Bot

Basal insulin-assisted oral therapy; basal-assisted oral therapy; B.O.T.;

Initial describer

In 1946, Hagedorn developed the first long-acting insulin. It was named after him as "Neutral Insulin Hagedorn" = NPH insulin. Today, it is the most commonly used intermediate-acting insulin worldwide (Chandalia 2012).

BOT is a form of therapy in which a long-acting basal insulin is combined with oral antidiabetic drugs (OAD).

In the APOLLO study, first published in the Lancet in 2008, BO therapy was investigated in comparison to therapy with a short-acting prandial insulin analog and found to be significantly more beneficial (Bretzel 2008).

In addition to the BOT, there is also a special form, the so-called BOT plus.

It is a successor scheme of the BOT. It is used when the BOT setting is no longer sufficient. At the same time, it is also a precursor of conventional insulin therapy.

In BOT plus, a short-acting insulin is injected before the problem meal (meal with the highest p.p. blood glucose) in addition to the long-acting insulin. The dose is usually 20% of the dose of the long-acting insulin.

The advantages of BOT- plus are:

• more balanced daily profile
• low rate of hypoglycemia
• suitable for "top-up" with short-acting insulin analogues if it is unclear how much will be eaten.

(Berthold 2021)

Pharmacodynamics (effect)

• Influences fasting and pp glucose levels
• does not lead to weight gain (Koczorek 2016)
• compared with insulin monotherapy, only 1/3 of the insulin dose is required
• using an analog insulin results in the lowest hypoglycemia rate of all insulin regimens
• relatively good control can be achieved with only one dose of insulin
• additional postprandial insulin doses are possible if required (Herold 2020)
• high patient acceptance due to:
• easy feasibility
• hardly any blood glucose monitoring required
• few injections
• low insulin dose (hardly any weight gain)
• because of the low insulin dose the development of insulin resistance is delayed (Berthold 2021)

Indication

• type 2 diabetics who cannot be adequately controlled with oral antidiabetics (Laubner 2007)

Dosage and method of use

In addition to oral antidiabetic agents (with the exception of sulfonylureas), a

• a delay insulin(NPH insulin) is injected s. c. between 22.00 - 0.00 hrs.

or

• a long-term analog insulin is injected s.c. irrespective of the time of day (most common form of application [Herold 2020]).

Initially, a small dose such as 6 IU should be used, which can then be increased in small steps as needed. The target value is a fasting blood glucose (NBZ) between 90 - 110 mg / dl. In this way - in addition to avoiding diabetes-related long-term consequences - optimal nocturnal protection of the beta cells can be achieved (Herold 2020).

Preparations

Analog insulins:

• Insulin Glargine (Lantus ®)
• Insulin Detemir (Levemir ®)
• Insulin Degludec (Tresiba ®)

(Herold 2020)

NPH insulins:

• Berlinsulin H Basal®
• Huminsulin Basal®
• Insulatard Human Novo Nordisk®
• Protaphan HM Novo Nordisk®
• Insuman Basal Aventis®
• Insulin B Brown

(Berger 2013)

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2. Berger M et al (2013) Practice of insulin therapy. Springer Verlag 50
3. Berthold H K (2021) Leitfaden Geriatrie - Medizin: interprofessionelles Arbeiten in Medizin - Pflege - Physiotherapie. Elsevier Urban and Fischer Publishers 579
4. Bretzel R G et al (2008) Once-daily basal insulin glargine versus thrice-daily prandial insulin lispro in people with type 2 diabetes on oral hypoglycaemic agents (APOLLO): an open randomised controlled trial. Lancet 371 (9618) 1073 - 1084
5. German Medical Association (2021) National health care guidelines: type 2 diabetes. AWMF Register No. nvl-001
6. Chandalia H B et al (2012) RSSDI Textbook of Diabetes Mellitus. Jaypee Brothers Medical Publishers New Delhi 10, 539.
7. Diederich S et al (2020) Reference endocrinology and diabetology. Georg Thieme Publishers Stuttgart
8. Herold G et al (2020) Internal medicine. Herold Publishers 735
9. Kasper D L et al (2015) Harrison's Principles of Internal Medicine. Mc Graw Hill Education
10. Koczorek M (2016) BOT - ideal for overweight diabetics. Info Diabetology (10) 65
11. Laubner K et al (2007) Drug therapy of diabetes mellitus. The internist (48) 297 - 310