Starting insulin therapy

To the Editor: I would like to add two points to the excellent review on starting insulin in patients with type 2 diabetes by Brateanu et al in the August 2015 issue.¹

First, in my practice, I review glucose patterns and recommend that mealtime insulin be started early after basal insulin is started and not simply wait for the next hemoglobin A_1c result. In my experience, basal insulin is often mindlessly up-titrated, month after month, to fix a high fasting glucose. During the first 2 to 3 weeks of basal insulin titration, I ask patients to test before breakfast, dinner, and bedtime, not just fasting. In so doing, I detect, in most patients, significant bedtime hyperglycemia arising from dinner, usually their largest meal. Then I prescribe dinnertime rapid-acting insulin to correct the bedtime hyperglycemia, and this in turn ameliorates the fasting hyperglycemia. Additional mealtime doses can be added if necessary.²

After all, why should we ignore hyperglycemia occurring at other times and focus only on fasting glucose? With blood glucose pattern review, we can detect those glucose elevations that need to be targeted regardless of when they occur. It has been repeatedly shown that up to almost 50% of patients will fail to reach a hemoglobin A_1c below 7%, even after months of up-titration of basal insulin.^3,4 Most patients will benefit by starting mealtime rapid-acting insulin early on.

And second, when adjusting mealtime rapid-acting injected insulin, there is no need to measure postprandial glucose in most patients with type 2 diabetes. A rigorous clinical trial⁵ showed that testing before the next meal or, in the case of dinner, before bedtime worked as well as or better than postprandial testing. By implementing the above steps, I think we all can provide better, more individualized therapy for our patients.