Say, the patient is not doing
that well and continues to
maintain a high A1c despite
your best medical therapy.
So, patients who come in with an HbA1c above 9
can be considered for insulin.
In my practical experience,
most clinicians aren't thinking
about using insulin right off the bat
unless they come in with
an A1c of 11 or more.
But one thing that’s certainly true is patients who are
failing badly and taking two oral anti-diabetes drugs,
there's not much point in putting them
on a third oral diabetes – anti-diabetes drug.
At that point, it's time to reconsider therapy
and include insulin in that regimen.
The problem with insulin is
there's just a lot of variability.
How often the patient uses it, their diet,
how used they are to checking their home glucose,
how involved their health literacy, all of these things
factor into the efficacy of insulin.
It's, frankly, probably easier to take a pill.
But you can start with something basic,
like augmentation of their usual therapy with basal insulin.
There is the dose,
0.3 units per kilogram per day.
That's – this is really where you want it.
If you haven’t initiated doing home glucose monitoring,
you're going to want to initiate home glucose monitoring
and warning the patient about hypoglycemic symptoms
and how to react because, of course,
it’s one of the downsides of insulin treatment.
It is a nice opportunity, in my opinion,
to check on lifestyle because
you can follow along and you notice when
they go – when the patient goes high
with their glucose readings at home and
when they go low and what happened.
Oh, that’s the day I exercised.
That’s the day I forgot to eat.
Or when it's high,
oh, that was a big party I went to and I kind of went nuts
and ate whatever I wanted
and that's why glucose was 450.
So, it can give you some insights
into how to counsel patients about
because lifestyle never leaves
just because the patient goes through
diabetes education classes
and meets with an educator
or a (inaudible) or whatever.
It's never quite over.
You have to keep up that lifestyle.
And importantly, once you initiate insulin treatment,
don't let go of metformin, foundational drug.
And it can help mitigate against the weight
gain you're going to experience with insulin.
But sulfonylureas, once you start prandial insulin,
there’s not much point in using sulfonylureas anymore.
Get them off because they might promote
hypoglycemia and weight gain.
And hypoglycemia is a serious risk.
So, really monitor it closely.
Keep these levels in mind.
Goal glucose levels for fasting patients,
90 to 130 mg/dL; for postprandial,
less than 180 mg/dL.
So with that, happy to give you that
overview on diabetes care.
I think the keys are,
get the diagnosis right.
And usually requires a
couple of readings to do so.
Also, never forget lifestyle
and try to keep the patient on
metformin as much as possible because
it really is a game changer of a drug
and can take time to work its effects.
Make sure they get their screening on a
routine basis for their eyes and for their feet
as well as for kidney disease,
with the microalbumin and creatinine ratio.
And you should have some
very satisfied and healthy patients.