Individualizing Insulin Therapy

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Medical Education Library

Individualizing Insulin Therapy

May 2012 · Vol. 61, No. 05 Suppl: S13-S27

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References

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Clinical Impression

After taking his history, performing a physical examination, and reviewing his laboratory data, MB’s physician confirms a diagnosis of DM (TABLE 11). While it is likely that MB has T2DM, his physician wants to rule out type 1 DM and latent autoimmune diabetes of the adult (LADA), so he orders tests for antibodies (GAD, IA-2, ICA). The antibody testing is negative, making T2DM the most likely diagnosis.

TABLE 11

Case study 3: Chart notes

Physical examination	Laboratory tests	Lifestyle habits	Current therapy
Physical examination	Laboratory tests	Lifestyle habits	Glucose-lowering	Other
BP: 142/88 mm Hg Weight: 176 lb (79.2 kg) BMI: 27 kg/m² Eyes: no retinopathy Neurology: intact Skin: intact	SCr: 1.4 mg/dL Microalbumin:creatinine ratio: 140 mg/g creatinine Ketonuria: 1+ A1C: 10.8% Cholesterol: Total: 210 mg/dL LDL: 146 mg/dL HDL: 30 mg/dL	Exercise: light yard work, no regular exercise Nutrition: 3 meals/d, eats most meals in a restaurant (lunch M-F; dinner 3-4 nights/wk)	None	None
BMI, body mass index; BP, blood pressure; HDL, high-density lipoprotein; LDL, low-density lipoprotein; SCr, serum creatinine.

Treatment Plan

Initiate basal-bolus therapy with fixed bolus doses of rapid-acting insulin at each meal (prandial insulin).
Ask MB to monitor blood glucose before meals and at bedtime.
Provide MB with a supplemental scale to correct hyperglycemia before meals.
Stress the importance of exercise and proper nutrition; gain agreement for short-term goals for exercise and nutrition; refer for diabetes and nutrition education if available.
Discuss the importance of smoking cessation; develop a plan.
Consider metformin and other non-insulin therapies when A1C is under control.

Barriers

MB is surprised that he has T2DM and is clearly anxious at receiving the diagnosis. He expresses concern about starting insulin because his uncle died within a year of starting insulin. MB also recalls that his uncle was always giving himself shots and monitoring his blood glucose level. He wants to know whether there is a simpler treatment option if he agrees to start insulin treatment. He also wants to know whether he will have to remain on insulin for the rest of his life. The following are possible responses his physician could use to address these concerns.

Patient concern: Fear of death

Physician responses:

Uncontrolled high blood sugars over a long period of time can cause serious complications, such as kidney and heart disease that can result in death. That is why it is important that we work together to gain control of your blood sugar levels over the next few months and then modify your treatment as needed to maintain control.
Unfortunately for many patients in the past, treatment with insulin was not used until it was too late and people already had serious complications from DM. This is likely the case for your uncle.

Patient concern: Treatment complexity

Physician responses:

Right now we have to control your blood glucose rapidly so your pancreas can regain some function and your body can better respond to insulin.
I will also provide you with step-by-step written instructions you can follow that describe how to start insulin and how to monitor your blood glucose.
We will communicate as often as you need to adjust your insulin doses over the next few weeks; when you feel comfortable, I can even show you how to adjust your insulin dose before a meal to correct a high blood sugar.
We can try this treatment for 3 months and then reevaluate your response, how you feel, and whether you want to continue to modify your treatment plan to keep your blood sugars controlled.

Patient concern: Lack of understanding that T2DM is a serious disease

Physician responses:

Please understand that T2DM is a serious disease that increases your risk for heart disease, stroke, blindness, and other diseases. Unfortunately, since diabetes does not cause bad symptoms until it is actually too late, many patients do not make the effort to properly control their diabetes. By working together, we can reduce the risk for these complications and do some screening tests to detect any complications before they become irreversible.

Dosing

There are several approaches to determining the initial doses of basal and prandial (bolus) insulin. One approach is to estimate the total daily dose (TDD) of insulin by multiplying the patient’s weight in kilograms by 0.5 U/kg/d.⁴⁴ Half of the TDD is given as basal insulin replacement; the other half is divided into 3 fixed preprandial doses of rapid-acting insulin. When the patient is ready to take on more complex management, the supplemental dose for bolus insulin can be calculated using a correction factor. If the bolus insulin is a rapid-acting insulin analog, 1800 is divided by the TDD of insulin; 1500 is used for a short-acting human insulin. This correction factor is an estimate of the fall in blood glucose per unit of bolus insulin. In our patient, the TDD would be: 80 kg x 0.5 U/kg/d or 40 U/d of insulin. Thus, 1 U of insulin should lower the blood glucose by about 45 mg/dL (1800/40 U = 45 mg/dL). For every 45 mg/dL above the pre-meal target, the patient would add 1 U of rapid-acting insulin to correct the hyperglycemia over the next 4 to 5 hours. The basal and prandial insulin doses would be titrated on a periodic basis (perhaps every 1 to 2 weeks) until the daytime levels of blood glucose are on target. The fasting (pre-breakfast) blood glucose would be used to adjust the basal insulin dose, while the pre-lunch, pre-dinner, and bedtime blood glucose results would be used to adjust the pre-breakfast, pre-lunch, and pre-dinner prandial (rapid-acting) insulin doses, respectively.