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Titrating Insulin to Glycemic Target

Titrating Insulin to Glycemic Target. Judy Bowen, MD CIM Rotation September, 2006. Case 1.

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Titrating Insulin to Glycemic Target

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  1. Titrating Insulin to Glycemic Target Judy Bowen, MD CIM Rotation September, 2006

  2. Case 1 • Mrs. G, 46 y.o. was diagnosed with Type 2 DM diagnosed 5 years ago (initially treated with diet and exercise, then glipizide XL 5 mg BID and metformin 1,000 mg BID) has these Hgb A1c values q 3 months over the past year: • 5.8% • 6.3% • 7.4% • 7.8%

  3. Case 1, continued • Her BMI is 33, BP is 126/72, micro-albumin is 9 on lisinopril 10 mg, LDL is 89 on Lipitor 10 mg. She takes 81 mg ASA daily. Her eye exam is up-to-date and normal. Monofilament exam is normal. Your exam is normal except for her obesity. • Her fasting a.m. CBGs are 140-180 • What do you recommend?

  4. 200 100 0 6 a.m. 6 a.m. noon 6 p.m 12 a.m. Schematic of 24-hour glucose profile Riddle M. AJM, 2004; 116:3S-9S

  5. Initiating basal insulin therapy • Add basal insulin therapy • Start with 10 units insulin in most patients • Use either NPH or glargine (both work) • NPH q HS, glargine either q HS or q AM • Glargine was associated with less nocturnal hypoglycemia (Riddle et al, Diabetes Care, 2003; 26:3080-3086) • Continue with oral agents • Consider adverse effects

  6. Treat-To-Target • Goal: near normal fasting CBGs (~100 mg/dl) • Adjust dose weekly • based on average of two previous fasting CGBs • Titration: • If CBG >/= 180, increase insulin by 8 units • If CBG 140-180, increase insulin by 6 units • If CBG 120-140, increase insulin by 4 units • If CBG 100-120, increase insulin by 2 units • No increase if any hypoglycemia (CBG < 72) with or without symptoms

  7. Relationship of A1c to CBG 4% 65 5% 100 6% 135 7% 170 8% 205 9% 240 10% 275

  8. Relationship of A1c to CBG 4% 65 5% 100 6% 135 7% 170 8% 205 9% 240 10% 275

  9. Case 1, continued • Mrs. G agrees to start bedtime glargine 10 units, and feels confident she can titrate using the “Treat to Target” instructions with RN follow up. Over the next 3 weeks, she achieves fasting CBGs in the 100-120 range with 20 units glargine at bedtime, and no symptoms of hypoglycemia. Her follow up Hgb A1c 3 months after starting insulin is 6.5%

  10. Case 2 • Mr. M, a 65 year-old patient with Type 2 DM for 10 years is on metformin 1,000 mg BID and insulin: • NPH q a.m. 30 units + Regular 10 units • NPH q p.m. (supper) 25 units + Regular 15 units • His fasting CBGs are in the 120’s but his Hgb A1c is now 8.0%. He wants better control. • What do you recommend?

  11. Switching to Basal/Prandial Insulin • To switch to glargine • Add up his current total insulin dose (80 units) • Reduce by 20% (64 units) • Give half as glargine (32 units) • Titrate using fasting CBGs and ‘treat-to-target’ • To add lispro/aspart • (Onset is 5-15 min, peak is 30-90 min, duration is 3.5 –5 hours) • Send to Diabetes Education to learn carb counting • Give remaining “half” of total dose based on meals: • 10 + 10 + 12 depending on carb load

  12. Pearls • Insulin therapy is associated with weight gain • Glargine doesn’t last 24 hours in every patient (nor is NPH predictable) • We usually wait too long to start insulin in Type 2 patients • Early insulin therapy may be associated with better daytime prandial secretion from native pancreas • Finger sticks are more painful than insulin shots

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