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What is the correct dose of Insulin to start with?

Q: I am 65 years old suffering from type II diabetes. I have been on medication but am not able to control the sugar levels. I was advised Insulin by two different doctors. There are two opinions on which insulin to start with. The first doctor prescribed Human Mixtard 30-70 (18 units AM and 8 units PM). The second doctor prescribed Lantus Optiset 16 units after dinner in combination with Diamicron MR-60 AM and Tigomet SR1 gm AM and PM before meals. I am inclined to go with Lantus Optiset only because it is once daily and seems to be a smaller dose. Would it limit my options in the future to change to another type of insulin? Is 16 units the right dose to start with?

A:Most patients need insulin at some stage when oral anti-diabetic agent are not effective. Irrespective of the formulation, the insulin units are equivalent. In other words, 18 + 8 units (total 26 units) of Mixtard are not equal to 16 units of Lantus; they are 10 units more. One has to titrate the dose of insulin in individual patients because one does not know the amount of insulin that a particular patient will require. One of the doctors apparently feels that the patient is likely to need 26 units or near about per day while the other feels that 16 units are likely to suffice. Maybe both are wrong and the patient may need 20 units! In transferring patients from oral tablets to insulin there is now adequate scientific evidence that Mixtard is better than Lantus. I doubt that in addition to insulin the patient will also require other oral medicines like gliclazide (Diamicron). Assuming that it is required, one should prescribe a fair-priced brand such as Lycazid (Rs. 31 for 10 tablets against Diamicrons Rs. 59), particularly when it is to be taken for life. The patient may or may not require metformin. Metformin is meant to help the body accept insulin. Some patients require; others do not depending upon the level of their insulin resistance. This can only be determined once the patient is put on insulin.

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