Type 2 Diabetes Mellitus: Outpatient Insulin Management

 

Am Fam Physician. 2018 Jan 1;97(1):29-37.

Author disclosure: No relevant financial affiliations.

In patients with type 2 diabetes mellitus, insulin may be used to augment therapy with oral glycemic medications or as insulin replacement therapy. The American Diabetes Association suggests the use of long-acting (basal) insulin to augment therapy with one or two oral agents or one oral agent plus a glucagon-like peptide 1 receptor agonist when the A1C level is 9% or more, especially if the patient has symptoms of hyperglycemia or catabolism. Insulin regimens should be adjusted every three or four days until targets of self-monitored blood glucose levels are reached. A fasting and premeal blood glucose goal of 80 to 130 mg per dL and a two-hour postprandial goal of less than 180 mg per dL are recommended. Insulin use is associated with hypoglycemia and weight gain. Insulin analogues are as effective as human insulin at lowering A1C levels with lower risk of hypoglycemia, but they have significantly higher cost. Patients with one or more episodes of severe hypoglycemia (i.e., requiring assistance from others for treatment) may benefit from a short-term relaxation of glycemic targets. Several new insulin formulations have been approved recently that are associated with less risk of hypoglycemia compared with older formulations. The goals of therapy should be individualized based on many factors, including age, life expectancy, comorbid conditions, duration of diabetes, risk of hypoglycemia, cost, patient motivation, and quality of life.

Type 2 diabetes mellitus is a chronic, progressive disease characterized by multiple defects in glucose metabolism, the core of which is insulin resistance in muscle, liver, and adipocytes and progressive beta cell failure.1 Beta cell failure progresses at a rate of approximately 4% per year, requiring the use of multiple medications, often including insulin, to attain and maintain glycemic control.2

Data from the National Health and Nutrition Examination Survey show that the percentage of U.S. adults with diabetes and an A1C level of more than 9% decreased slightly between 2003 to 2006 and 2007 to 2010, from 13% to 12.6% (relative risk reduction = 3.1%; 95% confidence interval, −3.8% to –3.0%).3 According to the Centers for Disease Control and Prevention, from 2010 to 2012, 57% of patients with type 2 diabetes used only oral diabetes medications.4 Thus, it is likely that many patients who should be receiving insulin therapy are not. American Family Physician recently published a review of noninsulin therapies for type 2 diabetes.5 Our article reviews insulin management in the outpatient setting.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Clinicians should minimize the use of concomitant medications that may cause weight gain when treating patients with insulin therapy for type 2 diabetes mellitus.

C

6, 911, 33

Consider initiating basal insulin to augment therapy with one or two oral agents or one oral agent plus a GLP-1 receptor agonist when the A1C is 9% or more, especially if symptoms of hyperglycemia or catabolism are present. Or, consider the addition of basal insulin to augment therapy with two oral agents with or without GLP-1 receptor agonists when the A1C is more than 8%.

C

9, 10

Consider initiating insulin replacement therapy when the blood glucose level is 300 to 350 mg per dL (16.7 to 19.4 mmol per L) or more or the A1C is more than 10% to 12%. Also consider adding rapid-acting insulin in those patients taking basal insulin who are already on augmentation therapy but not attaining A1C goals.

C

9, 10

Insulin analogues may be used to reduce the risk of hypoglycemia.

A

28, 29

The A1C goal should be individualized based on age, life expectancy, comorbid conditions, duration of diabetes, risk of hypoglycemia, adverse consequences related to hypoglycemia, or patient motivation and adherence.

C

9, 10, 1825

Intensive control of type 2 diabetes (A1C goal below 7%) significantly decreases the need for photocoagulation treatment of diabetic retinopathy but increases hypoglycemia and mortality risk.

A

13, 3337


GLP-1 = glucagon-like peptide 1.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Clinicians should minimize the use of concomitant medications that may cause weight gain when treating patients with insulin therapy for type 2 diabetes mellitus.

C

6, 911, 33

Consider initiating basal insulin to augment therapy with one or two oral agents or one oral agent plus a GLP-1 receptor agonist when the A1C is 9% or more, especially if symptoms of hyperglycemia or catabolism are present. Or, consider the addition

The Authors

show all author info

AMANDA HOWARD-THOMPSON, PharmD, is a clinical pharmacy specialist at the Veterans Affairs Medical Center, Memphis, Tenn., and an associate professor at the University of Tennessee Health Science Center College of Pharmacy in Memphis....

MUNEEZA KHAN, MD, FAAFP, is an assistant professor and program director at the University of Tennessee Health Science Center College of Medicine's Saint Francis Family Medicine Residency.

MORGAN JONES, PharmD, MS, is a primary care clinical pharmacy specialist at the Cleveland Clinic Independence (Ohio) Family Health Center. At the time this article was written, she was a second-year resident in ambulatory care pharmacy and academia at the University of Tennessee Health Science Center College of Pharmacy.

CHRISTA M. GEORGE, PharmD, is an associate professor of clinical pharmacy and family medicine at the University of Tennessee Health Science Center College of Pharmacy.

Address correspondence to Amanda Howard-Thompson, PharmD, Veterans Affairs Medical Center, 1689 Nonnconnah Blvd., Room 1419, Memphis, TN 38132 (e-mail: amanda.howard-thompson@va.gov). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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