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Required when target HbA1c not reached on basal insulin despite any fasting glucose level < 7 mmol/L and/or doses of 0.5 units/kg/day of basal insulin
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Start rapid-acting insulin (NovoRapid, Humalog or Apidra) immediately before largest meal (basal plus)
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Start at 4 units or 10% of dose of basal insulin (maximum starting dose 10 units)
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Stop sulfonylurea at meal once established on bolus insulin but continue lifestyle management and other glucose lowering therapies
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Monitor glucose levels before and 2 - 3 hours after meal via capillary blood glucose levels or continuous glucose monitoring
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Increase dose of rapid-acting insulin by 2 units if glucose levels rise > 3 mmol/L with meal (consistently, on 3 occasions)
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Ensure adherence and check injection technique before increasing doses
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Provide clear instructions for patients on how to administer and self-titrate bolus insulin
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Clear instructions for patients on how to administer and self-titrate bolus insulin
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Essential particularly if concerns over cognitive impairment (medication oversight may be required)
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Ideally administer injections of bolus insulin before meals
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Patients should be advised not to administer meal bolus if they are skipping that meal
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Patients should have different coloured pens for their different types of insulin
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Use BD fine 4 or 5 mm needles as associated with better absorption and less pain/trauma
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Encourage rotation of injection sites
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Insulin pens that use ½ unit increments may be useful in very insulin sensitive patients e.g thin older adult
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Explain that doses of bolus insulin may need to be reduced by 20 – 50% for meals immediately before and after strenuous exercise
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Memory adjuncts (e.g. NovoPen Echo; InsulCheck etc.) may be useful
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Refer to dietitian for ‘carbohydrate awareness’ and matching of insulin to carbohydrate intake
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Add in bolus insulin as above at other meals if HbA1c remains above target or if glucose levels rise by > 3 mmol/L at other meals (basal bolus)
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Doses of bolus insulin will likely be different at different meals
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If the patient remains above target despite bolus insulin at all meals then:
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Ensure adherence to all therapy
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Converting from basal and bolus insulin to premixed insulin
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Convert total daily dose of basal and bolus insulin to premixed insulin with half the dose pre-breakfast and half pre-dinner
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E.g. 40 units basal insulin and 12 units bolus insulin with meals → 38 units of premixed insulin bd
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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
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Consider keeping injection of rapid-acting insulin at lunch particularly if need to reduce breakfast dose of premixed insulin due to concerns over hypoglycaemia
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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
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If HbA1c remains above target:
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Check adherence to injections
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Check injection technique and injection sites
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Add in doses of bolus insulin with large snacks
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Re-refer to dietitian and consider carbohydrate counting
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Add in correction doses of rapid-acting insulin at meals to reduce hyperglycaemia
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Screen for depression and diabetes distress
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Consider referral to specialist services