Introduction
Glycemic Control in Diabetes
Glycemic Hexads
Target Values for Glycemic Control
Recommendation for Target Values in Type 1 Diabetes Mellitus
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The target glycated hemoglobin A1c (HbA1c) for all children with type 1 diabetes mellitus (T1DM), including preschool children, is recommended to be < 7.5% (< 58 mmol/mol) (Grade B, EL I)
Long-Term Glycemic and Metabolic Control
Recommendations for Target Values in Nonpregnant Adults with Type 2 Diabetes Mellitus (T2DM)
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Fasting plasma glucose (FPG): 4.4–7.2 mmol/L
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Postprandial plasma glucose (PPG): < 10.0 mmol/L
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2-h postprandial plasma glucose (2-h PPG): < 7.8 mmol/L
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HbA1c:
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< 6.5% (< 48 mmol/mol) in newly diagnosed patients with T2DM; those treated with lifestyle or metformin only; T2DM with long life expectancy or no significant cardiovascular (CV) disease.
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< 7.0% (< 53 mmol/mol) in most DM patients.
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< 8.0% (< 64 mmol/mol) in patients with history of severe hypoglycemia; limited life expectancy; advanced microvascular or macrovascular complications; or long-standing diabetes in whom the goal is difficult to achieve despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple antihyperglycemic therapy including insulin.
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For palliative care, the aim is to avoid symptomatic hyperglycemia (Grade A, EL I)
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Hypoglycemia/nocturnal hypoglycemia/glycemic variability: Achieving glycemic targets while minimizing glucose variability and hypoglycemia, particularly major and nocturnal hypoglycemia, is of much importance while considering insulin therapy (Grade A, EL I)
Current Status of Diabetes Management in East Africa
Inpatient Settings in East Africa
Ambulatory Patients (Outpatient Services) in East Africa
Critical Care in East Africa
Diabetes Complications in East Africa
Insulin Overview
Normal Insulin Physiology
Guidelines on Insulin Therapy
General Objectives
Specific Objectives
Methodology and Evidence
Level | Type of evidence |
---|---|
IA | Systematic review (with homogeneity) of RCTs |
IB | Individual RCT (with narrow CI) |
IC | All or none RCT |
IIA | Systematic review (with homogeneity) of cohort studies |
IIB | Individual cohort study (including low quality RCT, e.g., < 80% of follow-up) |
IIC | “Outcomes” research; ecological studies |
IIIA | Systematic review (with homogeneity) of case–control studies |
IIIB | Individual case–control study |
IV | Case series (poor quality cohort and case–control study) |
V | Expert opinion without explicit critical appraisal or based on physiological bench research or “first principles” |
Grade | Descriptor | Quantifying evidence | Implications for practice |
---|---|---|---|
A | Strong recommendation | Level I evidence or consistent findings from multiple studies of levels II, III, or IV | Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present |
B | Recommendation | Levels II, III, or IV evidence and findings are generally consistent | Generally, clinicians should follow a recommendation but should remain alert to a new information and sensitive to patient preferences |
C | Option | Levels II, III, or IV evidence but findings are inconsistent | Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role |
D | Option | Level V evidence: little or no systematic empirical evidence | Clinicians should consider all options in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role |
Insulin Therapy
Generic | Brand | Manufacturer | Form | Onset | Peak | Duration | Availability delivery | Storage |
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NPH | Insulatard | Novo Nordisk | Human | 1–3 h | 4–8 h | 12–16 h | 10 mL vial, 3 mL penfill (5/box) | Refrigerate: 2–8 °C, use within 6 weeks if below 25 °C, and 4 weeks if below 30 °C |
Insugen N | Biocon | |||||||
Humulin N | Eli Lilly | |||||||
Wosulin N | Wockhardt | |||||||
Biosulin L | MJ Biopharm | |||||||
Regular | Actrapid | Novo Nordisk | Human | 30–60 min | 2–4 h | 5–8 h | 10 mL vial, 3 mL penfill (5/box) | Refrigerate: 2–8 °C, use within 6 weeks if below 25 °C, and 4 weeks if below 30 °C |
Insugen R | Biocon | |||||||
Humulin R | Eli Lilly | |||||||
Wosulin R | Wockhardt | |||||||
Biosulin R | MJ Biopharm | |||||||
Lispro | Humalog | Eli Lilly | Analogue | 10–20 min | 30–90 min | 3–5 h | 1 × 5 × 3 mL prefilled pen | |
Aspart | Novo Rapid | Novo Nordisk | Analogue | 10–20 min | 30–90 min | 3–5 h | 1 × 5 × 3 mL prefilled pen | |
Glargine | Lantus | Sanofi | Analogue | 60–90 min | No peak (8–12 h not pronounced) | 20–26 h | 1 × 5 × 3 mL prefilled pen | |
Basolog | Biocon | 1 × 10 mL/1 × 3 mL vials | ||||||
Detemir | Levemir | Novo Nordisk | Analogue | 60–90 min | 20–26 (17.5 h reported) | 1 × 5 × 3 mL prefilled pen | ||
Degludec | Tresiba | Novo Nordisk | Analogue | 30–90 min | No peak | 42 h | 1 × 5 × 3 mL prefilled pen | No refrigeration for 48 days |
Premixed NPH/Regular | Mixtard 30/70 | Novo Nordisk | Human | Dual-acting 30–60 min | Varies maximum effect 2–8 h | 10–16 h | 1 × 10 mL vials and 1 × 5 × 3 mL prefilled pens | Refrigerate: 2–8 °C, use within 6 weeks if below 25 °C, and 4 weeks if below 30 °C |
Insugen 30/70 | Biocon | Human | ||||||
Humalog Mix 25 | Eli Lilly | Human | ||||||
Humalog Mix 50 | Eli Lilly | Human | ||||||
Wosulin 30/70 | Wockhardt | Human | ||||||
Insuman Combo 30 | Sanofi | Human | ||||||
Aspart | NovoMix 30 (70% Protamine/30% Aspart) | Novo Nordisk | Analogue | 5–15 min | Varies; ~ 1 to 4 h | 10–16 h | 1 × 5 × 3 mL prefilled pens | Store below 30 °C |
Recommendation
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Insulin analogues are available in East Africa and may be safely prescribed where appropriate, taking into consideration the cost and the benefits gained when compared with human insulin that is cheaper and readily available (Grade D, EL V)
Short-Acting Insulin
Rapid-Acting Insulin
Basal (Long-Acting) Insulin
Premixed Insulins
Insulin Therapy in T1DM
Recommendations
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Basal-bolus insulin therapy is a standard of care in management of diabetes in T1DM (Grade A, EL I)
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For T1DM patients with minimal metabolic decompensation (minimal dehydration, fully conscious) initiation starts with initial dose ranging from 0.4 to 1.0 units/kg/day (Grade A, EL III)
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Multiple daily injections of short-acting or rapid-acting insulin analogues given 0–15 min before meals together with one or more daily separate injections of intermediate or long-acting insulins are used. The basal-bolus regimen includes basal insulin (insulin degludec, insulin glargine, insulin detemir, and NPH) and bolus insulin (rapid-acting: insulin aspart, insulin lispro, or insulin glulisine; or short-acting: Regular/Neutral) (Grade A, EL I)
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Consider using rapid-acting insulin analogues for less hypoglycemia risk (Grade B, EL I)
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If other insulins are not available, premixed insulin injections may be used in T1DM adolescent patients. Premixed insulin analogues should be considered over human insulin for favorable degree of PPG control and significant lowering of HbA1c (Grade C, EL III)
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Patient education on matching prandial insulin doses to carbohydrate intake, premeal blood glucose levels, and anticipated physical activity should be encouraged (Grade A, EL II)
Type 2 Diabetes Mellitus (T2DM)
Insulin Therapy in T2DM: The Initiation Algorithm
Basal (Long-Acting) Insulin Regimen
Bolus Insulin Regimen
Premix Insulin Regimen
Parameter | Premixed human insulin | Premixed insulin analogue | Insulin co-formulation |
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PPG control | + | +++ | +++ |
FPG control | ++ | ++ | +++ |
HbA1c control | + | ++ | ++ |
Less hypoglycemia | + | ++ | +++ |
Mealtime flexibility | + | +++ | +++ |
Weight gain | + | ++ | ++ |
Recommendations
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Do not delay the decision to initiate insulin in diabetes patients (Grade A, EL I)
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Health care professionals (HCPs) should educate T2DM patients about insulin regimens and appropriate choice of regimen (Grade A, EL III)
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Consider initiating insulin therapy with or without metformin in patients with newly diagnosed T2DM who are symptomatic and/or have HbA1c ≥ 10.0% (≥ 86 mmol/mol) and/or blood glucose levels ≥ 16.7 mmol/L (Grade A, EL I)
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Initiate with once-daily basal insulin, once-daily premixed/co-formulation insulin, or twice-daily premixed insulin, either alone or in combination with GLP-1 RA (either alone or in combination with basal insulin, in same pen device) or in combination with other OADs on the basis of clinical features, glucose profile, risk of hypoglycemia, and patient preference (Grade A, EL II)
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Basal-bolus insulin regimens may be needed in severe hyperglycemia and in life-threatening or organ/limb-threatening clinical situations (Grade A, EL III)
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Analogue insulins with possible lower risk of nocturnal and symptomatic hypoglycemia may be used in preference to human insulins; however, economic considerations must be taken into account. Newer insulin co-formulations are associated with fewer hypoglycemic episodes (Grade B, EL I)
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Match the insulin dose to carbohydrate intake (Grade A, EL II)
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Counseling on scheduling regular blood glucose monitoring and awareness of hypoglycemic symptoms and their management are recommended to all patients initiating with insulin. The HCPs should provide guidance for adjusting insulin dose adjustments, administration, storage, and other practical aspects (Grade A, EL I)
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Target for FPG level is 4.4–7.2 mmol/L, PPG level is < 10 mmol/L, and 2-h PPG level is < 7.8 mmol/L. These targets can be individualized on the basis of the risk of hypoglycemia and the urgency for glycemic control (Grade A, EL I)
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Titration should be done at regular and short intervals to attain glycemic goals without causing hypoglycemia (Grade A, EL I)
Intensification of Insulin Therapy
Basal Plus/Basal-Bolus Insulin
Glucose value | Total daily dose | |
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Step 1: initiation with basal insulina | HbA1c < 8% (< 64 mmol/mol) | 0.1–0.2 units/kg |
HbA1c > 8% (> 64 mmol/mol) | 0.2–0.3 units/kg | |
Step 2: titrationb (every 2–3 days to reach glycemic goals) | Fixed regimen | Increase by 2 units/day |
Adjustable regimen | ||
FPG > 10 mmol/L | Add 4 units | |
FPG 7.77–10 mmol/L | Add 2 units | |
FPG 6.11–7.72 mmol/L | Add 1 unit | |
Step 3: monitor for hypoglycemia | BG < 3.88 mmol/L | Reduce by 10–20% |
BG < 2.22 mmol/L | Reduce by 20–40% |
Therapeutic option | Total daily dose | |
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Step I: add prandial insulin | When glycemic targets are unmet | TDD 0.3–0.5 units/kg (40–50% basal: 50–60% prandial)a |
Step II: titrationb (every 2–3 days to reach glycemic goals) | Fixed regimen (prandial insulin) | Increase TDD by 2 units/day |
Adjustable regimen (prandial insulin) | ||
FPG > 9.99 mmol/L | Increase TDD by 4 units | |
FPG 7.77–9.99 mmol/L | Increase TDD by 2 units | |
FPG 6.10–7.71 mmol/L | Increase TDD by 1 unit | |
2-h PPG or next premeal glucose > 9.99 mmol/L | Increase prandial dose for the next meal by 10% | |
When glycemic targets are unmet | TDD 0.3–0.5 units/kg (40–50% basal: 50–60% prandial)* | |
FPG/premeal BG > 9.99 mmol/L | Increase TDD by 10% | |
Step III: monitor for hypoglycemia | Fasting hypoglycemia | Reduce basal insulin dose |
Nighttime hypoglycemia | Reduce basal insulin or reduce short/rapid-acting insulin taken before supper or evening snack | |
Between-meal hypoglycemia | Reduce previous premeal short/rapid-acting insulin |
Premix Insulin
GLP-1 Receptor Agonists
Combination Injectable Therapy (Insulin + GLP-1 RA)
Recommendations
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Intensification of insulin therapy should be considered when patients fail to achieve glycemic goals even after optimal dose titration (Grade A, EL I)
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Intensification with premix insulin twice daily or thrice daily, insulin co-formulation-based regimen, prandial insulin (basal plus or basal bolus) with the largest meal of the day, or GLP-1 RA. Choice of intensification regimen is based upon diet, lifestyle, risk of hypoglycemia and weight gain, affordability, and patient preference (Grade A, EL II)
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In T2DM patients with uncontrolled hyperglycemia, GLP-1 RAs are suitable second-line or third-line treatment option (Grade A, EL I)
Insulin in Special Populations
Newly Diagnosed T2DM
Recommendations
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For newly diagnosed T2DM, consider initiating insulin therapy, if HbA1c ≥ 10.0% (≥ 86 mmol/mol), FPG > 13.9 mmol/L, PPG > 16.7 mmol/L, and/or if patient is symptomatic (Grade A, EL I)
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For newly diagnosed T2DM, consider initiating dual therapy, if HbA1c 9.0% (≥ 75 mmol/mol) (Grade A, EL II)
Elderly
Recommendations
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Consider antihyperglycemic therapy with low risk of hypoglycemia in elderly patients who are at increased risk of hypoglycemia (Grade A, EL II)
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Consider once-daily basal insulin injection regimen over multiple daily insulin injection regimen to reduce the risk of hypoglycemia if glycemic goals can be achieved within the individualized HbA1c target (Grade B, EL II)
Pregnancy
Recommendations
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Tighter glycemic targets are suggested during pregnancy: HbA1c 6.0–6.5% (42–48 mmol/mol); FPG 5.3 mmol/L; 1-h PPG 7.8 mmol/L; and 2-h PPG 6.7 mmol/L (Grade A, EL I)
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Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus (GDM) as it does not cross the placenta (Grade A, EL I)
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Antenatal patients may use any human insulin preparation, insulin aspart or insulin lispro preparations, or insulin detemir (Grade A, EL II)
Recommendation
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Consider using premix insulin with proven safety profile in lactating mothers with diabetes (Grade B, EL II)
Lactation
Renal Impairment
Recommendations
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Consider using insulin analogues in renal impaired patients with diabetes for improved glycemic control with low risk of hypoglycemia (Grade B, EL II)
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Frequent blood glucose monitoring and dose adjustments are recommended in chronic renal failure (CRF) diabetic patients when they are treated with insulin (Grade B, EL II)
Cardiac Impairment
Recommendations
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Choice of insulin regimen and preparation should be based upon cost, severity of hyperglycemia, risk of hypoglycemia, and likelihood of interventional procedure in near future (Grade B, EL II)
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Patients with T2DM on combination therapy of premixed insulin analogues and OADs should be carefully monitored for signs and symptoms of heart failure (HF), weight gain and edema, and a prompt clinical action is recommended if any deterioration in cardiac symptoms occurs (Grade B, EL II)
Hepatic Impairment
Recommendation
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Consider using insulin analogues in T2DM patients with hepatic impairment for improved glycemic control with low risk of hypoglycemia (Grade B, EL II)
Monogenic Forms of Diabetes
Recommendation
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In most patients with permanent neonatal diabetes, lifelong insulin therapy is required (Grade A, EL III)
Ramadan and Other Fasting States
Religious Fasting Recommendations
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T2DM patients wishing to fast and who are on premix insulin analogue therapy are recommended to use the usual morning dose at sunset (iftar) and half the usual evening dose at predawn (suhoor) meal, e.g., patients on biphasic insulin aspart 30 with 30 units in morning and 20 units in the evening before Ramadan, the recommended dose will be 30 units in the evening (iftar) and 10 units in the morning (suhoor) during Ramadan (Grade A, EL II)
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In T2DM patients with NPH or premix human insulin at suhoor, it is recommended to check blood glucose at noon before up-titration of the pre-suhoor dose (Grade B, EL II)
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Before starting Ramadan or other religious fasts, consider educating the patient with diabetes on risk quantification, blood glucose monitoring, nutrition intake, proper exercise, and dose adjustments to minimize hypoglycemic complications (Grade A, EL III)
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Consider advising pregnant women during Ramadan who are on sulfonyl urea therapy and/or insulin to exercise caution because of the high risk of hypoglycemia (Grade D, EL IV)
Infections
Glycemic management | |
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AFI patients with adequate oral intake | Frequent BGM to check for hyperglycemic episodes Continue OADs in patients eating well if BG is well controlled and no contraindication with OADs Initiate insulin If BG is poorly controlled with OADs |
AFI patients with compromised oral intake | Modification in diet (small portion sizes, at frequent intervals) |
AFI patients on concomitant corticosteroid therapy | In steroid-induced or worsened hyperglycemia, subcutaneous insulin using a basal or multiple daily injections regimen |
AFI patients with compromised hepatorenal function | Rapid-acting insulin in small, frequent doses to manage hyperglycemia |
AFI patients with compromised sensorium | Discontinue OADs and initiate IV insulin Alternatively, SC rapid-acting insulin may be used |
AFI in elderly patients | Frequent BGM to detect atypical symptoms of hyperglycemia and hypoglycemia |
AFI patients with cachexia/asthenia | An insulin regimen which provides both prandial and basal coverage, such as premixed/dual action or basal plus/basal-bolus insulin in patients with lack of energy (asthenia), with or without wasting, loss of weight, muscle atrophy, fatigue, and loss of appetite (cachexia) during the febrile or convalescence phase |
Recommendations
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Consider using subcutaneous (SC) insulin with a basal or multiple daily injections regimen in steroid-induced or worsened hyperglycemia (Grade B, EL III)
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Consider using Regular insulin or rapid-acting insulin in small, frequent doses to manage hyperglycemia in acute febrile illness patients with metabolic decompensation, compromised hepatorenal function, or cognitive impairment (Grade B, EL III)
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Consider using premixed or basal plus/basal-bolus insulin in patients with lack of energy (asthenia), with or without wasting, loss of weight, muscle atrophy, fatigue, and loss of appetite (cachexia) during the febrile or convalescence phase (Grade B, EL III)
HIV Infection and Comorbidities
Strategies | Management |
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General management | Treatment for comorbid conditions Hypertension—treatment with ACE inhibitors and ARBs not an optimal choice in patients with HIV Dyslipidemia—treatment with pravastatin, fluvastatin, atorvastatin, and rosuvastatin in patients with HIV |
Non-insulin therapies | Use metformin if well tolerated and if no contraindications are present Use SU/alpha-glucosidase inhibitors if metformin is contraindicated/not tolerated. Thiazolidinediones and DPP-4 inhibitors are also used in patients with HIV Use incretin mimetics if weight loss is desired |
Insulin | Initiate basal-bolus regimen or premixed insulin (1.0 U/kg/day) at diagnosis Insulin may be tapered or reduced (0.5 U/kg/day) once control is achieved Initiate insulin aspart in patients with ketonuria and for critically ill patients Educate HIV-infected patients on how to dispose of lancets, glucose strips, insulin syringes, pens, and needles to prevent HIV transmission |
Changes in HAART | Pre-existing T2DM may continue to be managed after diagnosis of HIV by continuing with the same drug therapy that was being used prior to detection of HIV Patients diagnosed with diabetes and HIV together may be treated with metformin if well tolerated and if no contraindications are present. Depending on the baseline HbA1c, insulin or low dose meglitinides can be initiated as a second-line therapy Patients developing diabetes after HAART may be treated with metformin or other OADs. Insulin is a better and safer choice and may be tapered or reduced once control is achieved |
Recommendation
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When insulin therapy is required, consider initiating insulin therapy with basal-bolus regimen or premixed insulin at diagnosis. Higher doses may be needed for control (Grade C, EL III)
Ketosis-Prone Diabetes
Recommendation
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Initiate insulin as per the clinical situation, but keep a close watch for hypoglycemia. Sudden, significant down-titration of dose frequency and/or requirement may be needed (Grade C, EL III)
Self-Monitoring of Blood Glucose (SMBG)
Recommendation
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Pragmatic suggestions for SMBG should accompany insulin prescriptions (Grade D, EL IV)
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Basal insulin is best monitored by FPG, 1–2 times a week (Grade A, EL II)
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Prandial insulin is best monitored by paired premeal and postmeal glucose values (Grade A, EL II)
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Premixed insulin is initially monitored by prebreakfast and predinner glucose values, followed by postprandial values (Grade A, EL 2)
Exercise
Recommendation
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Check blood glucose before and after exercise, and take appropriate action. If exercise is enduring, e.g., bicycle riding, check blood glucose in between exercise and take appropriate action (Grade A LE I)
Hypoglycemia, Weight Gain, and Psychosocial Aspects
Hypoglycemia
Weight Gain
Psychosocial Aspects
Educational Motivation/Counseling Support
Mental Illness
Special Situations
Inpatient Settings
Treatment for Non-critically Ill Patients
Recommendations
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Consider using basal plus bolus correction insulin regimen, with the addition of meal-related insulin in patients who have good nutritional intake, in non-critically ill patients (Grade A, EL I)
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Avoid sliding scale insulin in the inpatient hospital setting (Grade A, EL I)
Treatment for Critically Ill Patients
Surgery
Perioperative Management
Patients on Enteral/Parenteral Nutrition
Situation | Basal/nutritional | Correctional |
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Continuous enteral feedings | Continue prior basal or, if none, calculate from TDD or consider 5 units NPH/detemir every 12 h or 10 units glargine/degludec daily nutritional: regular insulin every 6 h or rapid-acting insulin every 4 h, starting with 1 unit per 10–15 g of carbohydrate; adjust daily | SC regular insulin every 6 h or rapid-acting insulin every 4 h for hyperglycemia |
Bolus enteral feedings | Continue prior basal or, if none, calculate from TDD or consider 5 units NPH/detemir every 12 h or 10 units glargine/degludec daily nutritional: give regular insulin or rapid-acting insulin SQ before each feeding, starting with 1 unit per 10–15 g of carbohydrate; adjust daily | SC regular insulin every 6 h or rapid-acting insulin every 4 h for hyperglycemia |
Parenteral feedings | Add regular insulin to TPN IV solution, starting with 1 unit per 10 g of carbohydrate; adjust daily | SC regular insulin every 6 h or rapid-acting insulin every 4 h for hyperglycemia |
Insulin Therapy in Patients in Their Home Setting
Practical Aspects
Insulin Delivery Devices
Recommendation
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Health care authorities and planners should be alerted to the risks associated with syringe or pen needles 6 mm or longer in children (Grade A, LE II)
Insulin Transport and Storage
Recommendation
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Transportation of insulin from a health facility to home can be safely done without an icepack if no extremes of temperatures are envisaged. If uncertainty exists about an exposure to high temperatures (> 30 °C) it is advised to transport insulin on an ice pack (Grade A, LE IV)
Injection Sites
Recommendation
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Recommended injection and infusion sites are the abdomen, thigh, buttock, and upper arm (Grade A, LE I)
Needle Length
Recommendation
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A 4-mm needle is recommended for all patients with diabetes (Grade A, LE I)
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The safest currently available syringe needle for all patients is 6 mm in length. However, when any syringe needle is used in children ≥ 6 years old, adolescents, or slim to normal weight adults (body mass index of 19–25 kg/m2—calculated as the weight in kilograms divided by the height in meters squared) injections should always be given into a lifted skin fold at 90° (Grade A, LE I)
Injection Site Complications
Recommendation
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Injections should be systematically rotated to avoid lipohypertrophy. This means at least 1 cm (1-finger breadth) from previous injections (Grade A, LE II)
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Injection sites should be examined by the health care worker at least once a year and preferably every visit (Grade A, LE II)
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After the insulin has been pushed in, patients should count slowly to 10 and then withdraw the needle from the skin. This is necessary to prevent medication leakage so as to get the full dose (Grade A, LE I)
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Many patients in East Africa reuse syringes for various reasons, including financial. This is not recommended by the manufacturer. There is an association between needle reuse and lipohypertrophy. Patients who reuse needles should not be subjected to alarming claims of excessive morbidity from this practice (Grade A, LE III)
Needle Stick Injuries
Recommendation
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Safety injection devices should be considered first-line choice if injections are given by a third party. Pens and syringes with needles used in this setting should have protective mechanisms for all sharp ends of the delivery device (Grade A, LE II)
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The health care worker should be involved in the training of the patient and safe disposal of sharps (Grade A, LE I)
Lipoatrophy
Pain
Barriers and Myths Concerning Insulin
Biosimilar Insulins
Recommendation
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In switching from one insulin to another similar insulin (original to biosimilar) it is advised to carry out a dose titration always starting with a reduced dose and to up-titrate to avoid hypoglycemia. Self-monitoring of blood glucose is therefore necessary (Grade D, LE V)