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Test Your Knowledge Question #795

Sep 14, 2015

One of your patients is a 3-state regional salesman who has a fairly unpredictable work schedule. When he gets hungry while on the road, he tends to eat at the first restaurant he sees. For the past 3 months, he has managed his type 2 diabetes with metformin, glipizide and glargine. Despite this regimen, his current A1C is 7.8%. You are in agreement that he needs to add a bolus insulin dose to his regimen. Which type of insulin would be the most appropriate choice?


Answer: A. Rapid-acting insulin analogues

This patient would benefit from the addition of a prandial insulin dose with a shorter-acting insulin. While human regular insulin is generally less expensive, the rapid-acting insulin analogues (lispro, aspart, glulisine) result in better postprandial glycemic control than human regular insulin. These insulins can be added to the patient’s day in a graduated fashion, starting with the largest/highest carbohydrate meal, then the next largest and finally, the smallest meal. This approach allows self-monitored glucose results to guide the titrations to the appropriate dose. The long-acting and intermediate acting-insulins are generally used for basal insulin dosing. While a premixed insulin may be a more convenient and simpler choice (dosed before breakfast and before supper) than basal-bolus, it is not well suited to individuals who do not have a consistent and predictable lifestyle with regular timing of meals as delayed or missed meals raise the risk of hypoglycemia with these formulations.


  1. Inzucchi S, et al. Management of hyperglycemia in type 2 diabetes: A patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012; 35(6):1364-1379.
  2. Cheng A. The rules of 3’s: Insulin use in type 2 diabetes. Canadian Diabetes Association. Available at http://www.diabetes.ca/documents/for-professionals/CD--Spring_2011--A.Cheng_.pdf. Published Spring 2011. Accessed Oct. 17, 2012.