Individualizing Insulin Therapy

Patient concern: Hypoglycemia

Physician responses:

• Hypoglycemia remains a concern, and is more frequently seen with premix than with basal insulin; however, as long as you remain consistent with your meal and activity schedule, the risk for bad hypoglycemia is low.
• We should review your written action plan so that you are sure what signs or symptoms of a low blood sugar might occur and what you should do to treat them.

Patient concern: Weight gain

Physician responses:

• It is possible that you might gain a few additional pounds. You can avoid this by increasing your physical activity, and importantly, continue healthy eating. We should schedule a time for you to meet again with a dietician who can discuss options that might work for you.

Dosing

There are different approaches for converting from basal insulin to twice-daily premix insulin. One approach is to determine the TDD of basal insulin, and give half at breakfast and the other half at dinner as premix insulin.³⁹ Since KW is taking 60 U of basal in the evening, she should take 30 U at breakfast and 30 U at dinner. Dose titration is according to the 1-2-3 Study algorithm shown in case study 2.

Another approach is to administer biphasic insulin aspart 70/30 0.2 U/kg before breakfast and 0.1 U/kg before dinner as was done in the PREFER study (TABLE 13).⁴⁵ Subsequent dosing can be determined based on the PREFER algorithm below. Of note is that at study end, premix insulin doses were equally divided between breakfast and dinner. Breakfast and dinner doses are titrated based on blood glucose levels before dinner and breakfast, respectively. In the PREFER study, the use of premix insulin provided comparable A1C reduction as basal-bolus therapy (basal once daily + bolus TID) in insulin-naïve patients. However, patients previously treated with basal insulin such as KW experienced greater A1C reductions with basal-bolus insulin than with premix insulin.