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Effective Use of Insulin in Diabetes: Update for 2007. Thomas M. Flood, MD Director Georgia Center for Diabetes Atlanta, Georgia. ?. Key Question. Completely comfortable Somewhat comfortable Slightly comfortable Not comfortable at all Use your keypad to vote now!.

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effective use of insulin in diabetes update for 2007

Effective Use of Insulin in Diabetes: Update for 2007

Thomas M. Flood, MD

Director

Georgia Center for Diabetes

Atlanta, Georgia

key question

?

Key Question
  • Completely comfortable
  • Somewhat comfortable
  • Slightly comfortable
  • Not comfortable at all

Use your keypad to vote now!

How comfortable are you with initiating insulin therapy in your patient population?

faculty disclosure
Faculty Disclosure
  • Dr Floodhas no relevant financial relationships with any commercial interests to disclose.
learning objectives
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
a1c targets suggested by different organizations
A1C Targets Suggested by Different Organizations

Optimal target:A1C <6% (normal range)

*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.

key question6

?

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!

state of diabetes in america blood sugar control across the united states as measured by a1c
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

VT = 26.7

NH = 20.4

MA = 29.5

CT = 28.4

RI = 29.5

NJ = 67.3

DE = 66.4

MD = 68.1

VT

OR

64.2

NH

ID

63.3

NY

71.1

W

24.2I

SD

24.6

MA

MI

65.4

WY

63.0

CT

RI

IA

58.9

PA

70.9

NE

56.5

NJ

OH

71.7

NV

67.3

IL

72.6

IN

66.4

MD

UT

72.4

DE

CO

67.1

WV

69.5

CA

34.5

VA

67.7

KS

67.0

KY

66.8

MO

66.2

NC

65.7

TN

65.6

OK

65.6

AR

69.6

AZ

67.3

SC

66.3

NM

68.6

MS

72.8

AL

71.3

GA

69.3

LA

71.3

TX

67.7

FL

63.9

N >157,000

Top 10 Highest

AACE. State of Diabetes in America. May 2005. Available at: http://www.aace.com/public/awareness/stateofdiabetes/DiabetesAmericaReport.pdf

diabetes demographics in the united states
Diabetes Demographics in the United States

Population Aged ≥20 Years

Adapted from: National Center for Health Statistics. Health, United States, 2006. With Chartbook on Trends in the Health of Americans. Hyattsville, Md: 2006.

no a1c threshold in type 2 diabetes
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

?

0

5

6

7

8

9

10

11

Updated Mean A1C (%)

UKPDS = United Kingdom Prospective Diabetes Study.

Stratton IM et al. BMJ. 2000;321:405-412.

risk factor control in adults with diabetes nhanes iii 1988 1994 nhanes 1999 2000
Risk Factor Control in Adults With Diabetes: NHANES III (1988-1994)/NHANES 1999-2000

NHANES III, n = 1204

NHANES 1999-2000, n = 370

48.2%

50

44.3%

P <.001

37.0%

40

35.8%

33.9%

29.0%

30

Patients (%)

20

10

7.3%

5.2%

0

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;291:335-342.

stages of type 2 diabetes criteria for advancing to next stage
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

0

-12

-10

-6

-2

0

2

6

10

14

Years From Diagnosis

Based on data of UKPDS 16.

UKPDS Group. Diabetes. 1995;44:1249-1258.

stepwise management of type 2 diabetes

Biggest Clinical Hurdle?

+Insulin

+Oral combo + insulin

+

+

+Oral combination

+

+Oral monotherapy

Diet and

exercise

Stepwise Management of Type 2 Diabetes

Adapted from Williams G. Lancet. 1994;343:95-100.

key question13

?

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!

oral antihyperglycemic monotherapy maximum therapeutic effect on a1c

Nateglinide

Sitagliptin

Rosiglitazone

Pioglitazone

Repaglinide

Glimepiride

Glipizide GITS

Metformin

Insulin

0

-1.0

-1.5

-2.0

-0.5

Reduction in A1C (%)

Oral Antihyperglycemic MonotherapyMaximum Therapeutic Effect on A1C

Acarbose

Precose [PI]. West Haven, Conn: Bayer; 2003; Aronoff S et al. Diabetes Care. 2000;23:1605-1611; Garber AJ et al. Am J Med. 1997;102:491-497; Goldberg RB et al. Diabetes Care. 1996;19:849-856; Hanefeld M et al.Diabetes Care. 2000;23:202-207; Lebovitz HE et al. J Clin Endocrinol Metab. 2001;86:280-288; Simonson DC et al. Diabetes Care. 1997;20:597-606; Wolfenbuttel BH, van Haeften TW.Drugs. 1995;50:263-288.

ukpds early initiation of insulin therapy improves a1c control
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

0

0

1

2

3

4

5

6

Years From Randomization

ULN = upper limit of A1C nondiabetic range.

Wright A et al. Diabetes Care. 2002;25:330-336.

clinical inertia failure to advance therapy when required
Clinical Inertia: “Failure to Advance Therapy When Required”

Last A1C Value Before Abandoning Treatment

10

9.6%

9.1%

Mean A1C at Last Visit (%)

9

8.6%

8.8%

8

ADA Goal

7

Sulfonylurea

Combination

Diet/Exercise

Metformin

2.5 Years

2.9 Years

2.2 Years

2.8 Years

Brown JB et al. Diabetes Care. 2004;27:1535-1540.

key question17

?

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!

patient barriers to insulin use perception vs reality
Patient Barriers to Insulin Use: Perception vs Reality

OAD = oral antidiabetic drug.

Meese J. Diabetes Educ. 2006;32:9S-18S; Peyrot M et al. Diabet Med. 2005;22:1379-1385.

clinician barriers to insulin use perception vs reality
Clinician Barriers to Insulin Use: Perception vs Reality

Douek IF et al. DiabetMed. 2005;22:634-640; Malmberg K et al. J Am Coll Cardiol. 1995;26:57-65; Malmberg K et al. BMJ. 1997;314:1512-1515; Romano G et al. Diabetes. 1997;46:1601-1606; UKPDS Group. Lancet. 1998;352:837-853.

information and patient education links for healthcare professionals
Information and Patient Education Links for Healthcare Professionals
  • American Association of Diabetes Educators (www.diabeteseducator.org)
  • American Association of Clinical Endocrinologists (www.aace.com)
  • American Diabetes Association (www.diabetes.org)
  • International Diabetes Federation (www.idf.org)
  • National Diabetes Education Initiative (www.ndei.org)
  • National Diabetes Education Program (ndep.nih.gov)
  • National Institute of Diabetes and Digestive and Kidney Diseases (www2.niddk.nih.gov)
next steps
Next Steps…
  • What do we do for the patient who has failed on 1 or 2 oral agents?
basal insulin therapy
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”

FPG = fasting plasma glucose.

ADA. Diabetes Care. 2006:29(suppl 1):S4-S42; AACE position statement. Available at: http://www.aace.com/pub/pdf/guidelines/OutpatientImplementationPositionStatement.pdf.

Nathan DM et al. DiabetesCare. 2006;29:1963-1972.

rationale for basal insulin therapy insulin and glucose patterns
Rationale for Basal Insulin Therapy:Insulin and Glucose Patterns

Basal insulin

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;318:1231-1239.

options for initiating insulin therapy
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.

idealized profiles of human insulin and basal insulin analogs
Idealized Profiles of Human Insulinand Basal Insulin Analogs

NPH

Plasma Insulin Levels

Detemir

Glargine

2:00

4:00

6:00

8:00

12:00

14:00

16:00

18:00

20:00

22:00

24:00

0:00

10:00

Time

Plank J et al. Diabetes Care. 2005;28:1107-1112; Rave K et al. Diabetes Care. 2005;28:1077-1082; Rosenstock J, Goldstein BJ, et al, eds. Textbook of Type 2 Diabetes. London, UK, and New York, NY: Martin Dunitz; 2003:131-154.

twice daily split mixed regimens or lispro mix 75 25 aspart mix 70 30

Breakfast

Lunch

Dinner

Insulin Action

4:00

8:00

12:00

16:00

20:00

24:00

4:00

8:00

Time

Twice-Daily Split-Mixed Regimens or Lispro Mix (75/25)–Aspart Mix (70/30)

Glucose levelsInsulin 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;347:1342-1349.

slide27
Open-Label, Twice-Daily Exenatide vs Once-Daily Insulin Glargine: Self-Monitoring Blood Glucose Profiles (n = 549)

Insulin Glargine

10 U/d, titrated to target FPG <100 mg/dL

Exenatide

5 μg bid 1st 4 weeks, then 10 μg bid

240

240

220

220

200

200

180

180

Blood Glucose (mg/dL)

160

160

140

140

Baseline (week 0)

120

120

Baseline (week 0)

Endpoint (week 26)

Endpoint (week 26)

100

100

Prelunch

Prelunch

Predinner

Predinner

3 AM

3 AM

Prebreakfast

Prebreakfast

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;143:559-569.

steps in transition from basal to basal bolus insulin therapy in t2dm

STEP 3

STEP 4

STEP 2

STEP 1

Add insulin

Last meal

Add insulin

Next largestmeal

  • Glargine, Detemir,
  • or NPH HS
  • Weekly titration based on FPG
  • All oral agents continued

Above

target

Above

target

Above

target

Add insulin

Main meal

Steps in Transition From Basal to Basal-Bolus Insulin Therapy in T2DM

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;4:352-357.

case study initiating insulin therapy
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, 12.5 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.

case study cont d
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
decision point

?

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!

treat to target trial oral agents glargine or nph at bedtime
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:

Hermansen K et al. Diabetes Care. 2006;29:1269-1274; Riddle MC et al. Diabetes Care. 2003;26:3080-3086.

treat to target trial oral agents glargine or nph at bedtime n 756 efficacy results
Treat-to-Target Trial: Oral Agents + Glargine or NPH at Bedtime (n=756): Efficacy Results

*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;26:3080-3086.

treat to target trial timing and frequency of hypoglycemia
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

0

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;26:3080-3086.

detemir vs nph insulin in t2dm n 476
Detemir vs NPH Insulin in T2DM (n = 476)

Detemir

NPH

400

350

300

250

200

150

100

50

0

A1C (%)

10.0

9.0

8.0

7.0

6.0

Detemir

NPH

Hypoglycemia Events*

8

20

24

0

2

12

16

4

8

20

24

-2

0

12

16

4

Study Week

Study Week

*All reported events, including symptoms only.

Hermansen K et al. Diabetes Care. 2006;29:1269-1274.

case study cont d37
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)

120-140 2

140-160 4

160-180 6

>180 8

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;26:3080-3086.
  • Hermansen K et al. Diabetes Care. 2006;29:1259-1271.
  • Davies M et al. Diabetes. 2004;53(suppl 2):1980.
case study cont d38
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
decision point39

?

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!

treat to target trial
Treat-to-Target Trial

50

45

Units

Total Daily Dose (U)

42

37

40

33

28

30

21

20

10

10

0

21

0

1

2

3

4

5

6

7

8

10

12

15

18

N = 756.

Riddle MC et al. Diabetes Care. 2003;26:3080-3086.

Weeks in Study

case study cont d41
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
case study cont d42
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
decision point43

?

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.

case study cont d44
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
at lower a1c levels ppg contributes more to overall a1c than fpg
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;26:881-885.

slide46
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

L90

D90

B90

BL

BD

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;28:260-265.

case study cont d47
Case Study (cont’d)

Daily Blood Glucose Diary

Week Ending

March 24

twice daily split mixed regimens or lispro mix 75 25 aspart mix 70 3048

Breakfast

Lunch

Dinner

Insulin Action

4:00

8:00

12:00

16:00

20:00

24:00

4:00

8:00

Time

Twice-Daily Split-Mixed Regimens or Lispro Mix (75/25)–Aspart Mix (70/30)

Glucose levelsInsulin 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;347:1342-1349.

idealized profiles rapid acting insulin analogs

Rapid-acting

Inhaled insulin*

Idealized Profiles: Rapid-Acting Insulin Analogs

Regular insulin

Plasma Insulin Levels

2:00

4:00

6:00

8:00

12:00

14:00

16:00

18:00

20:00

22:00

24:00

0:00

10:00

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; 2003:131-154; Plank J et al. Diabetes Care. 2005; 28:1107-1112; Rave K et al. Diabetes Care. 2005;28:1077-1082.

case study cont d50
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 100-110 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
meal insulin rapid acting analogs lispro aspart glulisine vs regular

Analog insulin

RHI

Timing of

food absorbed

Meal Insulin: Rapid-Acting Analogs (Lispro, Aspart, Glulisine) vs Regular

10

8

6

Insulin Activity

4

2

0

1

2

3

4

5

6

7

8

9

10

11

12

0

Hours

RHI = regular human insulin.

Adapted with permission from Howey DC et al. Diabetes. 1994;43:396-402.

advantages of rapid acting analogs
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;352:174-183.

Becker RHA et al. Exp Clin Endocrinol Diabetes. 2005;113:435-443.

*Heise T et al. Diabetes. 2005;54(suppl 1):A145.

decision point53

?

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!

pre and postmeal efficacy of insulin glulisine vs regular human insulin
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

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.

case study cont d55
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
pce takeaways basal prandial insulin replacement
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
key question59

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Key Question
  • Much more comfortable
  • Somewhat comfortable
  • Slightly comfortable
  • Not comfortable at all

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How much more comfortable do you now feel you will be initiating insulin therapy in your patient population?