Case 2: Treatment Options

Treatment Option B: Initiate Insulin Glargine in Addition to 2 OADs; Follow Up

Patients who have failed to reach and maintain target glucose levels on 2 OADs rarely achieve glycemic targets over the long term by adding a third oral medication.⁶ At this point in his disease progression, Mr. W has severe ß-cell dysfunction and will require insulin.

Action: Initiating a once-daily injection of a basal insulin at bedtime would be a good therapeutic strategy.⁷ Starting 10 units of either NPH or insulin glargine once daily at bedtime is a safe and often effective way to improve BG control in the patient who is failing on combination oral therapy (see Table 4 Treat-to-Target in Case 1).

Comment: Some patients experience nocturnal hypoglycemia (2:00–3:00 am) when NPH is administered at dinner. If NPH is the insulin prescribed, moving the dose to bedtime may help to reduce this risk of nocturnal hypoglycemia. Glargine may also be a good choice in such patients because of its effectiveness and lack of a significant peak.⁸

Most patients with diabetes who progress to severe ß-cell dysfunction will need both basal and prandial insulin.⁹ Therefore, basal insulin administration here may be considered a way of introducing the patient to insulin with a once-daily injection. But clinicians need to know that ultimately, once-daily basal insulin is often insufficient, as it does not provide prandial coverage.⁹

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