Effective Switch From Premixed to Basal-Prandial Insulin to Achieve Glycemic Goals in Type 2 Diabetes

Frank Lavernia, MD

Abstract:

Objective
This article describes a patient with type 2 diabetes mellitus achieving glycemic control after transitioning from premixed to basal-prandial insulin.

Methods
A case report illustrates the challenges of achieving glycemic control in type 2 diabetes, and results of a literature search regarding premixed and basal-prandial insulins are presented.

Results
A 52-year-old obese man with type 2 diabetes for 10 years initiated therapy with 2 oral antidiabetic drugs (OADs). When OAD therapy no longer maintained glycemic targets, and the addition of exenatide proved intolerable, he started premixed insulin aspart 70/30. However, lapses in exercise and irregular meal patterns led to a loss of glycemic control and nocturnal hypoglycemia. Switching to a basal-prandial regimen, starting with basal insulin glargine and then adding prandial insulin glulisine, subsequently resulted in a glycated hemoglobin level of 6.7%.

Summary
The patient benefited from the addition of 1 or more prandial insulin injections to a once-daily basal insulin analog.

Conclusion

Timely initiation of insulin therapy represents the best option for achieving euglycemia and potentially improving long-term outcomes in the management of type 2 diabetes. This case study illustrates the benefits of combining insulin glulisine with insulin glargine when glucose levels become unresponsive to OADs or premixed insulin. A reduction of FPG levels (via basal insulin therapy) and subsequently of postprandial glucose excursions (via prandial insulin therapy) is crucial in attaining glycemic goals. Patients with type 2 diabetes requiring insulin therapy to maintain normoglycemia may find that the addition of 1 or more prandial injections of a rapid-acting analog to a once-daily basal insulin analog represents a flexible approach to achieving glycemic goals.

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