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Insulin Initiation and Titration for Family Physicians: Case Study #1: William

Insulin Initiation and Titration for Family Physicians: Case Study #1: William. Alice Y.Y. Cheng, MD FRCPC Peter Lin, MD CCFP. Case Study #1: William. Patient history and presentation 59-year-old male stockbroker Type 2 diabetes x 8 years Weight = 90 kg A1C = 7.9%

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Insulin Initiation and Titration for Family Physicians: Case Study #1: William

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  1. Insulin Initiation and Titration for Family Physicians:Case Study #1: William Alice Y.Y. Cheng, MD FRCPC Peter Lin, MD CCFP

  2. Case Study #1: William Patient history and presentation • 59-year-old male stockbroker • Type 2 diabetes x 8 years • Weight = 90 kg • A1C = 7.9% • He is on metformin, an insulin secretagogue and a TZD – he is at the maximum dose of all three oral agents • You have been proposing that he start insulin during the past few visits in the last year, and he is now becoming more agreeable to the idea

  3. William’s SMBG Logbook

  4. Case Study #1: William (cont’d) Case review • William has suboptimal glycemic control, according to the guidelines • He is maxed out on oral agents • He continues to have high BG levels, particularly in the morning • What insulin regimen would you prescribe?

  5. Type 2 Diabetes: Insulin Categories • Basal • Basal plus bolus • Pre-mixed twice daily

  6. Case Study #1: William (cont’d) • The easiest insulin to start would be basal insulin at bedtime, which has the advantage of a single injection – so it is easy to remember • At this point, the TZD should be discontinued (to minimize risk of edema); however, the metforminand insulin secretagogue can both be continued

  7. CHOOSE AN INSULIN CATEGORY CHOOSE A BRAND DOSING SEE REVERSE FOR TIPS

  8. Basal Insulin Dosing and Titration 10 1 1 4.0–7.0

  9. Case Study #1: WilliamThree Years Later • William had achieved an A1C <7.0% over the past few years with basal insulin plus metformin and an insulin secretagogue • However, in the past 6 months his A1C has started to climb; it is now 7.5% • He is currently on 50 units of basal insulin daily

  10. William’s SMBG Logbook

  11. CHOOSE AN INSULIN CATEGORY DOSING SEE REVERSE FOR TIPS CHOOSE A BRAND

  12. Bolus Insulin Dosing and Titration 5 0 0

  13. Bolus Insulin Dosing and Titration (cont’d) 10 10 10

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