Insulin Series. Give your views on all three questions.

Q.1) Dose to start basal insulin like degludec and glargine ? A) I usually follow 0.1 units/kgbw at 10 pm. To simplify, I start with 10 units at 10pm in almost all patients. Recently, I got a patient of weight 140kgs, I started her with 14 units at bedtime. Q.2 ) Which oral anti-diabetic drugs to start along with Basal Insulins? A) Metformin, Linagliptin are good drug to add on. I dont remember exactly, I have read somewhere that when starting insulins Linagliptin has to be started at 2.5mg only, not 5mg? Kindly correct me on this what exactly it is regarding Linagliptin. Also tell me about Glimipiride and Gliclazide to give along with Basal Insulins?? Q.3) How to titrate dose of Basal Insulins? Dose increment by how many units in how many days? A) Kindly give your views regarding titration. In my opinion, and what I follow is 2 to 3 units increment every 4 days.

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God is one! Though there are multiple paths to reach him! One can not restrict oneself into fixed ideas in order to reach the almighty. But one has to be flexible and check all options and alternative and choose the best path that suits one self!! Treatment of diabetes is also on similar lines, can not be fixed in any rules. One has to be flexible and find the best suitable options out of multiple options available, what is best for one need not be the best path for others!!! I follow following rough principles 1) For newly diagnosed, young or early diabetic I start with low dose such as 6 or 8 units Glargine insulin per day 2) For old diabetic, those on multiple oral hypoglycemic, those who are having Diabetes for many years like 15 - 20 years - I start on higher dose of Glargine along with oral hypoglycemic agent 3) I generally add full dose of DPP4 inhibitors such as Sitagliptin/ Vildagliptin / Linagliptin - I do not use half dose because they by definition correct postprandial blood sugar, they have least potential for causing hypoglycemia 4) I generally use Metformin as base for all diabetic patients. Which means all other medicines are added to Metformin, and Metformin is always present in prescription as base drug - many reasons for doing so - it has least potential to cause hypoglycemia and it increases glucose sensitivity 5) I avoid sulphonylurea because they have highest potential to cause hypoglycemia. If sulphonylurea is avoided one can sleep peacefully at night, sulphonylurea can cause severe and life threatening hypoglycemia. I use sulphonylurea only as last option when all other options are exhausted 6) SGLT2 inhibitor is wonderful new addition. Many of my patients, extremely difficult to control Diabetes have become well controlled diabetes after starting SGLT2 inhibitor, remember it is additional to Metformin. Metformin is base on which all other are added. 7) And incremental dose every 4 days, there are instances when I have increased dose of Glargine insulin by 10 units every day and reached target of 40 - 50 units per day within few days, it depends on how severe is Insulin resistance, how high is blood sugar and how much critical ill the patient is... some times it's very important to bring down blood sugar, and some times patients life depends on bringing blood sugar under control - at such times I have not kept any limitations of how much increase in dose of Glargine insulin, as I have described the increment can be large and rapid

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Degludec is superior to glargine as basal insulin 10 unit at same time Linagliptin 5 mg od Metformin good add glycizide Increase of2 unit48 to72 hr

Its correct