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Basal Bolus: The Strategy for Managing All Diabetes

Learn about the comprehensive basal-bolus approach to diabetes care, utilizing a mix of insulin and mealtime management strategies for optimal glycemic control. Understand the key steps, limitations, and benefits associated with this treatment method.

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Basal Bolus: The Strategy for Managing All Diabetes

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  1. Basal Bolus: The Strategy for Managing All Diabetes Fall, 2003 Paul Davidson, MD, FACE Atlanta Diabetes Associates Atlanta, Georgia

  2. ACE / AACE Targets for Glycemic Control HbA1c < 6.5 % Fasting/preprandial glucose < 110 mg/dL Postprandial glucose < 140 mg/dL ACE / AACE Consensus Conference, Washington DC August 2001

  3. Step Therapy • Diet • Exercise • Sulfonylurea or Metformin • Add Alternate Agent • Add hs NPH • Switch to Mixed Insulin bid • Switch to Multiple Dose Insulin Utilitarian, Common Sense, Recommended Prone to Failure from Misscheduling and Mismanagement

  4. Stumble Therapy • YAG Diet • Golf Cart Exercise • Sample of the Week Medication • Interupted, • Not Combined • Poor Understanding of Goals • Poor Monitoring HbA1c >8% (If Seen) Informed Patient Refers Self Elsewhere

  5. PETS TherapyStep--Spelled BackwardsAll at once, nothing first, Just like bubbles, when they burst. • Start with Fast to Glucose <126 mg/dL • Glargine, Wt x 0.1 units qd • Feed PSMF Diet • Add SU, MF, TZD, Repaglanide + prn Lispro for BG <150 • “Normal” BG from Day 1 • Monitor BG qid • See Patient Monthly, HFP • HbA1c Bimonthly GI Problems: Cut MF Hypoglycemia: Cut SU Hypoglycemia Again: Cut Repaglinide Allow 2 Month to See TZD Effect

  6. All persons need both basal and mealtime insulin to control glucose MIMICKING NATURE WITH INSULIN THERAPY (endogenous or exogenous) 6-19

  7. Limitations of NPH, Lente,and Ultralente • Do not mimic basal insulin profile • Variable absorption • Pronounced peaks • Less than 24-hour duration of action • Cause unpredictable hypoglycemia • Major factor limiting insulin adjustments • More weight gain

  8. Insulin GlargineA New Long-Acting Insulin Analog • Modifications to human insulin chain • Substitution of glycine at position A21 • Addition of 2 arginines at position B30 • Gradual release from injection site • Peakless, long-lasting insulin profile Gly Substitution 1 Asp 5 10 15 20 10 1 5 15 20 25 30 Extension Arg Arg

  9. Ultralente NPH Glucose Infusion Rate SC insulin n = 20 T1DM Mean ± SEM 24 20 16 12 8 4 0 4.0 3.0 2.0 1.0 0 µmol/kg/min mg/kg/min CSII Glargine 0 4 8 12 16 20 24 Time (hours) Lepore M, et al. Diabetes. 2000;49:2142–2148.

  10. Glargine vs NPH Insulin in Type 1 DiabetesAction Profiles by Glucose Clamp 6 NPH 5 Glargine 4 Glucose utilization rate (mg/kg/h) 3 2 1 0 0 10 20 30 Time (h) after SC injection End of observation period Lepore, et al. Diabetes. 1999;48(suppl 1):A97.

  11. Treat to Target Study: NPH vs Glargine in DM2 patients on OHA • Add 10 units Basal insulin at bedtime (NPH or Glargine) • Continue current oral agents • Titrate insulin weekly to fasting BG < 100 mg/dL • Based on average FBG of 6th and 7th day - if 100-120 mg/dL, increase 2 units - if 120-140 mg/dL, increase 4 units - if 140-160 mg/dL, increase 6 units - if 160-180 mg/dL, increase 8 units

  12. The Treat-to-Target Trial Randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients Riddle, Rosenstock, Gerich DIABETES CARE 2003 26;3080-2083

  13. The Treat-to-Target Trial Randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients Riddle, Rosenstock, Gerich DIABETES CARE 2003 26;3080-2083 Percentage of Patients in Target (A1C < 7%)

  14. GEMS--Glargine Evening Mealtime Secretagogue • Basal Dosing • (Weight in #`s x 0.1) • Glargine hs • Prior to Meals • Short Acting Secretagogue • Rapaglinide 2 mg • Nateglinide 120 mg • Glimepiride 2 mg

  15. The Treat-to-Target Trial Randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients Riddle, Rosenstock, Gerich DIABETES CARE 2003 26;3080-2083

  16. The Treat-to-Target Trial Randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients Riddle, Rosenstock, Gerich DIABETES CARE 2003 26;3080-2083

  17. The Treat-to-Target Trial . Bedtime Glargine vs NPHWith Mealtime Regular 48 4 Glargine NPH 36 3 ** 24 2 Patients (%) Weight (kg) 12 1 * 0 0 Nocturnal Weight Gain Hypoglycemia *P < .0007**P < .02 (compared to NPH) Rosenstock, et al. Diabetes. 1999;48(suppl 1):A100. 6-52

  18. Treatment to Target Study: NPH vs Glargine in DM2 patients on OHA • 57% had HbA1c <7% • Nocturnal Hypoglycemia reduced by 42% in the Glargine group • 33% had HbA1c <7% without any nighttime hypoglycemia in glargine group • Results significantly better than with NPH

  19. Establishing Basal Requirement for Glargine Body Weight in pounds x 0.1 Average am BG x 2 after five days Add to Glargine (BG-100)/10 Repeat weekly Example: 200# 20 units glargine q hs AM BG averages 200 on 6th and 7th day Add (BG-100)10 to glargine, i.e. increase to 20 to 30 units q hs 2nd week--average 130 increase glargine from 30 to 33

  20. Overall Summary: Glargine • Insulin glargine has the following clinical benefits • Once-daily dosing because of its prolonged duration of action and smooth, peakless time-action profile • Comparable or better glycemic control (FBG) • Lower risk of nocturnal hypoglycemic events • Safety profile similar to that of human insulin

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