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Implementing Insulin Change

Dec 2, 2017

A 47-year-old patient has done an excellent job with lifestyle modifications and medication adherence. However, she has not been able to yet achieve her individualized A1C goal. Her current regimen consists of a metformin, sitagliptin, and insulin detemir (insulin started 4 months prior). However, over the past month as she has titrated her basal insulin toward her A1C goal, her self-glucose blood monitoring log shows large drops in her overnight glucose levels. After consulting with the treatment team, you decide to add rapid-acting prandial insulin to her regimen. How would you implement this strategy?


Correct Answer: B. Decrease the basal insulin dose and add 1 daily prandial injection before the largest meal of the day

Educational Critique: Basal insulin is generally titrated against fasting glucose levels. The addition of prandial insulin should be addressed when postprandial glucose measurements are significantly elevated (>180 mg/dL). This should be suspected when fasting glucose is at target, but A1C remains above goal after 3-6 months of basal insulin titration. Prandial insulin should also be considered when self-monitoring of glucose levels during up-titration of the basal insulin reveals large drops in overnight or between-meals glucose levels; as prandial insulin is added, basal insulin should be reduced. The addition of prandial insulin should be individualized to each patient's needs and abilities. These rapid-acting insulins are 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 as needed. This approach allows self-monitored glucose results to guide the prandial insulin injection to the appropriate dose and frequency.


Popul Health Manag. 2014 Aug 1; 17(4): 218–223.  doi:  10.1089/pop.2013.0099