Case 2: Treatment Options

Treatment Option D: Initiating Treatment With Analog Mix Insulin

Premixed insulin formulations such as analog mixes lispro 75/25 and aspart 70/30 have been developed in an effort to provide both basal and prandial insulin in a simplified regimen with fewer injections. The concept is that the rapid analog in these mixes provides effective prandial coverage when given at breakfast and supper; the intermediate-acting component of these mixes provides coverage for lunch and basal insulin for nighttime.

Human insulin 70/30 mix is made up of 30% regular insulin and 70% NPH. For patients who pay out of pocket for their insulin, it may be less expensive than the analog formulations. It should be dosed 30 to 45 minutes before the meal, since the fast-acting component is human regular insulin.¹¹ Postprandial glycemic control may not be as good as with the analog mixes.¹²

Comment:

The major advantage of the mixes is fewer injections and the convenience of not having to mix insulins. For some patients, however, disadvantages include the following:

• Cannot adjust the ratio of prandial and basal insulin; therefore, dose adjustment possibilities are limited


• Inflexibility in mealtimes, for example, lunch should coincide with mid-day peak of analog mix given at breakfast or hypoglycemia may occur


• Patients need about the same carbohydrate intake with each meal to maintain reasonable glycemic control


• Hypoglycemia may occur at night, as the intermediate-acting insulin component taken with dinner will peak in the middle of the night


• Hyperglycemia may occur in morning, since the duration of action of the intermediate-acting insulin is only 8 to 12 hours


• Postprandial hyperglycemia frequently occurs at lunch, since the mixes may provide poor prandial coverage at this time

For patients who are unable or unwilling to attempt MDI, analog mixes are an option. If physicians and patients are aware of the above limitations, success is possible with the mixes.

Conclusions:

Type 2 diabetes is a progressive disease. Ultimately, insulin will be necessary as ß-cell function deteriorates. The choice of a particular insulin regimen should take into account cost, patient lifestyle, degree of ß-cell dysfunction, complications, and occurrence of hypo- or hyperglycemic events. Patients who present initially with severe hyperglycemia and weight loss should be treated with insulin at the time of diagnosis, as in Case 1. In patients who present with less severe hyperglycemia, as in Case 2, a step-wise approach is usually applied, starting with lifestyle modification, progressing to the use of monotherapy or combination therapy with OADs.¹³ Unfortunately, complications are more likely if patients fail to maintain glycemic controls along this pathway. Insulin should be administered when such therapy fails to achieve glycemic targets, with the knowledge that both basal and prandial insulin are usually necessary. Additional studies currently under way will help physicians understand more fully that adhering to goals, utilizing diabetes educators, initiating insulin therapy earlier, and titrating often and as needed may greatly reduce the risk of diabetes-related complications.

This completes “Case 2”.

Please click here to return to the Insulin Therapy in the Primary Care Setting Program page, where you can launch the CME Posttest.

Back to “Case 2”