1. Effective Use of Insulin in Diabetes: Update for 2007
Thomas M. Flood, MD
Director
Georgia Center for Diabetes
Atlanta, Georgia

2. Key Question ?
How comfortable are you with initiating insulin therapy in your patient population?
Completely comfortable
Somewhat comfortable
Slightly comfortable
Not comfortable at all
Use your keypad to vote now!

3. Faculty Disclosure
Dr Flood has no relevant financial relationships with any commercial interests to disclose.

4. Learning Objectives State current management goals for diabetes
Identify barriers to optimal use of insulin, and how to overcome them
Discuss the roles of short-, intermediate-, and long-acting insulins in the management of diabetes

5. A1C Targets Suggested by Different Organizations
Optimal target: A1C <6% (normal range)
Organization
A1C Target (%)
AACE
<6.5
EASD
ADA
<7 (general)
<6* (individual patient)
*As close to normal (<6%) without significant hypoglycemia.
AACE = American Association of Clinical Endocrinologists; ADA = American Diabetes Association; EASD = European Association for the Study of Diabetes.

6. ? Key Question What percentage of patients with diabetes
achieve the AACE goal of A1C <6.5%?
25%
35%
55%
75%
Use your keypad to vote now!

7. National average = 67% above goal (A1C 6.5%)
State of Diabetes in America: Blood Sugar Control Across the United States as Measured by A1C
National average = 67% above goal (A1C 6.5%) WA
68.4 ME
27.2 MT
55.2 ND
29.7 MN
59.3 OR
64.2 VT
VT = 26.7
NH = 20.4
MA = 29.5
CT = 28.4
RI = 29.5
NJ = 67.3
DE = 66.4
MD = 68.1 ID
63.3 NY
71.1 NH SD
24.6 W
24.2I WY
63.0 MI
65.4 MA CT RI IA
58.9 PA
70.9 NE
56.5 NV
67.3 OH
71.7 NJ IL
72.6 IN
66.4 MD UT
72.4 CO
67.1 WV
69.5 DE CA
34.5 VA
67.7 KS
67.0 MO
66.2 KY
66.8 TN
65.6 NC
65.7 OK
65.6 AZ
67.3 AR
69.6 NM
68.6 SC
66.3 MS
72.8 AL
71.3 GA
69.3 TX
67.7 LA
71.3 FL
63.9
N >157,000
Top 10 Highest
AACE. State of Diabetes in America. May Available at:
American Association of Clinical Endocrinologists. State of Diabetes in America. Report presented at: American Association of Clinical Endocrinologists 14th Annual Meeting and Clinical Congress; Washington, DC; May 18,

8. Diabetes Demographics in the United States
Population Aged ≥20 Years
Physician-Diagnosed Diabetes (%)
Undiagnosed Diabetes (%)
Male
5.4
7.6
3.5
4.3
Female
7.1
2.6
1.8
White
5.0
6.2
2.8
Black
8.6
11.4
4.2
3.1
Mexican
9.7
11.8
4.7
3.3
Total
7.3
3.0
Adapted from: National Center for Health Statistics. Health, United States, With Chartbook on Trends in the Health of Americans. Hyattsville, Md: 2006.

9. No A1C Threshold in Type 2 Diabetes
Epidemiologic Data From the UKPDS 80
Myocardial infarction
Microvascular end points 60
AACE Goal
Adjusted Incidence per 1000 Person-Years (%) 40 20 ? 5 6 7 8 9 10 11
Updated Mean A1C (%)
UKPDS = United Kingdom Prospective Diabetes Study.
Stratton IM et al. BMJ. 2000;321:

10. Risk Factor Control in Adults With Diabetes: NHANES III (1988-1994)/NHANES 1999-2000
NHANES , n = 370
48.2% 50
44.3%
P <.001
37.0% 40
35.8%
33.9%
29.0% 30
Patients (%) 20 10
5.2%
7.3%
A1C <7%
BP <130/80 mm Hg
TC <200 mg/dL
Good control*
*Achieved all 3 indicated goals.
BP = blood pressure; NHANES = National Health and Nutrition Examination Survey; TC = total cholesterol. Saydah SH et al. JAMA. 2004;291:

11. Stages of Type 2 Diabetes: Criteria for Advancing to Next Stage?
A1C not at target: 7.0%
100
Monotherapy 75
Combination oral
therapy
β-Cell Function (% β) 50
Insulin 25
Type 2
Diabetes
Phase I
Type 2
Diabetes
Phase II
Phase III
-12
-10 -6 -2 2 6 10 14
Years From Diagnosis
Based on data of UKPDS 16.
UKPDS Group. Diabetes. 1995;44:

12. Stepwise Management of Type 2 Diabetes+
Diet and
exercise
+ Oral monotherapy
+ Oral combination
+ Oral combo + insulin
+ Insulin
Biggest Clinical Hurdle?
Adapted from Williams G. Lancet. 1994;343:

13. ? Key Question What is the approximate amount that A1C
can be lowered through use of oral agents? 1% 2% 3% 4%
Use your keypad to vote now!

14. Oral Antihyperglycemic Monotherapy Maximum Therapeutic Effect on A1C
Acarbose
Insulin
-0.5
-1.0
-1.5
-2.0
Nateglinide
Reduction in A1C (%)
Glipizide GITS
Glimepiride
Repaglinide
Pioglitazone
Metformin
Rosiglitazone
Sitagliptin
Precose [PI]. West Haven, Conn: Bayer; 2003; Aronoff S et al. Diabetes Care. 2000;23: ; Garber AJ et al. Am J Med. 1997;102: ; Goldberg RB et al. Diabetes Care. 1996;19: ; Hanefeld M et al. Diabetes Care. 2000;23: ; Lebovitz HE et al. J Clin Endocrinol Metab. 2001;86: ; Simonson DC et al. Diabetes Care. 1997;20: ; Wolfenbuttel BH, van Haeften TW. Drugs. 1995;50:

15. UKPDS: Early Initiation of Insulin Therapy Improves A1C Control
Conventional therapy
Insulin therapy
Sulfonylurea ± insulin therapy 9 8 7
A1C (%)
ULN = 6.2% 6 5 1 2 3 4 5 6
Years From Randomization
ULN = upper limit of A1C nondiabetic range.
Wright A et al. Diabetes Care. 2002;25:

16. Clinical Inertia: “Failure to Advance Therapy When Required”
Last A1C Value Before Abandoning Treatment 10
9.6%
Mean A1C at Last Visit (%)
9.1% 9
8.6%
8.8% 8
ADA Goal 7
Sulfonylurea
Diet/Exercise
Combination
Metformin
2.5 Years
2.9 Years
2.2 Years
2.8 Years
Brown JB et al. Diabetes Care. 2004;27:

17. ? Key Question What are the barriers for your patients with
type 2 diabetes regarding initiation of
insulin therapy?
Concern that insulin use is “forever”
Fear of injection
Equating insulin use with worsening diabetes and complications
Fear of weight gain
Use your keypad to vote now!

18. Patient Barriers to Insulin Use: Perception vs Reality
Failing oral therapy
58% of patients believe using insulin means they have failed OAD therapy
OAD failure is due to progressive nature of type 2 diabetes; insulin is best agent to control disease
Needle phobia
Fear associated with early experiences
Current needles considered painless; easy-to-use injection systems are available
Fear of complications
Common association of insulin with diabetic complications
Complications are due to uncontrolled, progressive disease; insulin actually results in reduction of vascular damage
OAD = oral antidiabetic drug.
Meese J. Diabetes Educ. 2006;32:9S-18S; Peyrot M et al. Diabet Med. 2005;22:

19. Clinician Barriers to Insulin Use: Perception vs Reality
Hypoglycemia is prevalent with insulin use
Severe hypoglycemia is very uncommon in patients with type 2 diabetes, occurring at 10% the rate in patients with type 1 diabetes
Insulin use increases atherosclerosis
Studies indicate no exacerbation of cardiovascular disease
There is weight gain with insulin use
Weight gain is modest and can be controlled with diet and exercise
Patients have a negative attitude regarding insulin use
Insulin is a “positive” approach to achieving glycemic control
Douek IF et al. Diabet Med. 2005;22: ; Malmberg K et al. J Am Coll Cardiol. 1995;26:57-65; Malmberg K et al. BMJ. 1997;314: ; Romano G et al. Diabetes. 1997;46: ; UKPDS Group. Lancet. 1998;352:

20. Information and Patient Education Links for Healthcare Professionals
American Association of Diabetes Educators (
American Association of Clinical Endocrinologists (
American Diabetes Association (
International Diabetes Federation (
National Diabetes Education Initiative (
National Diabetes Education Program (ndep.nih.gov)
National Institute of Diabetes and Digestive and Kidney Diseases (www2.niddk.nih.gov)

21. Next Steps…
What do we do for the patient who has failed on 1 or 2 oral agents?

22. Basal Insulin Therapy Usual first step when beginning insulin therapy
Continue OAD and add basal insulin to optimize FPG
A1C of up to 9.0% often brought to goal by addition of basal insulin therapy to OADs
Easy and safe: patient-directed treatment algorithms with small risk of serious hypoglycemia
ADA and EASD recommended: “Although 3 OADs can be used, initiation and intensification of insulin therapy is preferred based on effectiveness and expense”
Basal Insulin Therapy
The addition of basal insulin therapy to oral antidiabetic drugs (OADs) is the usual first step in transitioning from OAD therapy.
The goal is to optimize fasting plasma glucose (FPG) values and reduce glucolipotoxicity.
In many cases, A1C levels of up to 9.0% can often be brought to goal using basal insulin therapy.
There are several patient-directed treatment algorithms available, which make titration to effective doses easy for the patient to manage.
There is a small risk of hypoglycemia associated with basal insulin therapy.
References
American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2006;29(suppl 1): S4-S42.
American Association of Clinical Endocrinologists. Implementation Conference for ACE Outpatient Diabetes Mellitus Consensus Conference recommendations: Position statement. Available at: Accessed July 3, 2006.
Category: Insulin Therapy
Keywords: basal, FPG, A1C, initiate, goals, insulin
FPG = fasting plasma glucose.
ADA. Diabetes Care. 2006:29(suppl 1):S4-S42; AACE position statement. Available at:
Nathan DM et al. Diabetes Care. 2006;29:

23. Rationale for Basal Insulin Therapy: Insulin and Glucose Patterns
Normal
T2DM
Glucose
Insulin
400
120
100
300 80
μU/mL
mg/dL
200 60 40
100 20
6:00
10:00
14:00
18:00
22:00
2:00
6:00
6:00
10:00
14:00
18:00
22:00
2:00
6:00 B L D B L D
Time
Time
B = breakfast; D = dinner; L = lunch; T2DM = type 2 diabetes mellitus.
Polonsky KS et al. N Engl J Med. 1988;318:

24. Options for Initiating Insulin Therapy
Basal insulin
NPH insulin (at bedtime)
Insulin detemir (once or twice daily)
Insulin glargine (once daily)
Premixed insulin preparations
70/30 NPH insulin/regular insulin
50/50 NPL insulin/insulin lispro
70/30 NPA insulin/insulin aspart
75/25 NPL insulin/insulin lispro
Analog premixes
NPA = neutral protamine aspart; NPL = neutral protamine lispro.

25. Idealized Profiles of Human Insulin and Basal Insulin Analogs
NPH
Plasma Insulin Levels
Detemir
Glargine
0:00
2:00
4:00
6:00
8:00
10:00
12:00
14:00
16:00
18:00
20:00
22:00
24:00
Time
Plank J et al. Diabetes Care. 2005;28: ; Rave K et al. Diabetes Care. 2005;28: ; Rosenstock J, Goldstein BJ, et al, eds. Textbook of Type 2 Diabetes. London, UK, and New York, NY: Martin Dunitz; 2003:

26. Twice-Daily Split-Mixed Regimens or Lispro Mix (75/25)–Aspart Mix (70/30)
4:00
16:00
20:00
24:00
Breakfast
Lunch
Dinner
Insulin Action
8:00
12:00
Time
Glucose levels Insulin levels
Adapted with permission from Leahy J. In: Leahy J, Cefalu W, eds. Insulin Therapy. New York: Marcel Dekker; 2002:87; Nathan DM. N Engl J Med. 2002;347:

27. Open-Label, Twice-Daily Exenatide vs Once-Daily Insulin Glargine: Self-Monitoring Blood Glucose Profiles (n = 549)
Exenatide
5 μg bid 1st 4 weeks, then 10 μg bid
Insulin Glargine
10 U/d, titrated to target FPG <100 mg/dL
240
240
220
220
200
200
Mean end of study dose was 25 U compared with 47 U in the Treat-to-Target trial.
Least-squares mean (SE) data for self-monitored blood glucose concentrations at baseline and week 26 are shown for the exenatide and insulin glargine groups. In a 24-hour period, data were collected just before each meal (fasting, pre–midday meal, pre– evening meal), 2 hours after each meal (post–morning meal, post–midday meal, post– evening meal), and at 3:00 a.m. At week 26, the exenatide group had higher mean values for blood glucose levels at fasting (P <0.001), before lunch (P = 0.023), before dinner (P = 0.006), and at 3:00 a.m. (P <0.001), but the group had lower glucose levels after morning (P <0.001) and evening (P <0.001) meals than the group receiving insulin glargine.
Heine RJ et al. Ann Intern Med. 2005;143:
180
180
Blood Glucose (mg/dL)
160
160
140
140
120
Baseline (week 0)
120
Baseline (week 0)
Endpoint (week 26)
100
100
Endpoint (week 26)
Prebreakfast
Prelunch
Predinner
3 AM
Prebreakfast
Prelunch
Predinner
3 AM
Both medications lowered A1C from 8.2% to 7.1% from baseline
Weight change: exenatide –2.3 kg, glargine +1.8 kg
Nausea: exenatide 57.1%, glargine 8.6%
Heine RJ et al. Ann Intern Med. 2005;143:

28. Steps in Transition From Basal to Basal-Bolus Insulin Therapy in T2DM
Glargine, Detemir,
or NPH HS
Weekly titration based on FPG
All oral agents continued
STEP 1
Above
target
Add insulin
Main meal
STEP 2
Above
target
Add insulin
Next largest meal
STEP 3
Above
target
Add insulin
Last meal
STEP 4
Above target:
A1C >7.0%
FPG >110 mg/dL
A1C <7.0%, FPG <110 mg/dL
HS = at bedtime.
Adapted with permission from Karl DM. Curr Diab Rep. 2004;4:

29. Case Study

30. Case Study: Initiating Insulin Therapy
60-year-old man: 10-year history of T2DM and hypertension
Current T2DM medications: metformin 1000 mg bid, rosiglitazone 8 mg AM, and glimepiride 8 mg qd
Hypertension medications: 40 mg lisinopril, 10 mg amlodipine, mg HCTZ
Dyslipidemia medication: 10 mg atorvastatin
Physical exam: weight = 245 lb (10-lb increase); height = 6’0”; BMI = 34.2 kg/m2; waist circumference = 44 in; BP = 130/80 mm Hg
Laboratory: TC = 167 mg/dL; TG = 206 mg/dL; HDL = 35 mg/dL; LDL = 90 mg/dL
A1C = 8.9%; plasma glucose in the office = 198 mg/dL
Creatinine 1.1 mg/dL, normal LFTs
HCTZ = hydrochlorothiazide; TG = triglycerides; HDL = high-density lipoprotein; LFTs = liver function tests; BMI = body mass index.

31. Case Study (cont’d) Patient agrees to basal insulin therapy, however:
Expresses feelings of failure at inability to control glycemia with OADs
Displays anxiety about injections
You explain the progressive nature of diabetes:
Convey that insulin injections are the best way to achieve glycemic control
Describe injection options (“painless” needles, injector pens, etc)
Indicate that you and the patient will be a “team” in getting to the A1C goal

32. ? Decision Point Which insulin would you use? NPH at bedtime
Glargine once daily
Twice-daily premixed
Detemir at bedtime
Use your keypad to vote now!

33. Treat-to-Target Trial: Oral Agents + Glargine or NPH at Bedtime
Patients (n = 756) with inadequate glycemic control (A1C >7.5%) taking 1 or 2 oral agents
Started with 10 U/d bedtime basal insulin and adjusted weekly to target FPG 100 mg/dL:
Mean self-monitored FPG values from preceding 2 days (mg/dL)
Increase of insulin dosage
(U/d)
≥180 8
140 – 180 6
120 – 140 4
100 – 120 2
Exceptions were no increase in dosage if plasma-referenced glucose <72 mg/dl was documented at any time in the preceding week, and in addition to no increase, small insulin dose decreases (2 – 4 units/day per adjustment) were allowed if severe hypoglycemia (requiring assistance) or plasma-referenced glucose <56 mg/dl were documented in the preceding week.1
1Riddle MC et al. Diabetes Care. 2003;26:
Hermansen K et al. Diabetes Care. 2006;29: ; Riddle MC et al. Diabetes Care. 2003;26:

34. Treat-to-Target Trial: Oral Agents + Glargine or NPH at Bedtime (n=756): Efficacy Results
Patients (n=756) with inadequate glycemic control (A1C >7.5%) on 1 or 2 oral agents
Randomized to bedtime glargine or NPH
Target FPG 100 mg/dL
Adjustments made once weekly; therapy is advanced unless hypoglycemia present
*In both groups, FPG decreased from 194 or 198 mg/dL to 117 or 130 mg/dL, respectively, by study end, and A1C decreased from 8.6% to 6.9% by 18 weeks.
Riddle MC et al. Diabetes Care. 2003;26:

35. Treat-to-Target Trial: Timing and Frequency of Hypoglycemia
Hypoglycemia by Time of Day
Basal insulin
Insulin glargine
350 * *
NPH insulin
300 *
250 *
Hypoglycemia Episodes (PG 72 mg/dL)
200 * * *
150
100 50
B L D
20:00
22:00
24:00
2:00
4:00
6:00
8:00
10:00
12:00
14:00
16:00
18:00
20:00
Time
*P <.05 (between treatment).
Riddle MC et al. Diabetes Care. 2003;26:

36. Detemir vs NPH Insulin in T2DM (n = 476)
400
350
300
250
200
150
100 50
A1C (%)
10.0
9.0
8.0
7.0
6.0
Detemir
NPH
Hypoglycemia Events* -2 4 8 12 16 20 24 2 4 8 12 16 20 24
Study Week
Study Week
*All reported events, including symptoms only.
Hermansen K et al. Diabetes Care. 2006;29:

37. Case Study (cont’d) 10 U glargine is added to OADs
Patient is sent home with the “2, 4, 6, 8 algorithm” with a target FPG goal of 100 to 110 mg/dL.1 Similar algorithm can be used with detemir2
FPG (mg/dL)  Insulin Dose (U/d)
>
Alternative strategy: increase basal insulin dose by 2 units every 3 days until FPG 100 mg/dL*3
*Certain populations (children, pregnant women, and the elderly) require special considerations.
Riddle MC et al. Diabetes Care. 2003;26:
Hermansen K et al. Diabetes Care. 2006;29:
Davies M et al. Diabetes. 2004;53(suppl 2):1980.

38. Case Study (cont’d) Patient is seen 1 month later
FPG still above 200 mg/dL, using up to 30 U daily
Patient is frustrated and feels the insulin does not work

39. ? Decision Point What do you do now? Keep increasing the insulin dose
Go to twice-daily premixed
Switch to exenatide
Send patient for gastric bypass consult
Use your keypad to vote now!

40. Treat-to-Target Trial50
Units 45
Total Daily Dose (U) 42 40 37 33 28 30 21 20 10 10 1 2 3 4 5 6 7 8 10 12 15 18 21
N = 756.
Riddle MC et al. Diabetes Care. 2003;26:
Weeks in Study

41. Case Study (cont’d)
Patient is taking 75 U with FPG controlled (<100 mg/dL to rarely >110 mg/dL) since last visit 4 months ago
Patient’s last A1C = 6.9%, monitoring occasional postprandial blood sugars
Patient finds insulin injections painless and after speaking with you, feels that he is now a partner in his therapy program

42. Case Study (cont’d)
Over the next 3 years, patient seen for routine follow-up every 3 to 4 months
Remains medically stable, with A1C values 6.5% to 7.2%
3.25 years after adding basal insulin glargine, A1C has increased to 8.2%, however, FPG checks remain <120 mg/dL

43. ? Decision Point What do you do now? Increase glargine
Switch to twice-daily premixed
Switch to 4-shot basal-bolus program
Increase monitoring to AC and HS, and have patient report after 2 weeks
Use your keypad to vote now!
AC = before meals; HS = at bedtime.

44. Case Study (cont’d)
Because the patient’s FPGs are good and post-prandial glucose levels are high, the decision is made to switch to twice-daily premixed insulin
The patient is encouraged to increase daily monitoring to adjust insulin dose

45. At Lower A1C Levels, PPG Contributes More to Overall A1C Than FPG
Contribution (%) 1 2 3 4 5
A1C Quintile
PPG = postprandial glucose.
Reprinted with permission from Monnier L et al. Diabetes Care. 2003;26:

46. Plasma Glucose (mg/dL)
Prandial Excursions Are Evident, Especially Around a Single Key Meal: Insulin Glargine vs Premixed (n = 209)
350
300
250
200
150
100 50
Premixed†
Glargine
Baseline
Plasma Glucose (mg/dL) * * * * *
Week 28 BB
B90 BL
L90 BD
D90
Bed
3 AM
Time of Day
Total units = 51.3 ± 26.7 with glargine plus OADs vs 78.5 ± 39.5 with premixed insulin (BIAsp 70/30)
*Denotes statistically significant difference between treatment groups at specific times.
†Premixed = BIAsp 70/30.
Raskin P et al. Diabetes Care. 2005;28:

47. Case Study (cont’d) Daily Blood Glucose Diary 147 110 153 185 57 138
Week Ending
March 24
Breakfast
Lunch
Dinner MS
Middle of Night
Dose
Blood Sugar
Monday
147
110
153
185 57
Tuesday
138
112
170
164 48
Wednesday
140 90
155
205 
Thursday
166
105
134
213 60
Friday
Saturday
Sunday

48. Twice-Daily Split-Mixed Regimens or Lispro Mix (75/25)–Aspart Mix (70/30)
4:00
16:00
20:00
24:00
Breakfast
Lunch
Dinner
Insulin Action
8:00
12:00
Time
Glucose levels Insulin levels
Adapted with permission from Leahy J. In: Leahy J, Cefalu W, eds. Insulin Therapy. New York: Marcel Dekker; 2002:87; Nathan DM. N Engl J Med. 2002;347:

49. Idealized Profiles: Rapid-Acting Insulin Analogs
Inhaled insulin*
Regular insulin
Plasma Insulin Levels
0:00
2:00
4:00
6:00
8:00
10:00
12:00
14:00
16:00
18:00
20:00
22:00
24:00
Time
*Inhaled dry human insulin (Exubera®) powder
Rosenstock J, Goldstein BJ, et al, eds. Textbook of Type 2 Diabetes. London, UK, and New York, NY: Martin Dunitz; 2003: ; Plank J et al. Diabetes Care. 2005; 28: ; Rave K et al. Diabetes Care. 2005;28:

50. Case Study (cont’d)
Decision is made to switch to basal-prandial therapy to reduce hypoglycemia and postprandial highs
60% of patient’s total daily insulin dose is given as basal insulin – 54 U glargine qhs titrated to FPG mg/dL
Before the main meal, a rapid-acting analog is added: glulisine, initiated at 5 units, up-titrated using a treat-to-target algorithm
Patient continues to self-monitor glucose

51. Meal Insulin: Rapid-Acting Analogs (Lispro, Aspart, Glulisine) vs Regular
Analog insulin 10
Timing of
food absorbed 8
RHI 6
Insulin Activity 4 2 1 2 3 4 5 6 7 8 9 10 11 12
Hours
RHI = regular human insulin.
Adapted with permission from Howey DC et al. Diabetes. 1994;43:

52. Advantages of Rapid-Acting Analogs
Short duration of action—fewer between-meal “hypos” than regular insulin
Flexible mealtime dosing
More consistent kinetics
Day to day
Across anatomical sites
With large doses
Slightly faster onset of glulisine action (compared to lispro) in obese and morbidly obese subjects (independent of BMI)*
Adapted from Hirsch IB. N Engl J Med. 2005;352:
Becker RHA et al. Exp Clin Endocrinol Diabetes. 2005;113:
*Heise T et al. Diabetes. 2005;54(suppl 1):A145.

53. ? Decision Point The best time to use a rapid-acting insulin
analog is:
Before a meal
After a meal
Either works well
Use your keypad to vote now!

54. Significant reduction in A1C with pre- and postmeal glulisine
Pre- and Postmeal Efficacy of Insulin Glulisine vs Regular Human Insulin
Significant reduction in A1C with pre- and postmeal glulisine
P <.05
P <.05
P <.05
Baseline
Endpoint
Efficacy of Algorithmic Basal-Prandial Insulin Analog Titration
At week 24, the A1C was significantly reduced in both the ALG and Carb Count groups (P<0.0001).
Reference
Bergenstal R, Johnson M, Powers M, Wynne A, Vlajnic A, Hollander A. Using a simple algorithm (ALG) to adjust mealtime glulisine (GLU) based on preprandial glucose patterns is a safe and effective alternative to carbohydrate counting (Carb Count). Diabetes. 2006;55(suppl 1):A105.Abstract 441P.
Significant A1C reduction with premeal glulisine compared to premeal human insulin
Garg SK et al. Endocr Pract. 2005;11:11-17; Garg SK et al. Poster presented at ADA 64th Annual Scientific Sessions, June 4-8, 2004, Diabetes. 7:529P.

55. Case Study (cont’d)
At 6-month follow-up patient is doing well with 70 U glargine and 10 U to 17 U glulisine at supper
Actual dose adjusted by
Meal carbohydrate content
Activity
Insulin supplement of additional 1 U for every 25 mg/dL above 130 mg/dL (prandial glucose)
A1C = 6.3%
He feels well, has infrequent “hypos,” and is pleased with his blood glucose control

56. Q & A

57. PCE Takeaways

58. PCE Takeaways: Basal-Prandial Insulin Replacement
An effective insulin treatment strategy provides both basal and postprandial insulin coverage
Initially, prandial insulin may be needed only at the largest meal of the day, with coverage at other meals added based on prandial glucose levels
Rapid-acting insulin analogs closely match normal mealtime insulin patterns
Prandial Insulin Replacement: Summary
An effective strategy for the treatment of patients with type 2 diabetes is the use of an insulin regimen that provides both basal and postprandial insulin coverage.
Initially, prandial insulin may be needed only at the largest meal of the day. Over time, premeal glucose levels may indicate the need for administration of prandial insulin at more meals.
Rapid-acting insulin analogs, which closely match normal mealtime insulin patterns compared with regular human insulin, are an effective option.
A simple algorithm based on premeal blood glucose levels can been shown to be a safe and effective way to titrate prandial insulin doses.

59. Key Question ?
How much more comfortable do you now feel you will be initiating insulin therapy in your patient population?
Much more comfortable
Somewhat comfortable
Slightly comfortable
Not comfortable at all
Use your keypad to vote now!