# Presentation: 092669

## Titrating Insulin to Glycemic Target

- Judy Bowen, MD
- CIM Rotation
- September, 2006

## Case 1

- Mrs. G, 46 y.o. was diagnosed with Type 2 DM diagnosed 5 years ago (initially treated with diet and exercise, then glipizide XL 5 mg BID and metformin 1,000 mg BID) has these Hgb A1c values q 3 months over the past year:
- 5.8%
- 6.3%
- 7.4%
- 7.8%

## Case 1, continued

- Her BMI is 33, BP is 126/72, micro-albumin is 9 on lisinopril 10 mg, LDL is 89 on Lipitor 10 mg.  She takes 81 mg ASA daily.  Her eye exam is up-to-date and normal.  Monofilament exam is normal.  Your exam is normal except for her obesity.
- Her fasting a.m. CBGs are 140-180
- What do you recommend?

## Schematic of 24-hour glucose profile

- Riddle M. AJM, 2004; 116:3S-9S

## Initiating basal insulin therapy

- Add basal insulin therapy
- Start with 10 units insulin in most patients
- Use either NPH or glargine (both work)
- NPH q HS, glargine either q HS or q AM
- Glargine was associated with less nocturnal hypoglycemia (Riddle et al, Diabetes Care, 2003; 26:3080-3086)
- Continue with oral agents
- Consider adverse effects

## Treat-To-Target

- Goal:  near normal fasting CBGs (~100 mg/dl)
- Adjust dose weekly
- based on average of two previous fasting CGBs
- Titration:
- If CBG >/= 180, increase insulin by 8 units
- If CBG 140-180, increase insulin by 6 units
- If CBG 120-140, increase insulin by 4 units
- If CBG 100-120, increase insulin by 2 units
- No increase if any hypoglycemia (CBG < 72) with or without symptoms

## Relationship of A1c to CBG

**4%**

**5%**

**6%**

**7%**

**8%**

**9%**

**10%**

**65**

**100**

**135**

**170**

**205**

**240**

**275**

## Relationship of A1c to CBG

**4%**

**5%**

**6%**

**7%**

**8%**

**9%**

**10%**

**65**

**100**

**135**

**170**

**205**

**240**

**275**

## Case 1, continued

- Mrs. G agrees to start bedtime glargine 10 units, and feels confident she can titrate using the “Treat to Target” instructions with RN follow up.  Over the next 3 weeks, she achieves fasting CBGs in the 100-120 range with 20 units glargine at bedtime, and no symptoms of hypoglycemia.  Her follow up Hgb A1c 3 months after starting insulin is 6.5%

## Case 2

- Mr. M, a 65 year-old patient with Type 2 DM for 10 years is on metformin 1,000 mg BID and insulin:
- NPH q a.m. 30 units + Regular 10 units
- NPH q p.m. (supper) 25 units + Regular 15 units
- His fasting CBGs are in the 120’s but his Hgb A1c is now 8.0%.  He wants better control.
- What do you recommend?

## Switching to Basal/Prandial Insulin

- To switch to glargine
- Add up his current total insulin dose (80 units)
- Reduce by 20% (64 units)
- Give half as glargine (32 units)
- Titrate using fasting CBGs and ‘treat-to-target’
- To add lispro/aspart
- (Onset is 5-15 min, peak is 30-90 min, duration is 3.5 –5 hours)
- Send to Diabetes Education to learn carb counting
- Give remaining “half” of total dose based on meals:
- 10 + 10 + 12 depending on carb load

## Pearls

- Insulin therapy is associated with weight gain
- Glargine doesn’t last 24 hours in every patient (nor is NPH predictable)
- We usually wait too long to start insulin in Type 2 patients
- Early insulin therapy may be associated with better daytime prandial secretion from native pancreas
- Finger sticks are more painful than insulin shots