What to do after basal insulin: 3 Tx strategies for type 2 diabetes

In order to use the ICR regimen, a patient would need to be able to accurately determine the nutritional content of his meals (starch, protein, carbohydrates, and fat) and calculate the appropriate insulin dosage. For successful diabetes management, it is essential to evaluate the patient’s skills in these areas before starting an ICR regimen, and to routinely assess hypoglycemic episodes at follow-up visits.

An ICR approach is usually reserved for patients who require tighter glucose control than that obtained from fixed prandial insulin doses, such as patients with type 1 diabetes, those with variable meal schedules and content, those with a malabsorption syndrome that requires consuming meals with a specific amount of carbohydrates, athletes on a structured diet with specific carbohydrate content, and patients who want flexibility with carbohydrate intake with meals.

The risk of hypoglycemia is a major barrier to initiating basal-bolus insulin therapy. Hypoglycemia is classified as a blood glucose level of <70 mg/dL, and severe hypoglycemia as <50 mg/dL, regardless of whether the patient develops symptoms.²² Symptoms of hypoglycemia include dizziness, difficulty speaking, anxiety, confusion, and lethargy. Hypoglycemia can result in loss of consciousness or even death.²²

A patient who has frequent hypoglycemic episodes may lose the protective physiologic response and may not recognize that he is experiencing a hypoglycemic episode (“hypoglycemia unawareness”). This is why it is crucial to ask patients if they have had symptoms of hypoglycemia, and to correlate the timing of these symptoms with blood glucose logs. For example, it is possible for a patient to experience hypoglycemic symptoms for blood glucose readings in the 100 to 200 mg/dL range if his or her average blood glucose has been in the 250 to 300 mg/dL range. Such patient may not realize he is experiencing hypoglycemia until he develops severe symptoms, such as loss of consciousness.

Adding a rapid-acting insulin prior to one meal a day is a reasonable starting point for intensifying insulin therapy.

Hypoglycemia unawareness must be addressed immediately by reducing insulin dosing to prevent all hypoglycemic episodes for 2 to 3 weeks. This has been shown to “reset” the normal physiologic response to hypoglycemia, regardless of how long the patient has had diabetes.^23,24 Even if your patient is aware of the warning signs of a hypoglycemic episode, it is important to routinely ask about hypoglycemia at all diabetes visits because patients may reduce insulin doses, skip doses, or eat defensively to prevent hypoglycemia.

Other than the risk of hypoglycemia, insulin typically has fewer adverse effects than oral medications used to treat diabetes. Most common concerns include weight gain, hypoglycemia, injection site reactions and, rarely, allergy to insulin or its vehicle.¹⁶

CORRESPONDENCE
Jay Shubrook, DO, FAAF P, FACOF P, BC-ADM, Touro University College of Osteopathic Medicine, 1310 Club Drive, Vallejo, CA 94592; jay.shubrook@tu.edu