Monday, October 29, 2012

Is our case a victim of "Treatment Inertia"

Diabetes is just a game of numbers

 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.

Quick Review
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.

"Treatment inertia"
 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.

Adequate aggressive insulin use will allow  a person with type 2 Diabetes to gain control of their blood sugar and then possible  wean off of / or reduce their dose of the insulin and be able to have a better response to *oral medications or other injectable medications such as Byetta ,Bydureon or Victoza . 

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

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Your comments and questions are appreciated. David Calder,MD