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Viewpoints on Early Insulin Initiation

Diabetes In Control staff contacted several physicians all across the US to find out what they had to say about early insulin initiation. What they said may surprise you….

Dr John Murray, MD, Florida

I usually reserve insulin for my type 2 patients till they have tried at least 3 oral medications and have had some type of education. However if the A1c is above 8% after 6 months I will not hesitate to start them on Lantus at bedtime. I usually have them start on 10 units and then have them increase the dose based on fasting glucose levels. For most but not all of my patients I have them go up 2 units about every 3 to 4 days till the fasting gets to 130 on a regular basis. If they are on glipizide or another sulfonylurea I will have them half the evening dose to avoid nocturnal hypoglycemia. I try to evaluate the overall health of my patients and consider the age of the patient; usually if the patient is very old I will not start insulin.

When patients have a fear of insulin it is either because of needle pain or fear of low glucose levels. I have one of my MA’s inject the patient with a pen needle to show how it feels, and explain that Lantus is a long acting steady insulin that does not drive their glucose down quickly.

Dr. Ronald Hall, MD, Kentucky

I used to wait a long time to start insulin but recently I have become more aggressive in my choices. Since most of my type 2 patients are overweight I want them to get control without weight gain and I found that the sulfonylureas and tzd’s were adding to weight gain. I have been moving more of my patients to both long acting insulin and GLP-1 analogs after metformin. I find that they seem to be willing to try an injection when I explain that there is a reduced risk of hypoglycemia and let them try a needle on themselves. As to dosing long acting insulin, if A1c is below 8% then I start at 10 units, and if A1c is over 9% then I start at 20 units. I have them call in a fasting once a week and make adjustments over the phone. I have also had patients who I gave a scale to increase on their own. I don’t think that there are very many patients who I would not use long acting insulin on. I guess if they had severe arthritis or had some type of disease that affected memory I would not prescribe for them unless there was a caregiver involved.

Dr. David Hobbs, MD, Florida

I cater to an older population and so insulin is a very late choice for me. I am more likely to try a variety of oral medications before considering insulin. I will start someone on glargine or detimir if their labs prevent them from using metformin, but it is always at a low dose of 5-10 units. I typically leave them on this low dose for a month or so to see what happens before titrating or changing oral meds. I also will refer them to an endocrinologist if the low dose insulin is not working.

Dr. Elaine Greifenstein, MD, Ohio

I have been very aggressive in my practice with the use of injectables. Being in a small town I don’t have the luxury of an endocrinologist nearby and have to manage the complex as well as simple cases. All my diabetic patients get a monitor the first day with a pre and postprandial assignment, along with carbohydrate counting instructions. I start most of them on metformin the first day and have them use a pen needle to feel what a shot feels like. This works 2 ways, first it lets them know that their diabetes is serious and if I have to start them on insulin they already know it does not hurt. Lately I have been adding a DPP-4 inhibitor and then if that does get fasting readings to goal in 30 to 60 days I will start them on either a GLP-1 analog or basal insulin depending on their weight or whether it is a postprandial spread or continuous high fasting. I usually start the basal insulin at 10-15 units a day and have them titrate based on fasting readings up to 30 units. If they do not gain control at 30 units I will most likely add a short acting analog at their highest carb percent meal, usually breakfast. Over the past few months I have also been using the GLP-1 analog, exenatide, with the basal insulin with good results. It constantly amazes me that my primary care partners will postpone insulin for such a long time.

Ghosn Issa, MD, Florida

I am an endocrinologist and I get referrals from primary care offices in the Panhandle area. Most of the patients are referred because their disease is not controlled by oral medications or even GLP-1 analogs. Many of them are already on a basal insulin when they get to me and at a high dose. This means that I often have to begin mealtime insulin right away. I will usually keep the patient on metformin and then decrease the basal by 30-40% and split that difference into 3 mealtime injections. I require the patients to do pre and post prandial readings to assess the dosing regimen. If I do get a patient who is not yet on any insulin I will prescribe it at our first appointment, based on patient weight. I am always amazed at how long it takes primary care physicians to start a patient on basal insulin and would guess that if they started patients sooner I would not get as many referrals.

These interviews have been edited for clarity and ease of reading.

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