Basal Insulin Initiation
Do We Still Need Insulin?
When and in Whom to Initiate Insulin in T2D
When to consider insulin initiation | When NOT to initiate insulin |
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Maximally tolerated non-insulin agents but A1C above the individualized target (usually 7.0%) New diagnosis A1C ≥ 8.5% Metabolic decompensation End-organ failure Patients with previous or current gestational diabetes Acute illness Prolonged course of steroids Intolerance to oral medications Any time you consider this is an appropriate option for your patients from diagnosis onwards | There are no contraindications for the use of insulin but insulin may not be appropriate for: Some older, asymptomatic patients, who may not gain sufficient benefit because of short life expectancy People limited in their capacity (physical or cognitive) to manage their diabetes who are at greater risk of hypoglycemia |
What are the Barriers to Insulin Initiation?
Provider barriers | Panel recommendations to address provider barriers |
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Excess weight gain Hypoglycemia Impaired quality of life | |
Assumptions about patient inability to use insulin Assumptions about patient refusal to use insulin | |
Drug costs Availability of staff Skills needed to support insulin initiation Time | Utilize resources from Diabetes Canada including: The Insulin Prescription Tool: http://guidelines.diabetes.ca/bloodglucoselowering/insulinprescriptiontool and videos: http://guidelines.diabetes.ca/insulin |
Reluctance to utilize insulin early in the diagnosis of T2D [9] |
Concern | Panel recommendations |
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Fear of needles or apprehension toward injections Feeling that insulin is too complicated | Demonstrate injection technique: show the insulin pen and small needle tips. Apply the principles of systematic desensitization (self-controlled exposure) Highlight that the injection is into subcutaneous tissue, not a vein Invite patient to try these without insulin, in your office (i.e., dry injection); give first injection together with patient to observe, support and ensure correct administration of insulin Educating on injections: see |
Pro-action. Do not wait to talk about insulin once the patient needs insulin. Explain from the time of diagnosis that insulin is a likely treatment option in the course of T2D [46] Discuss with the patient, using decisional balance analysis (pros and cons), that need to advance therapy is due to the progressive nature of diabetes, not because the patient has done something wrong | |
Insulin is a natural hormone and a replacement therapy [42] Explain why insulin becomes necessary for most patients with diabetes eventually; it is not a punishment [46] | |
Reassure the patient that most hypoglycemic episodes are mild. Severe hypoglycemia (defined as requiring assistance by another person) is relatively rarea [52] http://guidelines.diabetes.ca/browse/chapter14; Educate the patient on how to recognize and respond to symptoms [52] http://guidelines.diabetes.ca/browse/chapter14 Make sure the patient and partner/family (if applicable) know how to recognize, treat, and avoid hypoglycemia, and how to self-adjust insulin [34] Use systematic desensitization to allow the patient to work from a psychologically safe zone to a medically safe zone | |
Encourage healthy diet and moderate exercise. Monitor weight. http://guidelines.diabetes.ca/fullguidelines Combine insulin with metformin or other NIAHA with weight benefit. http://guidelines.diabetes.ca/cdacpg_resources/CPG_Quick_Reference_Guide_WEB.pdf [14, 29] | |
Offer a 3-month trial period with subsequent reassessment. http://guidelines.diabetes.ca/fullguidelines Prescribe once-daily basal insulin that minimizes inconvenience and is easy to use. http://guidelines.diabetes.ca/bloodglucoselowering/insulinprescriptiontool |
What is Your Role in Insulin Therapy?
Listen and ask | Actively listen to fears and concerns. Normalize these concerns before discussing alternatives Invite discussion, show conviction of belief and supportive body language |
Educate | Ask permission to educate about the importance of insulin, the progressive nature of the disease, how to self-manage their disease |
Address | Proactively address patient concerns that may deter initiation and adherence to insulin Ask questions, identify the barriers, outline goals |
Support | Enlist support of diabetes management team Provide continuous support and education through the course of treatment |
Empower | Encourage and educate the patient on self-management: demonstrate how the pen works and let them try it, explain how to take medications, how to self-monitor blood glucose, how to prevent and treat hypoglycemia, reinforce healthy lifestyle and diet Be comfortable with the principle of shaping: in other words, with repetition and support for next step goals, self-efficacy in a new behavior can develop |
Basal Insulin Dose and Titration Recommendations
What Do We Want in a Basal Insulin Recommendation?
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A starting dose that can be safely applied and individualized.
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A titration schedule that is simple and can be safely patient-driven, with a fasting blood glucose (FBG) target that can be individualized. Patient-driven titration schedules are as effective as provider-driven titration schedules [19, 59‐64] and engage the patient, which in turn can lower barriers to insulin therapy [4, 65, 66].
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Recognition that insulin initiation and titration are two separate behaviors for the patient, each of which needs to be addressed in relation to patient readiness to change.
How to Select a Basal Insulin?
Insulin classification | Duration of action | CV safety | Risk of nocturnal hypoglycemia | Considerations | |
---|---|---|---|---|---|
Intermediate-acting | NPH | ~ 18 h | – | +++ | Needs resuspension Administered usually twice daily |
Long-acting | Detemir | 16–24 h | – | ++ | Administered once or twice daily |
Gla-100 | ~ 24 h | Demonstrated (neutral) | ++ | Administered once daily, same time of day Available in a fixed-ratio combination with lixisenatide | |
Next generation | Gla-300 (U300) | ~ 30 hb | Demonstrateda (neutral) | + | Smaller volume (U300) Administered once daily Flexible + |
Degludec (U100, U200) | ~ 30 hb | Demonstrated (neutral) | + | Option smaller volume (U200) Administered once daily Flexible ++ U100 available in a fixed-ratio combination with liraglutide |
How to Dose?
Basal Insulin Dose and Titration Recommendations (2017)
Panel recommendations | Comments | |
---|---|---|
The initial dosea | 10 U/day Other considerations: Using FBG as starting point: e.g., if FBG is 16 mmol/L start at 16 U [59] | May need to be lower for some patients—recall that the starting dose should be individualized [14] The lower dosages have the advantage of decreasing the risk of a hypoglycemic reaction with the first injection, but make the titration period a bit longer Discuss and negotiate your patient’s expectation |
Fasting SMBG target | Target should be 4.0–7.0 mmol/L for most people Patient/HCP contact recommended at 7.0 mmol/L. HCP may then suggest continuing to 4.0–5.5 mmol/L | Individualize target with a step approach (within 3 months) [14] Important to educate that diabetes is a progressive disease and this is a moving target [4] |
Dose adjustments | Select a simple titration algorithm that matches patient lifestyle [57] The following dose adjustment algorithms have been shown to be safe and effective. Select the one that is easiest for the patient to follow: One easy titration algorithm is Other titration algorithms include: Other considerations: If (nocturnal) hypoglycemia occurs (BG < 4.0 mmol/L) reduce the dose by 2–4 units, or 10% of the basal dose based on clinical judgement [57] For other considerations, see Table 6 | Measure glucose level at least every morning before breakfastc [57] Remind patient to adjust the basal insulin based on morning glucose not bedtime glucosec [57] Assess for possible hypoglycemia (< 4.0 mmol/L) and decrease titration [52] http://guidelines.diabetes.ca/fullguidelines/chapter14 Recognize that patient fear of hypoglycemia is easily elicited (hypoglycemia is a traumatic stress) and that providers underestimate the psychological impact of nonsevere hypoglycemia [51] Mitigating hypoglycemia: Is there an identifiable cause? [52] http://guidelines.diabetes.ca/fullguidelines/chapter14 Teach patients how to prevent, recognize, and treat hypoglycemia [52] http://guidelines.diabetes.ca/fullguidelines/chapter14 Confirm with patient that it is not “pseudo-hypoglycemia”. Explain what pseudo-hypoglycemiad is and ways to mitigate it [54] If no identifiable and preventable cause is identified, reduce the dose Confirm patient is using an accurate glucometer |
Optimal/maximum basal insulin dose | Communicate how long it will take them to reach target (e.g., if the expected dose is 60 units at 1 U/day increase, then it will take on average 6 weeks) | Indication that basal insulin is not enough includes: Up-titrations without a corresponding drop on BG (verify patient adherence and check injection sites). http://www.fit4diabetes.com/canada-english/fit-recommendations/ Patient has surpassed 1 U/kg/day of basal insulin without sufficient FBG control [87] FBG in target, but A1C above target |
Frequent Questions and What to Do with Previous Drugs When Initiating Basal Insulin
Question | Answer |
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Is 4.0 to 7.0 mmol/L too aggressive? | Depends on individual target and patient characteristics (e.g., younger patient, patient with established retinopathy/nephropathy, etc.). http://guidelines.diabetes.ca/cdacpg_resources/CPG_Quick_Reference_Guide_WEB.pdf |
Is there a ceiling to titration process? | There is no such thing as a maximum dose [8] Consider resuming titration when FBG values are above patient-agreed target for 3 consecutive days; resume 1 unit daily titration unti FBG < 7.0 mmol/L is reached without hypoglycemia Patient/HCP contact recommended at 7.0 mmol/L |
What to do if daytime hypoglycemia occurs while on secretagogues? | Dose adjustment of secretatogue and/or basal insulin recommended If on NPH, consider basal analogue |
When is it appropriate to intensify treatment with another agent? | When A1C level remains above individual target after 3–6 months despite appropriate treatment initiation and optimization have occurred or insulin dose is > 1.0 U/kg/day. http://guidelines.diabetes.ca/cdacpg_resources/CPG_Quick_Reference_Guide_WEB.pdf |
What to do if sickness occurs? | Normally continue with the usual dose of basal insulin Test more frequently If problems eating or hydrating: stop metformin, SGLT2 inhibitor, insulin secretagogue, ACE inhibitor, ARBs, diuretic, NSAIDs Use SADMANS http://guidelines.diabetes.ca/browse/appendices/appendix7_2015. Complete the card (accessed by clicking on the link) and give it to your patient, including when to call and whom to reach for support [88] |
What to do if patient has recently been hospitalized for a few days? | Verify if the dosages were modified during the hospitalization. The dosages are often decreased as the patient eats hospital food, and must often be increased back towards the previous dosages |
What to do if unsure whether the dose was given? | Do not give the dose if unsure Test more frequently If values rise, may consider giving half the dose [88] Additional comments: Suggest using supportive tools or an insulin pen that has a memory feature that will indicate if the dose was given and when |
What to do if gave the dose twice? | Test more frequently Take extra snack at bedtime Wake up every 2–3 h to test glucose. If < 7.0 mmol/L, take an extra snack [88] Additional comments: Check available resources in area: For example, call a nurse for advice, diabetes educator available for support, a 24 h pharmacy for a pharmacist’s advice Phone an “on-call” service and consider referral to ER |
What to do if missed a dose? | If < 6 h: take usual dose (be aware of potential increase in risk of hypoglycemia with next injection) If 6–12 h: take 50% of normal dose If > 12 h: consider omitting dose or give 50% when remember and 50% next dose and resume as per usual dosing administration schedule [89]
Additional comments
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Does insulin stacking (build-up of insulin in the circulation) occur with the long-acting basal insulins? [90] | No, there will be a steady state reached. The steady state will take longer to reach the longer the half-life of the insulin, minimizing the fluctuations in insulin levels [90] |
When to consider seeking support from other HCPs? [87] | Patient has surpassed 1 U/kg/day of basal insulin without sufficient FBG control Patient has recurrent episodes of hypoglycemia Patient lacks engagement in the titration process. It is important to explore reasons for lack of engagement by screening for diabetes distress |
When to refer to a specialist? [87] | Patient has frequent episodes of unexplained hypoglycemia Patient experiences complications (allergic reactions, lack of treatment response, edema, etc.) A1C level remains above individual target after 3–6 months despite appropriate treatment initiation and optimization have occurred At any point when comfort level is exceeded with available resources. It should be openly acknowledged that if either the patient or provider thinks they are “in over their head,” accessing additional resources is appropriate |
Anti-hyperglycemic agent | Anti-hyperglycemic agents when initiating basal insulin | Comments | |
---|---|---|---|
Metformin | Continued | – | |
Insulin secretagogues (meglitinide and sulfonylurea (SU)) | Option to continue, reduce, or stop meglitinide [8] | If SU is stopped or reduced, titration of insulin is even more important When stopping SUs: Patients may need more insulin or go beyond basal insulin as glucose levels may go higher As a guideline, stopping SU is equivalent to about 20 U of insulin. Individual results necessitate monitoring and titration [94] | |
TZDs | Usually discontinueda [95] | ||
Incretin agents (GLP-1R agonist, DPP4i) | – | ||
SGLT2 inhibitor | Continued | – |
Patient Support and Medical Follow-up
How to Ensure Success of Basal Insulin Management?
Panel Recommendations for Medical Follow-up with Diabetes HCPs
When | What and why |
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24–72 h | When initiating insulin or titration Support insulin initiation and reinforce titration |
1–2 week(s) | Patients report BG readings Ensure titration is occurring normally |
1 month | Patients report BG readings Ensure titration is occurring normally (it is encouraged to continue with biweekly contacts thereafter) |
3 months | A1C measurement If not at goal, patient may continue with titration for another 3 months This contact point should occur in person or by virtual consult |
6 months | A1C measurement Follow-up of titration If A1C above target, review glycemic profile and consider adding mealtime insulin |
Within 24 h of hypoglycemia | Educate patient on recognizing, preventing, and treating hypoglycemia If recurrent hypoglycemia occurs, re-evaluate titration schedule or reduce dose (frequent, recurrent hypoglycemia is typically defined as 1–2 lows in 1 week) |