A Safe and Simple Algorithm for Adding and Adjusting Mealtime Insulin to Basal-Only Therapy
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Abstract:
Numerous studies have shown that early initiation of intensive treatment significantly improves β-cell function and long-term glycemic control in individuals with type 2 diabetes (1–4). However, despite national and international clinical guidelines that recommend escalation of therapy if individualized glycemic targets are not met within 3–6 months (5), transition to basal-only insulin therapy and then to intensive insulin management is often delayed despite significant and sustained hyperglycemia. As reported by Khunti et al. (6), the time to treatment intensification from noninsulin medications to basal-only insulin therapy is often delayed by up to 7 years in adults with type 2 diabetes with A1C levels ≥8.0%, and the average time to transition of patients from basal-only insulin to basal-plus-mealtime insulin is 3.2 years.Keywords:
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AbstractAbstractObjective: This report illustrates the treatment progression of a patient with rapidly decompensating type 2 diabetes. Methods: The patient had to transition to insulin therapy within 2 years of her initial diagnosis, following only a brief period of glycemic control with diet management, weight loss, and oral agents. This relatively rapid progression to insulin requirement is occasionally seen in adults with typical type 2 diabetes that may classify as a number of different subtypes of diabetes. Results: The case presented demonstrates how a simple stepwise approach to dose titration with basal insulin helped a patient with severe depletion of endogenous insulin achieve initial glycemic control, and how the addition of prandial insulin helped control her mealtime glycemic excursions. Conclusion: The use of basal-prandial insulin therapy is an effective option for patients with rapidly decompensating type 2 diabetes to achieve their glycemic goals without delays and to minimize associated morbidities.Keywords: type 2 diabetesbasal-prandial insulinβ-cellsglycemic excursionslatent autoimmune diabetes in adults
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Recent studies have suggested that combining basal insulin and glucagon-like peptide-1 (GLP-1) agonists (e.g., exenatide) might be particularly useful
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A new insulin regime is described, in which the primary aim is to attain normal basal plasma glucose concentrations by means of a constant insulin delivery rate from the long-acting Ultratard insulin. Additional twice daily Actrapid insulin is given to cover meals, and we have investigated this regime in 29 insulin dependent diabetics, with control assessed by admission for 24 hour profiles. Patients with low insulin requirements only need a basal insulin supplement with Ultratard insulin. With increasing insulin requirements the dose of short-acting insulin increases more than the basal insulin supplement. Thus fixed combinations of short- and long-acting insulins cannot produce good control in all patients. Twenty-one patients were deemed ‘well controlled’ in that they had no symptomatic hypoglycaemia, an overnight plasma glucose concentration of <5·5 mmol/l and a mean late post-prandial glucose concentration of <6·5 mmol/l. Their average ‘mean excess glycaemic exposure’ (mean incremental plasma glucose above 5 mmol/l) was 0·7 mmol/l (normal range 0–0·5 mmol/l), which is considerably less than that found in many maturity-onset diabetics. The distinction between basal and meal insulin requirements simplifies rules of insulin therapy.
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A new insulin regime is described, in which the primary aim is to attain normal basal plasma glucose concentrations by means of a constant insulin delivery rate from the long-acting Ultratard insulin. Additional twice daily Actrapid insulin is given to cover meals, and we have investigated this regime in 29 insulin dependent diabetics, with control assessed by admission for 24 hour profiles. Patients with low insulin requirements only need a basal insulin supplement with Ultratard insulin. With increasing insulin requirements the dose of short-acting insulin increases more than the basal insulin supplement. Thus fixed combinations of short- and long-acting insulins cannot produce good control in all patients. Twenty-one patients were deemed ‘well controlled’ in that they had no symptomatic hypoglycaemia, an overnight plasma glucose concentration of <5·5 mmol/l and a mean late post-prandial glucose concentration of <6·5 mmol/l. Their average ‘mean excess glycaemic exposure’ (mean incremental plasma glucose above 5 mmol/l) was 0·7 mmol/l (normal range 0–0·5 mmol/l), which is considerably less than that found in many maturity-onset diabetics. The distinction between basal and meal insulin requirements simplifies rules of insulin therapy.
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IN BRIEF Basal insulin therapy is well established for glycemic control in patients with diabetes but often is not optimally implemented, leading to poor clinical outcomes and adherence. Primary care providers can and should work together with other members of the diabetes care team to allow for effective titration of basal insulin that involves patients and their caregivers. Adequate guidance and monitoring during the titration process can minimize some of the adverse effects caused by basal insulin administration, while improving glycemic control in a timely manner.
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Indiana University School of Medicine Department of Family Medicine, Indianapolis, IN The corresponding author is Karmjot Hundal, DO; [email protected]. The author declares no conflicts of interest.
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Regular insulin
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Optimal insulin therapy should mimic endogenous insulin secretion in healthy subjects and maintain normal glycemic control. Short- or rapid-acting insulin is used to mimic the response of insulin secretion after meal. Basal insulin restrains hepatic glucose production in fasting state, and should be mimicked by neutral protamine Hagedorn (NPH) or long-acting insulin. Long-acting basal insulin analogues offer some advantage over the NPH insulin in terms of less glycemic variability when used once daily. Various scientific associations recommend once-daily basal insulin when starting insulin therapy; therefore, long-acting basal insulin analogues play important part of continual and optimal insulin therapy. In this article, we review long-acting basal insulin analogues currently available in Japan and new basal insulin in research and development phase.
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NPH insulin
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