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Case Study: Five Steps to Freedom: Dose Titration for Type 2 Diabetes Using Basal-Prandial-Correction Insulin Therapy

The first 300 words of the full text of this article appear below.

	Presentation of a Hypothetical Patient

 
Mary, age 53, was seen as a new patient. She had a history of type 2 diabetes for 17 years. Her BMI was 31 kg/m². She had attempted to adhere to lifestyle measures for treatment of diabetes and had previously consulted with diabetes educators. She was fairly active at her job.

She was taking 90 units of peakless insulin (glargine) at bedtime in addition to pioglitazone, 45 mg daily; metformin, 1,000 mg twice daily; and glimperide, 8 mg daily. Her hemoglobin A_1c (A1C) was 8.5%. She had average prebreakfast glucose readings of 110 mg/dl. At other times of day, there were premeal glucose readings of 170-240 mg/dl and some peak postprandial readings > 300 mg/dl.

Under the supervision of her previous health care provider, over a 12-month period of combined glargine and triple oral therapy, the strategies of changing the time of peakless insulin administration to the morning and, later, splitting the peakless insulin dose into equal morning and bedtime components had failed to change her blood glucose pattern. A conceptual diagram of the average daily excursions of blood glucose at the time of her presentation is shown in Figure 1.

View larger version (8K): [in this window] [in a new window]   Figure 1. Pattern of blood glucose suggesting insufficient prandial insulin effect.

At the conclusion of the visit, she commented that she wanted to do whatever was necessary to get better results, and she agreed to replace the glimepiride with prandial use of insulin. The glimepiride was discontinued. The pioglitazone dose was reduced to 30 mg daily, with consideration of possible future discontinuation because of cost factors. The metformin was continued.

The combined total amount of the starting doses of insulin under a basal-prandial-correction regimen was assigned at 80% of the former peakless insulin dose. The insulin was divided into 36 units of peakless insulin at bedtime and 12 units . . . [Full Text of this Article]

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