餐前胰島素有速效(Insulin Lispro，Insulin Aspart，Insulin Glulisine)和短效(RI)
1.餐前胰島素劑量須考量:
(1)個人胰島素敏感性及餐食的醣類及卡路里量。
(2)起始劑量可為0.1~0.15單位/公斤/每餐，或每單位胰島素控制10~15公克糖類估算。
2.其他注射法:
(1)依固定量，如4單位起跳。
(2)依餐後血糖值，如血糖值(mg/dl)/36(常數)=起始劑量(單位)
(3)依患者體重，0.05單位/公斤/=起始劑量(單位)(瘦小或胰島素敏感者)。
(4)依基礎胰島素(BI)劑量，如BI劑量(單位)X10%=起始劑量(單位)
3.調校方法:
(1)餐後血糖值超標，依固定量增加。如>140mg/dl，增加一單位。
(2)依餐後血糖值，如
如果平均空腹血糖超過 130, 每隔三天以上調整一次劑量, 每次增加 2-4 u. 調整胰島素劑量可能要數周至數個月的時間, 如果空腹血糖超過 250, 或已知病患胰島素抗性高, 可更積極的調整劑量, 但要做低血糖衛教
If the mean FBG is above target (typically 130 mg/dL [7.2 mmol/L]), an increase of 2 to 4 units in the basal insulin dose should be made periodically (approximately every three days) (algorithm 1) [36]. In this way, the basal insulin dose can be titrated over a period of several weeks or months. If FBG levels are very elevated (>250 mg/dL [13.9 mmol/L]) or if a patient is known to be very insulin resistant, titration can be more aggressive. Patients should reduce their insulin dose if hypoglycemia develops.
在病患接近血糖控制目標的時候, 如果病患晚上自然醒過來, 可以順便測一下睡眠之間的血糖, 以排除低血糖
As patients approach the glycemic target, it may be helpful to check a mid-sleep blood glucose to rule out hypoglycemia (this can be done when the patient spontaneously wakes overnight).
如果空腹血糖有達標(80-130或依照病患狀況設定不同標準), 但A1C 仍高, 建議病患測量空腹血糖(睡醒之後吃早餐之前), 午餐前血糖, 晚餐前血糖, 睡前血糖, 隨餐血糖可以挑選一天之中吃的最豐盛的一餐施打
也可以使用連續偵測血糖的血糖機, 測量兩周血糖,
Persistent elevation in A1C with FBG in target range — For patients with persistently elevated glycated hemoglobin (A1C) levels who have fasting blood glucose (FBG) levels in the target range (80 to 130 mg/dL [4.4 to 7.2 mmol/L], or higher, depending on the individualized glycemic target), we advise the patient to check fingerstick capillary glucose levels fasting, pre-lunch, pre-dinner, and before bed while the insulin regimen is further adjusted. Prandial insulin may be started as a single injection before the largest meal of the day, but many strategies are possible (algorithm 1). Short-term monitoring with continuous glucose monitoring for two weeks may also be helpful in insulin dose adjustment. (See "Self-monitoring of glucose in management of nonpregnant adults with diabetes mellitus".)
如果經過胰島素調整, 仍無法將 A1C 降到目標值, 需回顧一下患者的飲食與運動習慣, 建議患者常規測早上空腹血糖, 午餐前及晚餐前及睡前血糖. 一般來說, 胰島素治療失敗通常是由於沒有節制飲食或吃到不該吃的食物造成. 這類情況通常胰島素用量會超過每天 65-100u. 有時候在第二型糖尿病合併肥胖患者會更高.
Among patients whose A1C values remain above the desired target despite insulin adjustments, diet and exercise patterns should be reviewed. We advise the patient to continue to check fingerstick capillary glucose levels fasting, pre-lunch, pre-dinner, and before bed while the regimen is further adjusted. In general, dietary indiscretion and/or mismatch of food and insulin dose underlie the apparent failure of many patients treated with insulin regimens. Daily insulin doses typically exceed 65 to 100 units per day and may sometimes be much higher in patients with type 2 diabetes and obesity.
晚餐前血糖上升, 治療選擇包括在早餐時增加第二劑 detemir or NPH, 如果患者已經在施打 glargine or degludec, 可以增加隨餐胰島素. 另外, 調整午餐的飲食習慣也有效果.
Pre-dinner glucose elevated — If pre-dinner glucose values are elevated, options include adding second dose of detemir or NPH at breakfast or, if the patient is on glargine or degludec, adding prandial insulin at lunch. Dietary modification at lunch may also be effective.
如果治療目標是使用簡單便宜的方式控制持續性高血糖, 一天打兩次 NPH 或 detemir insulin 對於多數人而言是有效的選擇. 當使用 detemir, 一天兩次能更穩定的控制 24小時血糖.
If the goal is control of persistent hyperglycemia with a regimen that is simple and inexpensive, then twice-daily NPH or detemir insulin will be effective in many patients [37,39]. When the insulin preparation is detemir, glycemic control over a 24-hour period may also be more stable in patients taking two doses daily.
午餐前或睡前血糖上升, 可在早餐前或晚餐前加上隨餐胰島素, 包括短效或速效的胰島素, 這種狀況, 建議停止 metformin 以外的其他藥物 (如無其他禁忌症, 或耐受不良, 可持續服用 metformin)
Pre-lunch or bedtime glucose elevated — If blood glucose values are elevated before lunch and/or bed, we typically add prandial insulin. Either short-acting (regular) or rapid-acting insulin can be given before breakfast and/or dinner. In this setting, oral agents other than metformin are discontinued (in the absence of contraindications or intolerance, metformin can be continued).
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