- ACRONYMS AND DEFINITIONS
- ADA - American Diabetes Association
- Basal insulin - Long- and intermediate-acting insulins used to supply constant levels of insulin activity over the course of a day
- Carb - Carbohydrate
- T1DM - Type 1 diabetes
- T2DM - Type 2 diabetes
- Multidose insulin regimen - Insulin regimens that include both basal and premeal insulins
- Prandial insulin - Rapid and short-acting insulins given at mealtime
- Premeal insulin - also called “prandial” insulin. Rapid and short-acting insulins given at mealtime.
- Total daily dose of insulin - Sum in units of premeal and basal insulin given in a day
- 1 kilogram = 2.2 pounds
- IMPORTANT POINTS ABOUT DOSING INSULIN
- Overview
- There are a number of different ways to dose insulin, and no single regimen will work for every patient. Patient variables like education, motivation, diabetes control, and resources must all be considered when determining which method will best fit each individual.
- Low blood sugar (Hypoglycemia)
- In most patients, the main concern when initiating insulin is the risk of low blood sugars. To help lower the risk, blood sugar monitoring should be increased, and all patients should be aware of the signs, symptoms, and treatment of hypoglycemia (see hypoglycemia for more).
- Measures to help prevent low blood sugars
- Insulin-naïve patients should start at the lower end of dosing ranges and titrate slowly
- Patients should try to avoid insulin doses outside of their prescribed regimens as this may lead to incorrect adjustments
- Patients should attempt to consume a consistent diet of three meals a day while also keeping meals as uniform as possible in size and carbohydrate content. Patients should notify their provider and increase monitoring if they decide to make significant changes to their diet (e.g. start a keto diet, drastically reduce calorie intake).
- When using a multidose regimen (basal and premeal), adjust one regimen at a time and alternate between the two (see alternating regimens for more)
- INSULIN CATEGORIES
- For dosing purposes, insulins can be divided into two categories:
- Basal insulins - basal insulins provide a steady amount of background insulin activity over the course of a day
- Premeal insulin (prandial insulin) - premeal insulins provide a burst of insulin that acts quickly to abate the rise in blood glucose that is seen after consuming a meal
- See insulin chart for a review of available insulins including their pharmacokinetics, dosage forms, storage, and more
- Basal insulins
- Intermediate-acting insulins
- Humulin® N (NPH)
- Novolin® N (NPH)
- Long-acting insulins
- Basaglar® (insulin glargine)
- Lantus® (insulin glargine)
- Levemir® (insulin detemir)
- Semglee® (insulin glargine)
- Toujeo® (insulin glargine)
- Tresiba® (insulin degludec)
- Premeal insulins
- Rapid-acting insulins
- Admelog® (insulin lispro)
- Afrezza® (inhaled insulin)
- Apidra® (insulin glulisine)
- Fiasp® (insulin aspart)
- Humalog® (insulin lispro)
- Lyumjev® (insulin lispro-aabc)
- Novolog® (insulin aspart)
- Short-acting insulins
- Humulin® R (regular)
- Novolin® R (regular)
- BLOOD SUGAR GOALS
- TYPE 1 DIABETES INSULIN RECOMMENDATIONS
- ADA general treatment recommendations for T1DM
- T1DM patients should receive multidose injections (3 - 4 a day) of basal and premeal insulin or insulin pump therapy
- Most individuals with T1DM should use rapid-acting insulin analogs to reduce hypoglycemia risk
- Patients should match premeal insulin to carbohydrate intake, premeal blood glucose levels, and anticipated activity [26]
- Starting therapy
- Insulin dosing in T1DM will vary based on patient's age, weight, and residual pancreatic insulin activity
- T1DM patients will typically require a total daily insulin dose of 0.4 - 1.0 units/kg/day
- A typical starting dose in metabolically-stable patients is 0.5 units/kg/day
- After calculating the total daily dose, it should be given as follows:
- Basal insulin - given as half of the total daily dose ✝
- Premeal insulin - half of the total daily dose divided into thirds and given before each meal
- ✝ When first starting therapy, it is recommended that the initial basal dose be reduced by 20 - 30% to prevent hypoglycemia [11,19]
- T1DM patients may experience a "honeymoon phase" after starting insulin therapy where the initial effects of insulin are greater than what is seen later in the disease [7,13,26]
- Example
- Patient weighs 80 kg
- Total daily dose = 80 kg X (0.5 units/kg/d) = 40 units per day
- Basal insulin = 1/2 X 40 units = 20 units of basal per day✝
- Premeal Insulin = 1/2 X 40 units = 20 units / 3 = approximately 7 units before each meal
- ✝ If patient is just starting therapy, the initial basal dose should be reduced by 20 - 30%. In our example: 20 units X 0.20 = 4 units, so initial basal dose would be 20 - 4 = 16 units
- Adjusting therapy
- See adjusting basal insulin and adjusting premeal insulin below
- TYPE 2 DIABETES INSULIN RECOMMENDATIONS
ADA Insulin Dosing Recommendations for Adults with T2DM |
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Step 1 - start with long-acting insulin or bedtime NPH
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Step 2 - add premeal insulin before largest meal
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Step 3 - add premeal insulin before other meals in stepwise fashion
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ADA Insulin Recommendations for Youth with T2DM |
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Basal insulin
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ADA Insulin Recommendations for Elderly with T2DM |
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Overview
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Basal insulin
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Premeal (prandial) insulin
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- ADJUSTING BASAL INSULIN
- Overview
- Basal insulins provide a constant level of background insulin activity. In T2DM, they can be used as monotherapy or as a supplement to other therapies. The ADA recommends that insulin be considered as an initial therapy in type 2 diabetics who have evidence of ongoing catabolism (e.g. weight loss), symptoms of hyperglycemia, or when A1C is > 10% or blood glucose levels > 300 mg/dL.
- Basal insulin recommendations from the ADA are given below. Another method (Three-day method) that provides more specific instructions and has been proven effective in clinical trials is also provided.
- When NPH is used as the basal insulin, other considerations should be taken into account. See NPH dosing for more.
- ADA recommendations for basal insulin therapy in T2DM
- Start with a long-acting insulin or bedtime NPH
- Initial dose: 10 units/day or 0.1 - 0.2 units/kg/day
- Adjust dose: increase dose by 10 - 15% or 2 - 4 units once or twice weekly to achieve fasting blood sugar goal (see blood sugar goals for more)
- If hypoglycemia occurs: decrease dose by 10 - 20% or 4 units
- Three-day method for adjusting basal insulin
- 1. Measure fasting blood sugar (no calories for 8 hours) for previous three consecutive days
- 2. Calculate the average of the three fasting blood sugars
- 3. Adjust basal insulin dose based on the table below
- 4. Repeat steps 1-3 until target range (80 - 99) is achieved
Fasting blood sugar (mg/dl) average over 3 days |
Adjustment to basal insulin dose (units of insulin) |
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≥ 180 | add 8 units |
160 - 179 | add 6 units |
140 - 159 | add 4 units |
120 - 139 | add 2 units |
100 - 119 | add 1 unit |
80 - 99 | no change |
60 - 79 | subtract 2 units |
< 60 | subtract 4 or more units |
- ADJUSTING PREMEAL INSULIN
- Overview
- There are a number of ways to adjust premeal insulin. The ADA gives simple guidance that will likely be appropriate for most type 2 diabetics. More complex methods (scale method and carb counting method) are also detailed below. These methods are probably more appropriate for type 1 diabetics and/or patients who are highly motivated.
- ADA recommendations for premeal insulin in T2DM
- If A1C is still above target despite achieving fasting blood sugar goal on basal insulin, or if A1C is not at target and insulin dose is > 0.7 - 1.0 units/kg, add premeal insulin
- Frequency: Start by adding premeal insulin to the largest meal of the day. If adequate control is not achieved, add premeal insulin to a second and third meal if necessary.
- Initial dose: 4 units or 10% of basal dose
- If A1C < 8%, consider decreasing basal insulin dose by same amount
- Adjust dose: increase dose by 1 - 2 units or 10 - 15% twice weekly to achieve pre- and postprandial goals (see blood sugar goals for more)
- If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20%
- ADJUSTING PREMEAL INSULIN (SCALE METHOD)
- Scale method
- With the scale method, premeal insulin is adjusted based on a scale
- Patients should try to consume the same amount of carbohydrates at each meal (a typical amount is about 60 grams a meal and 15 grams for a bedtime snack)
- Carbohydrate goals vary by individual (see carbohydrate information below)
- Steps:
- 1. Measure blood sugar fasting (pre-breakfast), pre-lunch, pre-dinner, and pre-bedtime snack for previous three consecutive days
- 2. Average the pre-lunch, pre-dinner and pre-bedtime values separately
- 3. Adjust the premeal insulin dose based on the table below
- 4. Repeat steps 1-3 until target range is achieved
- 5. A Correction Factor (see below) should also be incorporated when blood sugars are checked
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Premeal blood sugar (mg/dl) average over 3 days |
Adjustment to premeal insulin dose |
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≥ 180 | add 3 units |
160 - 179 | add 2 units |
140 - 159 | add 2 units |
120 - 139 | add 1 units |
100 - 119 | maintain dose (desired range) |
80 - 99 | subtract 1 unit |
60 - 79 | subtract 2 units |
< 60 | subtract 4 or more units |
- ADJUSTING PREMEAL INSULIN (CARBOHYDRATE COUNTING)
- Carbohydrate counting
- In carbohydrate counting, premeal insulin is adjusted based on the amount of carbohydrates to be consumed in each meal
- The carbohydrate counting method is used to determine the amount of carbohydrates in a meal
- An insulin to carbohydrate ratio (ex. 1 unit/10g of carb) is used to calculate the premeal insulin dose
- A typical starting ratio is 1 unit of premeal insulin for every 10 grams of carbs to be consumed
- An individual may have different carbohydrate ratios for breakfast, lunch, and dinner because a person's response to insulin may vary throughout the day
- Example:
- 60 grams of carbs to be consumed for lunch
- Patient's ratio is 1 unit of insulin for every 10 grams of carbs
- Patient injects 6 units of premeal insulin before eating meal
- Steps for adjusting an insulin-to-carb ratio
- 1. Calculate the number of carbs to be consumed in a meal using carbohydrate counting
- 2. Dose premeal insulin based on number of carbs in a meal (typical starting point is 1 unit of premeal insulin for every 10 grams of carbs)
- 3. Measure blood sugar fasting (pre-breakfast), pre-lunch, pre-dinner, and pre-bedtime snack for previous three consecutive days
- 4. Average the pre-lunch, pre-dinner and pre-bedtime snack blood sugar values separately
- 5. Adjust the carbohydrate to insulin ratio as instructed in the table below
- 6. Repeat steps 1-5 until appropriate ratios are determined [3,4]
- 7. A Correction Factor (see below) should also be incorporated when blood sugars are checked
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If average blood sugar is > 120 mg/dl, adjust ratio by subtracting 2 - 3g of carbohydrate
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If average blood sugar is < 80 mg/dl, adjust ratio by adding 2 - 3g of carbohydrate
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If average blood sugar is 80 - 120 mg/dl, do not adjust ratio |
- ADJUSTING PREMEAL AND BASAL INSULINS CONCURRENTLY
- Overview
- When adjusting premeal and basal insulins concurrently, adjustments to one regimen may affect the other regimen. This can lead to overcorrections and hypoglycemia.
- Alternating between regimens may help prevent overcorrections
- Example:
- Day 3 - adjust basal
- Day 6 - adjust premeal
- Day 9 - adjust basal
- Day 12 - adjust premeal, and so on...
- CORRECTION FACTOR
- Overview
- When premeal blood sugar checks are high, a correction factor should be used with premeal insulin
- The correction factor supplies supplemental insulin to account for the elevated blood sugar
- Insulin used in the correction factor should not be included in calculations for adjusting premeal or basal insulin
- There are several methods that can be used to determine the correction factor
- When first starting therapy, the ideal total daily insulin dose will not be known, so the flat method is preferred over the individual method
- Flat method
- One unit of extra premeal insulin is added for every 25 mg/dl that blood sugar is above the upper limit of the desired range
- Example:
- Pre-lunch blood sugar is 200 mg/dl
- upper limit of desired range is 120 mg/dl
- 200 - 120 = 80 mg/dl above desired range
- 80 mg/dl ÷ 25 mg/dl = approximately 3
- add 3 extra units to premeal dose
- Individual method
- The individual method uses a patient's total daily insulin dose to calculate a correction factor
- The correction factor is calculated differently for regular insulins (Humulin R, Novolin R) and rapid insulins (Novolog, Humalog, Apidra, Fiasp)
Step 1 - calculate the correction factor
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Step 2 - Once the correction factor is calculated, the patient can then figure out how much insulin to supplement
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- NPH DOSING
- NPH properties
- NPH insulin is an intermediate-acting insulin that can be used as a basal insulin. Newer long-acting insulin analogs have largely supplanted NPH insulin as first-line basal insulins, but NPH remains the most affordable insulin available at $25/vial, and it is therefore still an important option for patients without insurance and/or those who are cost sensitive.
- When initiating NPH insulin, it's important to understand how its pharmacokinetic properties differ from other basal insulins. Long-acting insulins provide a steady-state of insulin that does not have a peak. NPH insulin has a peak effect that occurs between 4 - 10 hours after dosing. Because of this, NPH carries a higher risk of hypoglycemia. The duration of effect of NPH is around 16 - 20 hours which is shorter than the long-acting insulins that have a duration of 24+ hours. This means NPH often has to be dosed twice daily to achieve sustained control over a 24-hour period.
- The diagram below illustrates the different pharmacokinetics of NPH and long-acting insulins. [11,29]

- Important points about NPH dosing
- NPH is a suspension, and it is important that it is properly resuspended before dosing. Failure to properly resuspend NPH will result in dosing irregularities. Both the vials and the pens contain directions on how to resuspend each product. NPH should appear uniformly white and cloudy after proper resuspension.
- Since NPH has a peak effect, it is important that patients keep the timing of their injections and meals consistent in order to help prevent hypoglycemia. Patients should also try to keep their meals uniform in size and carbohydrate content.
- Patients who are also using premeal insulins should be aware that NPH may potentiate the peak effect of their premeal insulin. For example, a patient who injects NPH and a rapid-acting insulin before breakfast will see a peak effect from the rapid insulin around 1 - 3 hours after injection. The NPH will start to have its effect around 2 - 3 hours after injection, and the combined peak actions may lead to hypoglycemia. More frequent blood sugar checks and/or dose adjustments may be necessary when initiating therapy.
- In the evening, NPH should typically be dosed at bedtime (as opposed to dinner) as this has been shown to decrease the incidence of nighttime hypoglycemia [11,28]
- Twice-daily NPH
- In type 2 diabetics, twice-daily NPH is appropriate as monotherapy or adjunctive therapy in diabetics who lack significant control (A1C > 9%) despite other treatments. The question that often arises with twice-daily NPH is how much insulin should be given in the morning and how much should be given at night. In studies, NPH regimens have varied widely, with some splitting the dose 50-50, some giving 2/3 in the morning and 1/3 in the evening and others giving 1/3 in the morning and 2/3 in the evening. [30,31,32,33,34,35]
- The steps below are derived from clinical trials and guidelines. They are intended to provide a starting point for initiating and adjusting twice-daily NPH in type 2 diabetics. The recommendations should be individualized as some patients may require more aggressive adjustments (e.g. poorly-controlled morbidly obese diabetics) and others may require minor adjustments (e.g. elderly, hypoglycemia concerns). For recommendations in patients who are switching from another insulin to NPH, see converting from other insulins to NPH below.
Dosing NPH Insulin in T2DM | ||||||||||||||||||||||||||||||||||||||||||||
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Step 1 - Initial dose
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Step 2 - Monitor blood sugars
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Step 3 - Determine insulin adjustment
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Step 4 - Distributing the insulin adjustment
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- Twice-daily NPH example:
- Patient initiates NPH insulin at 10 units twice daily
- Patient blood sugar readings from 3 consecutive days are as follows:
- Fasting: 185, 133, 156
- Predinner: 256, 300, 190
- Average of all blood sugars = (185 + 133 + 156 + 256 + 300 + 190) / 6 = 203
- Based on table in Step 3, patient will add 8 units to the total daily NPH dose
- Average of fasting blood sugars is = (185 + 133 + 156)/3 = 158
- Average of predinner blood sugars is = (256 + 300 + 190)/3 = 249
- Based on tables in Step 4, fasting blood sugars are range 2, and predinner blood sugars are range 3
- Based on dose distribution table in Step 4, patient will add 67% of the 8 additional units to his morning dose and 33% to the bedtime dose
- 67% of 8 = 0.67 X 8 = 5.36 rounded down to 5 units
- 33% of 8 = 0.33 X 8 = 2.64 rounded up to 3 units
- Patient's new NPH dose is 15 units in the morning and 13 units at night
- Once-daily NPH
- The ADA guidelines list once-daily bedtime NPH as an option when initiating insulin in type 2 diabetics (see ADA T2DM insulin recommendations).
- Once-daily NPH is an appropriate adjunctive therapy for type 2 diabetics who have not achieved good control on other therapies. Poorly controlled diabetics (A1C > 9%) will likely need twice-daily NPH to reach their goals. Patients with normal AM fasting blood sugars should give their dose in the morning and not at bedtime.
- Dosing recommendations from the ADA are given below. Once-daily NPH can also be adjusted using the three-day method detailed above.
- ADA recommendations for bedtime NPH
- Initial dose: 10 units/day or 0.1 - 0.2 units/kg/day
- Adjust dose: increase dose by 10 - 15% or 2 - 4 units once or twice weekly to achieve fasting blood sugar goal (see blood sugar goals for more)
- If hypoglycemia occurs: decrease dose by 10 - 20% or 4 units
- Converting from long-acting insulins to NPH
- When converting from long-acting insulins to NPH, one of the most important things to consider is that NPH has a peak effect and long-acting insulins do not. The peak effect can increase the risk of hypoglycemia, and this is especially true in patients who are also using premeal insulins. For example, a patient who injects NPH and a rapid-acting insulin before breakfast will see a peak effect from the rapid insulin around 1 - 3 hours after injection. The NPH will start to have its effect around 2 - 3 hours after injection, and the combined peak actions may lead to hypoglycemia.
- In trials with type 1 diabetics who were switching from other basal insulins to NPH and vice versa, the total daily basal insulin dose was reduced by 25 - 30% upon initiation. This approach will help prevent hypoglycemia, but may require significant up titration after switching.
- Dose changes when switching from long-acting insulins to NPH should be individualized. Patients at greater risk for hypoglycemia should consider a 20 - 30% dose reduction when initiating NPH so they can gauge how the peak effect will affect their blood sugars. This is especially true in patients who are also receiving premeal insulin.
- Recommendations from manufacturers for converting between NPH and other insulins are given below - see converting between insulin brands and types [11]
- Dosing 70/30 insulin
- Novolin 70/30 and Humulin 70/30 contain 70% NPH and 30% regular insulin. Insulin mixes like 70/30 are more difficult to adjust because the premeal and basal insulin must be given at the same time, and they must always be dosed in a 7:3 ratio. Given these constraints, insulin mixes are not widely used any more.
- In studies with type 2 diabetics, 70/30 has typically been initiated at doses of 0.2 - 0.6 units/kg/day with two-thirds of the daily dose given before breakfast and one-third given before dinner. The daily dose can then be adjusted up or down in increments of 10% depending on blood sugar readings. [34,35]
- SLIDING SCALE INSULIN
- Sliding Scale Insulin involves checking the blood sugar and dosing the insulin (typically rapid or short-acting) based on the blood sugar value
- Doctors use a number of different regimens depending on the patient and their sensitivity to insulin. The example below is a common starting regimen.
Blood sugar (mg/dl) | Insulin dose in units of rapid or short-acting |
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< 150 | 0 |
150 - 200 | 2 |
201 - 250 | 4 |
251 - 300 | 6 |
301 - 350 | 8 |
351 - 400 | 10 |
401 - 450 | 12 |
> 450 | 14 |
- CONVERTING BETWEEN INSULIN BRANDS AND TYPES
- Overview
- Insulin manufacturers make some recommendations when converting between products, but they do not cover every scenario. In addition, there are few trials that have directly compared the glucose-lowering effects of different insulins.
- In general, patients who are at high risk for hypoglycemia should reduce the daily dose of their basal insulin by 20 - 30% when switching between insulin products in order to lower the risk of hypoglycemia. All patients should increase blood sugar monitoring when switching insulins to make sure their response to the new product is the same.
Converting between insulin brands and types |
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Rapid-acting and short-acting insulin
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Lantus, Semglee, Basaglar, Levemir, and Tresiba
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Lantus/Basaglar/Semglee ⇄ NPH
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Lantus/Semglee/Basaglar ⇄ Toujeo
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Levemir and NPH
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Toujeo and NPH
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Toujeo and Levemir
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Tresiba and Toujeo
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Tresiba and NPH
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- CARBOHYDRATE INFORMATION
- Carbohydrates and insulin
- It's important that diabetics who are taking insulin monitor their carbohydrate intake
- See the links below for more information on dieting and carbohydrates
- Carbohydrate counting - review of carbohydrate counting used in dosing premeal insulin
- Calories - review on calculating caloric requirements
- Diabetic diet - diabetic diet recommendations
- Carbohydrates - review of different carbohydrates found in foods
- BIBLIOGRAPHY
- 1 - PMID 18945920
- 2 - PMID 10332663
- 3 - PMID 18364392
- 4 - Braithwaite S: Case Study: Five Steps to Freedom: Dose Titration for Type 2 Diabetes Using Basal-Prandial-Correction Insulin Therapy. Clinical Diabetes Vol 23:1 p39-43 2005
- 5 - Kulkarni K: Carbohydrate Counting: A Practical Meal-Planning Option for People With Diabetes. Clinical Diabetes Vol 23:3 p120-122 2005
- 6 - PMID 16915796
- 7 - PMID 15616254
- 8 - PMID 16921608
- 9 - PMID 10378067
- 10 - PMID 21193625
- 11 - PMID 12734137 - Outpatient Insulin Therapy in Type 1 and Type 2 Diabetes Mellitus, JAMA (2003)
- 12 - PMID 16847295
- 13 - Herbst K, Hirsch I Insulin Strategies for Primary Care Providers. Clinical Diabetes. Vol 20:1 p1-7 2002
- 14 - PMID 17890232 - NEJM DM 2 study
- 15 - Hirsch I et al. A Real-World Approach to Insulin Therapy in Primary Care Practice. Clinical Diabetes. Vol 23:2 p78-86. 2005
- 16 - PMID 18165339
- 17 - PMID 12766131
- 18 - Glucagon PI
- 19 - Lantus PI
- 20 - Levemir PI
- 21 - Toujeo PI
- 22 - Tresiba PI
- 23 - Basaglar PI
- 24 - ADA 2015 Standards of Medical Care in Diabetes, Vol 38, Supplement 1, p. S46
- 25 - PMID 29222370 - ADA 2018 Standards of Medical Care in Diabetes
- 26 - ADA 2019 Standards of Medical Care in Diabetes
- 27 - ADA 2020 Standards of Medical Care in Diabetes
- 28 - PMID 11926785 - Administration of neutral protamine Hagedorn insulin at bedtime versus with dinner in type 1 diabetes mellitus to avoid nocturnal hypoglycemia and improve control. A randomized, controlled trial, Ann Intern Med (2002)
- 29 - PMID 16160867 - Pharmacokinetic and glucodynamic variability: assessment of insulin glargine, NPH insulin and insulin ultralente in healthy volunteers using a euglycaemic clamp technique, Diabetologia (2005)
- 30 - PMID 16732007 - A 26-week, randomized, parallel, treat-to-target trial comparing insulin detemir with NPH insulin as add-on therapy to oral glucose-lowering drugs in insulin-naive people with type 2 diabetes, Diabetes Care (2006)
- 31 - 15298338 - Insulin analogues (insulin detemir and insulin aspart) versus traditional human insulins (NPH insulin and regular human insulin) in basal-bolus therapy for patients with type 1 diabetes, Diabetologia (2004)
- 32 - PMID 15111525 - Insulin detemir offers improved glycemic control compared with NPH insulin in people with type 1 diabetes: a randomized clinical trial, Diabetes Care (2004)
- 33 - PMID 11092282 - Appropriate Insulin Regimens for Type 2 Diabetes, Diabetes Care (2000)
- 34 - PMID 12882841 - Beneficial effects of insulin versus sulphonylurea on insulin secretion and metabolic control in recently diagnosed type 2 diabetic patients, Diabetes Care (2003)
- 35 - PMID 27278922 - Biphasic insulin Aspart 30 vs. NPH plus regular human insulin in type 2 diabetes patients; a cost-effectiveness study, BMC Endocr Disord (2016)