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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 A1c 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 A1c 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.
- Brateanu A, Russo-Alvarez G, Nielsen C. Starting insulin in patients with type 2 diabetes: an individualized approach. Cleve Clin J Med 2015; 82:513–519.
- Rodbard HW, Visco VE, Andersen H, Hiort LC, Shu DHW. Treatment intensification with stepwise addition of prandial insulin aspart boluses compared with full basal-bolus therapy (FullSTEP Study): a randomized, treat-to-target clinical trial. Lancet Diabetes Endocrinol 2014; 2:30–37.
- Riddle MC, Rosenstock J, Gerich J; Insulin Glargine 4002 Study Investigators. The Treat-to-Target Trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care 2003; 26:3080–3086.
- Rosenstock J, Davies M, Home PD, Larsen J, Koenen C, Schernthaner G. A randomized 52-week treat-to-target trial comparing insulin detemir with insulin glargine when administered as add-on to glucose-lowering drugs in insulin-naive people with type 2 diabetes. Diabetologia 2008; 51:408–416.
- Meneghini L, Mersebach H, Kumar S, Svendsen AL, Hermansen K. Comparison of 2 intensification regimens with rapid-acting insulin aspart in type 2 diabetes mellitus inadequately controlled by once-daily insulin detemir and oral antidiabetes drugs: the Step-Wise Randomized Study. Endocr Pract 2011; 17:727–736.
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 A1c 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 A1c 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.
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 A1c 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 A1c 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.
- Brateanu A, Russo-Alvarez G, Nielsen C. Starting insulin in patients with type 2 diabetes: an individualized approach. Cleve Clin J Med 2015; 82:513–519.
- Rodbard HW, Visco VE, Andersen H, Hiort LC, Shu DHW. Treatment intensification with stepwise addition of prandial insulin aspart boluses compared with full basal-bolus therapy (FullSTEP Study): a randomized, treat-to-target clinical trial. Lancet Diabetes Endocrinol 2014; 2:30–37.
- Riddle MC, Rosenstock J, Gerich J; Insulin Glargine 4002 Study Investigators. The Treat-to-Target Trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care 2003; 26:3080–3086.
- Rosenstock J, Davies M, Home PD, Larsen J, Koenen C, Schernthaner G. A randomized 52-week treat-to-target trial comparing insulin detemir with insulin glargine when administered as add-on to glucose-lowering drugs in insulin-naive people with type 2 diabetes. Diabetologia 2008; 51:408–416.
- Meneghini L, Mersebach H, Kumar S, Svendsen AL, Hermansen K. Comparison of 2 intensification regimens with rapid-acting insulin aspart in type 2 diabetes mellitus inadequately controlled by once-daily insulin detemir and oral antidiabetes drugs: the Step-Wise Randomized Study. Endocr Pract 2011; 17:727–736.
- Brateanu A, Russo-Alvarez G, Nielsen C. Starting insulin in patients with type 2 diabetes: an individualized approach. Cleve Clin J Med 2015; 82:513–519.
- Rodbard HW, Visco VE, Andersen H, Hiort LC, Shu DHW. Treatment intensification with stepwise addition of prandial insulin aspart boluses compared with full basal-bolus therapy (FullSTEP Study): a randomized, treat-to-target clinical trial. Lancet Diabetes Endocrinol 2014; 2:30–37.
- Riddle MC, Rosenstock J, Gerich J; Insulin Glargine 4002 Study Investigators. The Treat-to-Target Trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care 2003; 26:3080–3086.
- Rosenstock J, Davies M, Home PD, Larsen J, Koenen C, Schernthaner G. A randomized 52-week treat-to-target trial comparing insulin detemir with insulin glargine when administered as add-on to glucose-lowering drugs in insulin-naive people with type 2 diabetes. Diabetologia 2008; 51:408–416.
- Meneghini L, Mersebach H, Kumar S, Svendsen AL, Hermansen K. Comparison of 2 intensification regimens with rapid-acting insulin aspart in type 2 diabetes mellitus inadequately controlled by once-daily insulin detemir and oral antidiabetes drugs: the Step-Wise Randomized Study. Endocr Pract 2011; 17:727–736.