It is critically important that patients get the first shot in the office, guided by a clinician who can teach proper injection technique. This also helps to dispel the apprehension of self-injection.
In addition to being surprised at how easy and painless injection can be, patients have the opportunity to observe the results and gain confidence in insulin’s efficacy. And, in my experience, adherence to an insulin regimen is much greater if the first injection is administered in an office setting.
(Tech-savvy patients may find it helpful to use a smartphone app, such as Glucose Buddy or Dbees.com, to help manage their diabetes. See “The 13 best diabetes iPhone & Android apps of 2013” at http://www.healthline.com/health-slideshow/top-iphone-android-apps-diabetes.)
Establish a titration schedule
It is important, too, to teach the patient how to titrate the insulin dose from the start, rather than waiting until the next visit to address this. Patient titration—facilitated by a clinician-provided titration schedule (available from the AACE and the ADA/EASD3,4)—has been shown to achieve target glucose levels faster than physician titration.17
I usually suggest that patients increase the basal insulin dose by 3 units every 3 days, with an upper limit of 0.5 U/kg/d, until fasting glucose is consistently between 100 and 150 mg/dL. I advise every patient who starts taking insulin to track morning readings and titrate the dose until one of 3 things occurs:
1) the 0.5 U/kg/d limit is reached;
2) the patient has a glucose reading <100 mg/dL; or
3) the patient achieves his or her HbA1c target (<7% for most patients).
In every case, I recommend that the patient call my office for further instruction.
If the patient has any low glucose readings, I reduce the basal insulin by 5 U/kg/d. If he or she is still above goal, I advise the patient to continue titration, but more slowly. If the patient is at goal, I advise continuing at the current dose.
Basal titration vs mealtime coverage. Most people with type 2 diabetes require between 0.2 and 1 U/kg of basal insulin daily. It is currently recommended that when a patient has titrated to a dose of 0.5 U/kg/d, it is time to look at the glucose pattern to determine whether further titrating basal insulin or addressing prandial hyperglycemia should be the next step.4,18 This requires a change in fingerstick pattern.
The patient can stop the first morning glucose check and start checking before meals and 90 to 120 minutes postmeal. This allows for exploration of the mealtime excursion. Generally, a difference of <50 mg/dL is preferred. If the morning glucose level is at target but HbA1c is high, it is likely that postprandial glucose is contributing to this difference. This is particularly true when the HbA1c is between 7% and 8%. If the glucose pattern shows high postmeal glucose readings, it is much safer to address mealtime insulin (not discussed in this article) than to continue to titrate the basal insulin.4,18
Avoid “overbasalization”—ie, titrating basal insulin beyond its normal role to suppress hepatic glucose production and get the fasting glucose to goal. Doing so puts the patient at risk for unexpected hypoglycemia, as the insulin will now try to overcome hyperglycemia with meals, as well. Basal insulins are not designed to meet insulin requirements at meals. If a patient misses a meal yet continues the same dose of basal insulin, the risk of a hypoglycemic episode increases substantially.
In the pipeline. There are a number of new basal insulins in development, including one that has a prolonged duration of action and the potential for every-other-day injections19 and another that uses an attached polyethylene glycol moiety to slow absorption and prolong its effect.20
The nuts and bolts of insulin prescribing
When you prescribe insulin, there are a number of components to consider.
Pen or vial? In addition to deciding whether to order pen or vial, it is essential to consider the volume of insulin needed. Glargine, detemir, and Humulin N are available in 10 mL vials (100 U/mL) and in 3 mL pens (100 U/mL). (Generic NPH is available in vials only.) Most patients prefer insulin pens, which are more convenient and easier to use than a vial and syringe.
The choice also depends on the dosage, however. A patient on a daily dose of 45 units would need one box of 5 pens (each prefilled pen has a 3 mL, or 300 unit, capacity) to have sufficient insulin for a month. Vials would be preferable for an individual who requires a larger single dose than a pen can dispense at one time (80 units of glargine, 60 units of detemir).