Optimizing Insulin Therapy in Diabetes - Episode 11
Robert Hood, MD: Here we are with a patient on over 200 units of insulin a day, and their A1C [glycated hemoglobin] is not at goal. Typically, you’ve been working with them for many visits. The patient’s usually very happy to have an alternative, especially when the alternative involves taking fewer injections a day. But we need to do things properly so that we get good outcomes and minimize the risk of hypoglycemia.
The first safety thing is that we have to assume these patients are probably not getting all of their injections, and that’s why in the protocol we did a dose reduction when A1C was less than or equal to 8%: a 20% reduction in the total daily dose of insulin. That’s making the assumption that patients maybe aren’t getting all of their insulin. To be safe with the A1C not being outrageously high, let’s cut back on the insulin and then we can go back upward subsequently.
We encourage patients to take their insulin a half hour before meals, so we match insulin with food as much as we can. We encourage the patients to eat 3 meals a day and not skip them. But if they’re due for their dose of insulin and they miss their meal, they are told to cut their dose in half—not withhold it altogether because it includes basal insulin, but reduce it in half to reduce the risk of hypoglycemia.
Blood sugar monitoring is very important. In the titration protocol, there was an emphasis on dose reduction for hypoglycemia that would trump any dose increase for hyperglycemia, but blood sugars were to be checked 4 times a day and reviewed on a regular basis. That’s certainly what we have to do in clinical practice. Blood sugars have to be checked, hypoglycemia needs to be addressed, and insulin needs to be adjusted.
Serge Jabbour, MD: To be successful on U-500, you need to understand how that insulin works. I tell patients it’s an insulin that is basal and granular at the same time. I tell patients to take it 30 minutes before their meal; if I do it twice a day, it’s 30 minutes before breakfast and 30 minutes before dinner. I show patients how to use the pen. If I don’t, my diabetes educator can do it or the pharmacist can do it. It’s more about educating the patient on the insulin, which is going to make it really successful.
Robert Hood, MD: I think any medication, but especially insulin, is all about education if you want to have a good start with your patient. Explain exactly what U-500 is all about. Talk about the risk of hypoglycemia. Talk about blood sugar monitoring. Talk about how the insulin is different than anything else that they’ve had before. It helps a lot if you’ve got a sample that you can give the patient to get started with. If it’s an appropriate time of the day, you can actually give their first injection. That’s always possible with U-500 because it is related to meals.
You really should emphasize the prescription with the patient, or actually show them the vial or pen that you’re using. Make sure when they go to the pharmacy, they’re getting exactly what you prescribe. Your prescribing needs to be meticulous to make sure that you’re not getting callbacks from the pharmacy or the patient’s confused about what to do.
If at all possible, please use the pen. We were delighted when Lilly came out with the U-500 pen. With the U-500 pen, what you see is what you get. It’s so easy to educate the patient. There are no mix-ups in the pharmacy. You give 100 units; you dial 100 units. If you do choose to give the vial and syringe, make sure you use the dedicated BD U-500 insulin syringe. What you see is what you get with that syringe as well, but when you have a vial—sometimes the pharmacy won’t have the U-500 syringe, or maybe the patient will be tempted to use all the U-100 syringes at home—there is more risk than there is with the pen device. So, if at all possible, please use the pen.
Transcript edited for clarity.