Chief Resident, Internal Medicine, Huntington Memorial Hospital

I thought we could shake things up a little for morning report next Wednesday. Instead of following our usual case presentation and discussion format, we will review an article published in American Academy of Family Physicians. Our Goal is to review insulin therapy for type 2 diabetics. We will cover the various forms of insulin therapy commonly used, from ultra short to very long acting insulins, the various schemes of insulin administration and their proper use. The article is:

Insulin Therapy for Type 2 Diabetes:
Rescue, Augmentation, and Replacement
of Beta-Cell Function
JENNIFER A. MAYFIELD, M.D., M.P.H., Seattle, Washington
RUSSELL D. WHITE, M.D., University of South Florida College of Medicine, Tampa, Florida

Type 2 diabetes is characterized by progressive beta-cell failure. Indications for
exogenous insulin therapy in patients with this condition include acute illness or
surgery, pregnancy, glucose toxicity, contraindications to or failure to achieve goals
with oral antidiabetic medications, and a need for flexible therapy. Augmentation
therapy with basal insulin is useful if some beta-cell function remains. Replacement
therapy with basal-bolus insulin is required for beta-cell exhaustion. Rescue
therapy using replacement regimens for several weeks may reverse glucose toxicity.
Replacement insulin therapy should mimic normal release patterns. Basal insulin,
using long-acting insulins (i.e., neutral protamine Hagedorn [NPH], ultralente,
glargine) is injected once or twice a day and continued on sick days. Bolus (or
mealtime) insulin, using short-acting or rapid-acting insulins (i.e., regular, aspart,
lispro) covers mealtime carbohydrates and corrects the current glucose level. The
starting dose of 0.15 mg per kg per day for augmentation or 0.5 mg per kg per day
for replacement can be increased several times as needed. About 50 to 60 percent
of the total daily insulin requirement should be a basal type, and 40 to 50 percent
should be a bolus type. The mealtime dose is the sum of the corrective dose plus
the anticipated requirements for the meal and exercise. Adjustments should be
made systematically, starting with the fasting, then the preprandial and, finally, the
postprandial glucose levels. Basal therapy with glargine insulin provides similar
to lower A1C levels with less hypoglycemia than NPH insulin. Insulin aspart and
insulin lispro provide similar A1C levels and quality of life, but lower postprandial
glucose levels than regular insulin. (Am Fam Physician 2004;70:489-500,511-2.
Copyright© 2004 American Academy of Family Physicians.)