Intensive Insulin Therapy
To help patients meet their glycosylated hemoglobin (HbA1c) goals, more of them should be using basal-bolus, or “intensive,” insulin. With intensive insulin treatment, patients give themselves an injection of short-acting insulin before each meal and an injection of longer-acting insulin before going to bed.
What holds them back, according to Richard Bergenstal, MD, Clinical Professor at the University of Minnesota Medical School in Minneapolis, is that counting carbohydrates at meals for matching up their rapid-acting insulin on top of “background” 24-hour insulin is perceived as too complicated. The solution—a simple mealtime insulin-dosing algorithm— appears to be safe, feasible, and effective, based on study results that he presented.
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“This new dosing approach relies on a simple algorithm that allows patients to start with a fixed dose of mealtime [insulin] glulisine and then adjust to target based on pre-meal glucose patterns,” Dr. Bergenstal explained.
When weekly blood sugar records show glucose to be out of range for a meal, insulin doses for the prior meal are adjusted upward or downward by 1 to 3 units accordingly.
The strategy was tested in a randomized clinical trial that compared the simplified fixed-dose method with carbohydrate counting among 273 patients with type-2 diabetes. The mean age of the patients was 55 years.
The patients received 24-hour insulin glargine (Lantus, Sanofi-Aventis) and rapid-acting insulin glulisine (Apidra, Sanofi-Aventis). The baseline adjusted mean HbA1c was 8.16% in both groups.
After 24 weeks, patients in the algorithm and carbohydrate-counting groups achieved similar mean HbA1c values (6.70 for the algorithm, 6.54 for carbohydrate counting), with most patients achieving HbA1c targets of below 7%. Furthermore, rates of hypoglycemia (indicated by a blood glucose level below 50 mg/dl) were lower in the algorithm group (4.9 vs. eight events per patient-year [P = .02]); however, these patients gained more weight (3.7 kg) than the carbohydrate-counting group (2.4 kg) (P = .06).
Body mass index (BMI) increased significantly in both groups, compared with baseline levels (P = .0001). The BMI increase was significantly greater in the algorithm group (1.3 kg/m2) than in the carbohydrate-counting group (0.8 kg/m2) (P = .03). canadian antibiotics
“When you drive blood sugar down, people start retaining the calories they eat,” Dr. Bergenstal explained. He said that the reduction in risk accompanying the HbA1c decreases was far beyond the risk added with extra weight gain. With tight glucose control, instead of excreting sugar in urine, the body converts the glucose to fat.
“We hope to help them take that off,” he said.
Dr. Bergenstal commented, “Some people just don’t want their whole life to be about their diabetes. So if they know, ‘I just take 10 units every breakfast and I take 12 at lunch—and 18 at supper’—that’s simple enough.”