If the patient presents and is considered stable enough for outpatient care but meets indications noted above for starting insulin, there are several acceptable ways of initiating insulin.
• One example is to calculate the total daily dose of insulin at 0.3 units/kg and start bedtime glargine at 50% of the total dose, splitting the remaining 50% with short-acting insulin before meals.
• Another example is to start an oral agent while simultaneously initiating glargine at a dose of approximately 0.1 units/kg.
• A third example is to calculate the total daily dose of insulin at 0.3 U/kg and use pre-mixed insulin with 2/3 the dose in the a.m. and 1/3 in the p.m.
At presentation, all patients should be instructed on blood glucose monitoring; hypoglycemia recognition and treatment; and how/when to contact health care support. Patients should check blood sugars frequently when insulin is initiated. Patients should receive daily phone or visit contact for at least 3 days and have 24-hour emergency phone support if needed.
Patients should be referred for nutrition and diabetes education and be seen in a timely way after diagnosis, e.g. within 1-7 days.
Insulin therapy may not be permanent, particularly if oral agents are added or if, at presentation, the patient is in metabolic stress (e.g. infections, acute metabolic complications, recent surgery, etc.) As the metabolic stress resolves, the insulin dose requirements may rapidly fall.
For the occasional unstable patient with type 2 diabetes, maximal doses of oral hypoglycemic agents may afford an approach to the patient who is psychologically resistant to or refuses insulin initiation (Clements, 1987; Peters, 1996).
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