Starting insulin therapy in type 2 diabetes requires individualized dosing, monitoring, and consideration of alternative medications.
Deintensification of insulin therapy in older adults should involve lowering basal insulin doses and evaluating overall health and lifestyle factors.
Insulin therapy can be managed in patients with advanced chronic kidney disease by considering GLP-1 agonists and close monitoring of kidney function.
Deep dives
Summary 1
The first main idea discussed in the podcast is the importance of starting insulin therapy in patients with type 2 diabetes who have high levels of hyperglycemia. Basal insulin is often the first choice, with guidelines recommending a starting dose of 0.1 to 0.2 units per kilogram per day. The dose can be titrated every two to three days based on fasting blood sugar levels. The podcast also mentions alternative options such as GLP-1 agonists and SGLT2 inhibitors, but notes that these may be more expensive and require insurance coverage. It is important to monitor and adjust insulin doses as needed to achieve glycemic control while avoiding hypoglycemia.
Summary 2
The second main idea explores the need for de-intensification of insulin therapy in certain patients, particularly in older adults. For patients who are experiencing hypoglycemia or whose insulin needs have decreased, reducing insulin doses is necessary. The podcast suggests lowering basal insulin doses by 10-20% and adjusting mealtime insulin doses to prevent severe lows. The importance of evaluating overall health, appetite, and lifestyle factors is emphasized in determining appropriate insulin adjustments. The goal is to establish a balance between mealtime and basal insulin to avoid excessive insulin use and weight gain. Lastly, the use of simplified regimens, such as transitioning basal insulin dosing from nighttime to morning, is mentioned as a potential strategy to simplify insulin therapy and improve adherence.
Summary 3
The third main idea focuses on the management of insulin therapy in patients with insulin-requiring type 2 diabetes and advanced chronic kidney disease (CKD). The podcast acknowledges that certain diabetes medications may not be suitable for patients with CKD due to safety concerns. However, it suggests considering the use of GLP-1 agonists, even in patients with moderate kidney impairment, as they may provide glycemic control benefits without significant risk of adverse effects. Individualized care, close monitoring of kidney function, and consultation with a healthcare provider are essential when managing insulin therapy in patients with advanced CKD.
Starting Basil Insulin in Type 2 Diabetes
When starting basil insulin in type 2 diabetes, it is important to pair it with education on detecting and treating hypoglycemia. Insulin should be initiated when beta cells begin to fail, and it is usually started at a dose of 0.1 to 0.2 units per kilogram per day, aiming for a fasting blood sugar target of 90 to 130. The dose can be increased by two units every three days if the blood sugar is not within the target range. Basil insulin is considered safe, and it is hard to make a patient hypoglycemic with basil insulin alone. Patients should be taught the rule of 15 for treating hypoglycemia, which involves consuming 15 grams of glucose, waiting 15 minutes, and then rechecking blood sugar. Glucagon can also be prescribed for severe cases of hypoglycemia. The American Diabetes Association (ADA) has a useful app for insulin therapy.
Managing Hypoglycemia and Simplifying Insulin Therapy
Counseling on detecting and treating hypoglycemia is essential when starting insulin therapy. Patients should be aware of symptoms such as hunger, anxiety, and sweating, and they should regularly monitor their blood sugar levels. In cases of hypoglycemia, consuming 15 grams of carbohydrates, such as glucose tablets, following the rule of 15, can help raise blood sugar levels. If hypoglycemia symptoms persist or if the patient becomes unconscious, glucagon can be administered. The goal of insulin therapy is not to normalize blood sugar levels but to achieve safe and rational targets. Simplification of insulin therapy is possible by considering basal plus one or basal plus two regimens, adjusting dosing based on meal frequency, and focusing on safe blood sugar ranges rather than achieving perfection.
Don’t be scared of insulin or hypoglycemia anymore! Our Kashlak Friend of the Pod Dr. Jeff Colburn gives us all the essentials you’ll need in your fanny pack for navigating the ups and downs of insulin in type 2 diabetes.
