Patient’s concern: Fear of needles
Physician’s responses:
- Insulin can be injected using a pen device with short, ultrathin needles that makes most of the injections painless. I would like you to see how simple and painless the injection can be by using this sample pen here in the office.
- Many patients are concerned about giving themselves an injection at first, but they quickly become comfortable doing so.
Dosing
Treatment with basal insulin can be initiated using one of several approaches. Using the treat-to-target approach, basal insulin 10 U once daily is initiated.35 The starting dose should be reduced to 6 U if the initial pre-breakfast or pre-dinner blood glucose is < 126 mg/dL or the patient’s body mass index (BMI) is < 26 kg/m2.36 Alternatively, the ADA/EASD recommends starting with 0.2 U/kg, which may be more practical in very overweight or obese patients.2 Titration of the basal insulin dose can be accomplished using one of the following physician-directed or patient-driven treat-to-target titration algorithms (TABLE 6).35,37,38 The insulin dose should be titrated based on the pre-breakfast fasting blood glucose level.
TABLE 6
Physician-directed or patient-driven treat-to-target titration algorithms
| Riddle et al35 | Davies et al37 | Meneghini et al38 | ||||
|---|---|---|---|---|---|---|
| Start with 10 U/d bedtime basal insulin and adjust weekly | Start with 10* U/d bedtime basal insulin and adjust weekly (physician-directed) Or Start with a dose numerically equivalent to the highest FPG (in millimoles/L)† over the previous 7 days and adjust every 3 days (patient-managed) | Start with basal insulin once daily and adjust every 3 days | ||||
| Mean of self-monitored FPG values from preceding 2 days | Change in insulin dose (U/d)# | Mean of self-monitored FPG values from preceding 3 days | Change in insulin dose (U/d) (physician-directed) | Change in insulin dose (U/d) (patient-managed) | Mean of self-monitored FPG values from preceding 3 days | Change in insulin dose (U/d) |
| ≥180 mg/dL 140-180 mg/dL 120-140 mg/dL 100-120 mg/dL | +8 +6 +4 +2 | ≥180 mg/dL (≥10 mmol/L) 140-179 mg/dL (7.8-9.9 mmol/L) 120-139 mg/dL (6.7 – 7.7 mmol/L) 100-119 mg/dL (5.5-6.6 mmol/L) | +6 to +8 +4 +2 0 to +2 | +2 +2 +2 0 to +2 | >110 mg/dL 80-110 mg/dL <80 mg/dL | +3 0 -3 |
| FPG, fasting plasma glucose. *In insulin-naive patients. †For example, if the highest FPG over the previous 7 days was 7 mmol/L, start with 7 U.#Small insulin dose decreases (2-4 U/d per adjustment) were allowed if severe hypoglycemia (requiring assistance) or plasma-referenced glucose < 56 mg/dL was documented in the preceding week. Reproduced with permission. Meneghini LF, et al. J Fam Pract. 2011;60(9 Suppl 1):S21-S28. Quadrant HealthCom Inc. Copyright 2011. | ||||||
Follow-Up Visit
RF begins basal insulin 10 U in the evening and is given simple instructions for insulin dose titration based on fasting plasma glucose results. At her follow-up visit, RF reports that she has increased her basal insulin to 18 U administered once daily. Review of her SMBG results show that her blood glucose levels throughout the day have improved, but are still not at goal. RF’s physician commends her on the progress she has made. RF and her physician agree that she should continue to increase her basal insulin dose. Eight months after beginning basal insulin, RF is administering 28 U (0.35 U/kg) of basal insulin in the evening. Review of her SMBG results over the previous 2 weeks show that her blood glucose rises during the day and is highest after dinner; her current A1C is 7.2%.
Treatment Plan
- Discuss dietary and lifestyle complements to insulin therapy such as:
- Use SMBG to identify foods that raise her blood glucose.
CASE STUDY 2
LW is a 64-year-old male with longstanding hypertension diagnosed with T2DM 8 years ago for which he was treated initially with lifestyle management and metformin. He has since been treated with other oral agents as add-on therapy; glipizide was discontinued due to hypoglycemia when he skips meals (usually lunch); pioglitazone was discontinued after the patient expressed concerns about the risk for bladder cancer he heard on television. He has mild retinopathy and mild loss of vibration sensation in the feet; there is no evidence of cardiovascular disease. He was diagnosed with osteoarthritis 3 years ago.
Clinical Impression
After taking his history, performing a physical examination, and reviewing his laboratory and SMBG data, his physician concludes that his treatment plan needs to be changed (FIGURE 3, TABLE 7, TABLE 8).
TABLE 7
Case study 2: Chart notes
| Physical examination | Laboratory tests | Lifestyle habits | Current therapy | |
|---|---|---|---|---|
| Glucose-lowering | Other | |||
| BP: 124/76 mm Hg Weight: 204 lb (92.7 kg) BMI: 31 kg/m2 Eyes: mild retinopathy Neurology: occasional tingling on bottom of right foot Skin: intact | SCr: 1.9 mg/dL eGFR: 51 mL/min Albuminuria: negative A1C: 8.1% Cholesterol: Total: 218 mg/dL LDL: 118 mg/dL HDL: 55 mg/dL Triglyceride: 204 mg/dL | Exercise: takes dog on occasional walk but otherwise sedentary Nutrition: eats 4 meals/d | Metformin 1000 mg BID Acarbose 50 mg TID Sitagliptin 100 mg QD | Lisinopril/HCTZ 20/25 mg QD Amlodipine 10 mg QD Acetaminophen extended-release 650 mg TID ASA 80 mg QD |
| ASA, acetylsalicylic acid; BMI, body mass index; BP, blood pressure; eGFR, estimated glomerular filtration rate; HCTZ, hydrochlorothiazide; HDL, high-density lipoprotein; LDL, low-density lipoprotein; SCr, serum creatinine. | ||||