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Insulin Initiation and Titration for Family Physicians: Case Study #1: William. Alice Y.Y. Cheng, MD FRCPC Peter Lin, MD CCFP. Case Study #1: William. Patient history and presentation 59-year-old male stockbroker Type 2 diabetes x 8 years Weight = 90 kg A1C = 7.9%

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insulin initiation and titration for family physicians case study 1 william

Insulin Initiation and Titration for Family Physicians:Case Study #1: William

Alice Y.Y. Cheng, MD FRCPC

Peter Lin, MD CCFP

case study 1 william
Case Study #1: William

Patient history and presentation

  • 59-year-old male stockbroker
  • Type 2 diabetes x 8 years
  • Weight = 90 kg
  • A1C = 7.9%
  • He is on metformin, an insulin secretagogue and a TZD – he is at the maximum dose of all three oral agents
  • You have been proposing that he start insulin during the past few visits in the last year, and he is now becoming more agreeable to the idea
case study 1 william cont d
Case Study #1: William (cont’d)

Case review

  • William has suboptimal glycemic control, according to the guidelines
  • He is maxed out on oral agents
  • He continues to have high BG levels, particularly in the morning
  • What insulin regimen would you prescribe?
type 2 diabetes insulin categories
Type 2 Diabetes: Insulin Categories
  • Basal
  • Basal plus bolus
  • Pre-mixed twice daily
case study 1 william cont d6
Case Study #1: William (cont’d)
  • The easiest insulin to start would be basal insulin at bedtime, which has the advantage of a single injection – so it is easy to remember
  • At this point, the TZD should be discontinued (to minimize risk of edema); however, the metforminand insulin secretagogue can both be continued
slide7

CHOOSE AN INSULIN CATEGORY

CHOOSE A BRAND

DOSING

SEE REVERSE FOR TIPS

case study 1 william three years later
Case Study #1: WilliamThree Years Later
  • William had achieved an A1C <7.0% over the past few years with basal insulin plus metformin and an insulin secretagogue
  • However, in the past 6 months his A1C has started to climb; it is now 7.5%
  • He is currently on 50 units of basal insulin daily
slide12

CHOOSE AN INSULIN CATEGORY

DOSING

SEE REVERSE FOR TIPS

CHOOSE A BRAND