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Insulin Initiation in Type 2 Patients

David Joffe, BSPharm, CDE, Editor-in-chief, Diabetes In Control

In 2003, the Treat to Target Trial study results were published. The study compared the effectiveness of a patient mediated titration schedule with both NPH and glargine, and also whether patient titration was as good as a prescriber-based titration….

Patients were randomized into groups using either glargine or NPH. The self titration started at 10u, regardless of patient weight or A1c, and they were placed on a forced titration based on 2 day average fasting glucose readings.

Patients on either type of insulin were given the following algorithm for dosing.

 

Previous 2 day fasting average mg/dl

Increase NPH or Glargine Dose (units)

>180
8
140-180
6
120-140
4
100-120
2

Reading of less than 72 in previous week

0

Severe hypoglycemia in previous week

-2
 
The results were impressive with 60% of the patients dropping their A1c from 8.6 on average to 7.0 or below, and with over 30% dropping FPG to 120 or less.

In 2007, the International Variability Evaluation 303 (PREDICTIVE 303) Study was released and showed that there were other regimens that could also work for patient self titration.

The 303 protocol was based on the following self titration methods:

Patients were instructed to adjust their insulin detemir dose every 3 days based on the mean of three ‘adjusted’ fasting plasma glucose readings and if insulin naïve were dosed based on unit per kilogram protocols.

 

Previous 3 day fasting average mg/dl

Increase in detemir (units)

>110
+3
80-110
0
80<
-3
 

Just as in the Treat To Target Protocols, patients achieved A1c and FPG targets equivalent to prescriber titrated dosing and a high percentage got to an A1c of 7 or less.

Currently researchers in the AUTONOMY study have been testing whether prandial insulin therapy in T2DM on glargine can be effectively and safely initiated in the primary care setting and that self-titration of lispro may be done by either of two simple algorithms without the complexity of carbohydrate counting and correction factor, regardless of patient age. Early evaluation of this just completed study is very positive.

These studies and the successful use of patient self titration by many of your colleagues give reason to not hesitate to start patients on insulin and allow them to manage their own dose.

Copyright © 2013 Diabetes In Control, Inc.