Treatment Options to Control Blood Glucose |
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Treatment Option C: Basal Insulin (eg, glargine, NPH)
Basal insulin controls blood glucose levels between meals and overnight. This insulin prevents unchecked gluconeogenesis and ketogenesis.9 Insulin glargine or NPH human insulin injected once daily at bedtime provides a basal insulin action with few peaks and is indicated for management of uncontrolled diabetes. Basal insulin may also be provided by NPH insulin given once daily at bedtime or twice daily in the morning and evening. In one comparative study, patients receiving either insulin glargine or NPH human insulin once- or twice-daily, depending on their prior treatment at baseline, had similar reductions in A1C from baseline to end point, and change in FPG from baseline was significant in both groups.10 In this study, there were slightly more hypoglycemic events in the NPH insulin arm, but there was no statistically significant difference between the 2 groups.
Before starting a patient on insulin, it is important to establish glycemic goals that are specifically tailored to the patient. The American Diabetes Association (ADA) currently recommends glycemic goals indicated in Table 2.11
Table 2. Recommended Levels| Fingerstick preprandial plasma glucose | 80 mg/dL–160 mg/dL |
| Fingerstick postprandial plasma glucose | <180 mg/dL |
| Preprandial plasma glucose | 90 mg/dL–130 mg/dL |
| Postprandial plasma glucose | <180 mg/dL |
| A1C | ADA: <7%; AACE: <6.5% |
Action: Basal treatment, at least until FPG is within normal ranges, is a good choice for Mrs. S at this time. The Treat-to-Target study12 recommendation is to start insulin glargine at 10 units; however, because her BG is markedly elevated, you choose to initiate at 15 units.
One-Week Follow-up Visit
HistoryMrs. S has seen a registered nurse, a registered dietitian, and a diabetes educator. She has adhered to a 1500 hypocaloric diet as recommended by the ADA and avoids concentrated sweets. She also began self-monitoring her BG 3 times daily as taught by the diabetes educator.
Mrs. S reports that the vaginal itching and dysuria have resolved, but polyuria and polydipsia persist. The blood sugars from her SMBG diary are as follows:
Table 3| Day | Before Breakfast | Before Supper | Bedtime |
| Thursday | — | 487 | “High” |
| Friday | 379 | 452 | 400 |
| Saturday | 411 | 390 | 405 |
| Sunday | 399 | 409 | — |
| Monday | 353 | — | 387 |
| Tuesday | 388 | 390 | 387 |
| Wednesday | 386 | 390 | 425 |
Physical Exam
No distress
185 pounds BP 142/88
Review Labs:
| CBC | Urine |
| Na+ 146 meq/L | Fasting ketones 1+ |
| K+ 4.1 meq/L | Albumin 3.8 g/dL |
| Total cholesterol 245 mg/dL | Creatinine 1.1 mg/dL |
| Fasting triglycerides 525 mg/dL | |
| HDL 23 mg/dL | |
| LDL mg/dL — (Cannot be computed when triglycerides are over 400 mg/dL) | |
| A1C 11.5% | |
| FPG 301 mg/dL | |
| AST 25 U/L | |
| ALT 36 U/L |
You and the nurse titrate the dose over the telephone over the next 3 weeks based on reports from Mrs. S about her SMBG diary and the Treat-to-Target study recommendations (Table 4).12
Table 4. Treat-to-Target
| Start With 10 IU/day Bedtime Basal Insulin and Adjust Weekly | |
| Mean of self-monitored FPG values from preceding 2 days | Increase of insulin dosage (IU/day) |
| >180 mg/dL (10 mmol/L) | 8 |
| 140–180 mg/dL (7.8–10.0 mmol/L) | 6 |
| 120–140 mg/dL (6.7–7.8 mmol/L) | 4 |
| 100–120 mg/dL (5.6–6.7 mmol/L) | 2 |
When Mrs. S returns for her next follow-up visit, she is on glargine 55 units each evening, and her SMBG diary is as follows:
Table 5| Before Breakfast | Before Lunch | Before Supper | After Supper |
| 111 mg/dL | 187 mg/dL | ||
| 109 mg/dL | 165 mg/dL | 198 mg/dL | |
| 98 mg/dL | |||
| 122 mg/dL |
Action: Your patient’s FPG levels are at target of 80 mg/dL to 120 mg/dL, although her PPG levels are elevated. This occurs because once-daily basal insulin, although effective in many patients who have residual ß-cell function, does not specifically augment levels following a meal. Your treatment options are to use a sulfonylurea or meglitinide, which would stimulate endogenous insulin release with meals or to introduce a fast-acting insulin at mealtimes. Mrs S’s high blood sugars, A1C of over 10%, and history of weight loss suggest the presence of significant insulin deficiency and make it more likely that she will need a fast-acting insulin with meals.
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