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Which response is one of the current guidelines for
switching a patient from insulin to an oral agent?
1. Slowly add metformin while decreasing insulin
2. Add 2 agents like metformin and a glitazone while
slowly reducing the insulin
3. Switch insulin to Glargine, add a sulfonylurea and
then reduce the insulin by adding metormin or a glitazone.
4. There are no guidelines
5. The patient should decrease carbs to less than 30
a day and decrease insulin accordingly, while starting metformin 500
bid and prandin 1mg before meals. After 4 days patient should stop insulin
and increase prandin to 2mg before meals.
One must recognize that there is no evidence of superiority of oral
agents to insulin, so that no "guidelines" would be likely
to be put forth. Typically, a physician and patient will consider such
a change when there has been considerable improvement in a patient's
status and it appears that oral agents would be sufficient to maintain
excellent glycemic control.
As worded, the question suggests that the switch is being considered
from insulin alone to oral agents alone. The usual pattern in administering
insulin to persons with type 2 diabetes is, however, to give such treatment
in addition to 1 or more oral agents, with numerous studies suggesting
improvement in glycemia with addition of insulin to sulfonylureas, to
metformin, and to thiazolidinediones (or of the oral agent to the insulin
treatment). This, then, would be the initial step for the person receiving
insulin only, to add any 1 of these agents. If discontinuation of insulin
is being strongly considered, after stabilization of glycemic control
with 1 agent it may be appropriate to add a second or even a third,
with cautious reduction of insulin as oral agent therapy is intensified.
Such an approach may eventuate in the patient no longer requiring exogenous
insulin.
One must recognize that current American Association of Clinical Endocrinologists/European
Association for the Study of Diabetes and American Diabetes Association
guidelines suggest a goal A1C of 6.5% and 7%, respectively, so that
unless such a level of control exists, it is probably premature to consider
insulin discontinuation. Of course, if the patient's status changes,
with, for example, discontinuation of glucocorticoid treatment, an unusually
successful program of lifestyle modification, or with development of
renal insufficiency, glucose levels may fall and it may be appropriate
to gradually decrease insulin dosages.
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