Diabetic Case: 75-year-old Man on Insulin Therapy

00:00 Let's go on to another case. Here we have a 75-year-old man who comes in for initiation of insulin therapy. He has moderate diabetic retinopathy with reduced visual acuity and lives alone. He has had difficulty with medication compliance and his hemoglobin A1c is 8.5%. He has also had hypertension and prostate cancer, which is in remission. How would you advice this patient? First of all, in analyzing this particular case you have an elderly patient living alone with poor eyesight. This is not a good candidate for very very tight glycemic control and certainly not somebody who can check his blood sugar frequently. He is also having difficulty complying with his medication and has multiple co-morbidities. In this situation, you would advise him to simplify his regimen to minimize fingersticks and injections and to use premixed and prefilled syringes. Premixed insulin is a fixed percentage of long acting and regular or analog insulin, for example, 70% NPH combined with 30% regular insulin given twice daily particularly in patients who are unable to comply with more frequent daily injections. In these patients, there is a greater risk of glycemic fluctuations, but also hypoglycemia which can occur when using a non-physiologic regimen. Premixed insulin containing larger proportions of rapid or short acting insulin tend to have higher peaks occurring at early at times and then mixtures containing smaller proportions of rapid and short acting insulin. Back to the therapy for type 2 diabetes. Lifestyle modifications combined with oral pharmacologic agents should be applied for optimal glycemic control. As type 2 diabetes progresses with continued loss of pancreatic beta cell function and insulin production, multiple oral agents may be required with non-insulin injectable agents or insulin as glycemic control worsens. There are many options for oral agents with major differences in cost, timing of administration, mechanism of action, and their side effect profiles.