Let's go on to another case. A 42-year-old man presents to his primary care physician for
preventative care. He does not have any current complaints. His father died of diabetic nephropathy.
His vital signs include a temperature of 36.7°C, a blood pressure of 150/95, and a pulse of
90 beats/minute. Fasting glucose is 159 mg/dL on 2 separate occasions and the hemoglobin A1c is 8.1%.
The patient is started on metformin and lifestyle modifications after the diagnosis of type 2
diabetes was made. Three months later he comes to a follow-up visit. His serum blood glucose is now
370 mg/dL and his hemoglobin A1c is 11%. The patient currently complains of weight loss and
excessive urination. What is the optimal therapy for this patient? In this clinical scenario, we
need to initiate insulin therapy. The driving factors here are a man whose blood glucose is poorly
controlled despite lifestyle modifications and metformin. His hemoglobin A1c is greater than 10
and his random blood glucose is greater than 300 and this is an indication to comment insulin.
Insulin therapy in type 2 diabetes is indicated where there is symptomatic hypoglycemia, markedly
elevated hemoglobin A1cs at the time of diagnosis, a failure of lifestyle modifications and
non-insulin therapies to achieve glycemic goals. The recommendation of the American Association of
Clinical Endocrinologists is a weight-based dosing of a basal insulin at doses of 0.1-0.3 units/kg.
Increase the dose over several units every 2-3 days to reach fasting plasma glucose goals based
on the patient's fingerstick blood glucose readings. Basal bolus insulin therapy is scheduled to
mimic the physiologic insulin secretion and has 3 components. First of all, a long or intermediate
acting insulin given once or twice daily to cover the basal insulin needs, bolus prandial insulin
with rapid or short-acting insulin given before meals, and then a correction insulin of rapid or
short acting insulin is given where there is hypoglycemia.