It is a game that allows you to be less than perfect and still win unless you become a victim of " treatment inertia". Todays post is a continuation of the case initially discussed Oct 17 and Oct. 22 . Please review the previous post for details.
middle age male with uncontrolled Type 2 diabetes. His fasting glucose is over 300 mg/dl and associated with markedly elevated LDL cholesterol and Triglyceride level. I have discussed the problems associated with trying to correct his LDL cholesterol and Triglyceride without first correcting his glucose levels on previous post.
Today we will discuss " treatment inertia" and insulin options.
is common and is basically a failure of diabetes patients and their doctors to adjust treatment regimens to keep up with with the progressive development of insulin deficiency in people with Type 2 Diabetes
Remember insulin works for people with Type 2 and Type 1 Diabetes .
Unfortunately insulin it is ofter thought of as the dreaded medication of last resort for people with type 2 diabetes.
I recall a discussion with a well known Diabetes specialist who started all of his new patients with type 2 diabetes on insulin and taught them how to control their blood sugars. He then waited until their blood sugars were under control and they were feeling well before discussing other treatment options. That approach seems a little extreme but is much better than the more common approach that happens every day in doctors offices around the world, Treatment Inertia. Treatment inertia is generated by patients and doctors reluctance to move to a medicine that works ,adequate insulin replacement .
Our patient is a self inflicted victim of treatment inertia . He is taking taking insulin but his technique and doses are inadequate doses to get the job done. As you may recall he has a fasting glucose of over 300mg/dl and takes inadequate doses of Lantus and a short acting insulin and plans to try Bydureon.
Remember it takes more insulin to bring glucose levels down than it does to maintain them in a lower risk range. 80 to 130 mg/dl
Successful use of insulin requires training and persistance
Correct the fasting glucose with adequate doses of Lantus insulin
See an endocrinologist if necessary to get and learn how to use a Lantus insulin adjustment protocol that will allow you to safely adjust lantus insulin to keep your fasting glucose in the target range .
Correct before meal glucose levels with with a rapid acting insulin such as Novolog or Humalog before the preceding meal.
Use insulin / carbohydrate ratios plus additional rapid acting insulin before Breakfast , lunch and dinner to correct the glucose before the meal and to cover the carbohydrate to be eaten. This will require work and a few visits with your doctor and /or Diabetes educator.
You will need 2 calculations:
-Insulin / Carbohydrate ratios
units of insulin needed / grams of carbohydrate to be eaten
-Corrective dose for elevated glucose before the meal
Insulin Units / to correct mg./dl ( mm/l )increase in glucose levels
This is easier than it sounds , for example;
My glucose before lunch is 200 mg/dl ( 11.1 mm/l)
I plan to eat 60 grams of carbohydrate for lunch
my insulin carbohyrate ratio is
1 unit of novolog/ 20 grams of carbohydrate = 3 units
my corrective dose is
1 unit of Novolog for each 50 mg(2.8 mm/l) increase in glucose over 100 mg/dl = 2 units
My total dose of Novolog before lunch = 5 units
This will allow him to gain control of his glucose levels , feel good again and may
allow his other diabetes medications to be more effective .He may be able to wean the insulin down slowly and control his glucose levels glucophage ( metformin) with one injection of Lantus insulin a day and one injection of Bydureon a week ( Byetta twice daily or victoza once daily) or a DPP-4 inhibitor
*DPP-4 inhibitors *GLP-1 Agonist *Glucophage
Januvia ( sitigliptin) Byetta or Bydureon (exenatide ) metformin
Onglyzia ( saxagliptin ) Victorza (liraglutide )
Tragentia (linaglipitin )
Insulin / Carbohydrate ratios
The amount of rapid acting insulin needed to cover a amount of carbohydrate to be eaten
Insulin / glucose ratio
Additional rapid acting insulin need to correct an elevated glucose before a meal. This is a very individual number that needs to be developed with help from your doctor or diabetes educator.For example a thin insulin sensitive person may require 1 unit of insulin to correct each 50 mg/dl ( 2.8 mm/L) increase in before meal glucose to their target goal and a heavier person who is more insulin resistent may require 1 unit of insulin/ 5 mg/dl (.3mm/L) to correct a elevated before meal glucose
Have fun Be Smart and remember managing diabetes is not easy but the rewards of management are great. Do not become a victim of treatment inertia .
David Calder, MD