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Which Insulin Do You Choose?

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?

Correct

Correct Answer: A. Rapid-acting insulin analogues

Educational Critique: 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.

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