We're getting questions about when and how to use insulin.
Type 2 diabetes patients often consider it a last resort...due to concerns about injections, weight gain, and hypoglycemia.
Consider these tips to make the transition to insulin easier.
When should insulin be started? Suggest adding insulin if A1C is > 1.5% above goal...especially if patients are already on 3 diabetes meds. Other meds aren't likely to be enough to reach glycemic goals.
Suggest starting with 10 units once daily of NPH or a long-acting analog (Lantus, Levemir) in most patients. Advise titrating by 1 to 2 units, or 5% to 10%, once or twice weekly...to meet glucose goals.
How should other diabetes meds be adjusted when insulin is added?
Recommend continuing metformin...to reduce weight gain.
Explain that it's also okay to continue incretin therapies (Byetta, Januvia, etc)...and SGLT2 inhibitors (Invokana, Farxiga).
Caution about using insulin with a glitazone (Actos, etc)...due to possible weight gain, edema, and heart failure.
Recommend stopping sulfonylureas if mealtime insulin is added...there's little added benefit and possibly more hypoglycemia.
When should mealtime insulin be added? Suggest adding mealtime "bolus" insulin if patients have a good fasting glucose but can't reach their A1C goal...or they're using > 0.5 units/kg/day of basal insulin.
Suggest adding regular or rapid-acting (Humalog, etc) insulin before the largest meal...then adding a dose before other meals if needed.
Suggest "premixed" insulin (70/30, etc) for patients who need a simpler approach...but keep in mind doses are harder to adjust.
How often should blood glucose be monitored? There's no hard and fast rule. But suggest this rule of thumb...check glucose the same number of times/day as the number of insulin injections required.
Less frequent monitoring is reasonable for stable patients. But tell patients to monitor more frequently when insulin is started...doses are adjusted...or if they're ill, have hypoglycemia, etc.
To hear a great discussion with a diabetes expert about when and how to use insulin, go to our PL Detail-Document and listen to PL VOICES.
See our PL Algorithm, Initiation and Adjustment of Insulin Regimens for Type 2 Diabetes...PL Chart, How to Switch Insulin Products...and a link to a good guide for dosing mealtime insulin.
Diabetes Care 2012;35:1364.