Treatment Options to Control Blood Glucose |
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Treatment Option E: Basal Insulin Replacement in Combination With Fast-Acting Insulin at Mealtimes
Basal and prandial insulin replacement is the most physiologic regimen and imitates a normally functioning pancreas. Insulin is normally released continuously in order to suppress hepatic glucose output between meals and overnight. A normal pancreas also releases a “bolus” of insulin after food is ingested to promote glucose utilization and suppress hepatic glucose production. Replacing insulin in a way that attempts to mimic the normal insulin secretory pattern is often referred to as the basal/bolus, or basal/prandial concept.17 Patients with severe degrees of insulin deficiency (ie, A1C greater than 10%) are most likely to need both basal and prandial insulin (Figure 1).
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| Figure 1. Basal-bolus |
Most patients with type 2 diabetes typically require a basal insulin dose that is roughly half the total daily insulin requirement.5
Action: You prescribe insulin glargine 15 units every evening and insulin aspart 5 units 10 to 15 minutes before each meal. You and the nurse titrate the dose weekly by telephone as suggested by her reports of her SMBG log book. Mrs. S returns to see you in 3 weeks, at which time she is taking 30 units of glargine at bedtime and 10 units of aspart with each meal. She shows you her blood sugar log book.
Table 7. Patient Log Book| Before Breakfast | Before Lunch | Before Supper | Bedtime |
| 101 mg/dL | 111 mg/dL | 149 mg/dL | 185 mg/dL |
| 121 mg/dL | 121 mg/dL | 221 mg/dL | |
| 87 mg/dL | 89 mg/dL | 115 mg/dL | 190 mg/dL |
| 98 mg/dL | 104 mg/dL | 145 mg/dL | |
| 114 mg/dL | 119 mg/dL | 225 mg/dL |
Comment: Mrs. S’s blood sugars are excellent for the most part; however, her bedtime fingersticks 2 to 3 hours after supper are still above target. By questioning her, you learn that Mrs. S consumes approximately 120 g of carbohydrates at her evening meals. A modest increase in the pre-supper dose of insulin aspart is needed to compensate at this meal. A rule of thumb is to increase the insulin aspart by 3 units for every 10 g of carbohydrates.
Action: Referral to an endocrinologist should be provided to patients for whom education on regular carbohydrate counting is necessary for glycemic control.
Most patients with advanced insulin deficiency should receive both basal and prandial insulin. This type of regimen is most effective at controlling blood sugars without resulting in hypoglycemia.18 Another advantage is the ability to adjust the timing and dose of the prandial insulin, thus allowing for greater flexibility with meals.
A potential disadvantage is that in patients who typically consume 3 meals a day, this regimen requires 4 injections: 3 of the fast-acting analog and 1 of the basal insulin. In patients who are unable or unwilling to begin taking insulin in this manner, a simpler regimen of once-daily glargine or twice-daily premix may be used as a bridge to this best regimen.18
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