may be useful in very insulin sensitive patients e.g thin older adult
  • Explain that doses of bolus insulin may need to be reduced by 20 – 50% for meals immediately before and after strenuous exercise
  • Memory adjuncts (e.g. NovoPen Echo; InsulCheck etc.) may be useful
  • Converting from basal and bolus insulin to premixed insulin
  • Convert total daily dose of basal and bolus insulin to premixed insulin with half the dose pre-breakfast and half pre-dinner
  • E.g. 40 units basal insulin and 12 units bolus insulin with meals → 38 units of premixed insulin bd
  • Consider alternative ratio if large difference in meal sizes (e.g. 2/3rd of total daily insulin at larger meal and 1/3rd of total daily insulin at smaller meal) and lower evening dose in elderly
  • Consider keeping injection of rapid-acting insulin at lunch particularly if need to reduce breakfast dose of premixed insulin due to concerns over hypoglycaemia
  • The doses of bolus insulin will likely need to be reduced if major changes in diet (e.g. Ramadan) and/or if new glucose lowering therapies are added to the regimen