How Would You Initiate Insulin in this 53-Year-Old Man with T2DM?


The decision to start insulin therapy requires frank dialogue with a patient about lifestyle, psychosocial, and employment matters. Given this patient's particulars, what type of insulin would you prescribe and on what schedule?

At a follow-up appointment your 53-year-old African American patient reported polyruia and polydipsia; his A1C had risen over 3 months from 8.1% to 9.2%. You have discussed with him the need to consider adding insulin to his current treatment with metformin 1000 mg twice daily. He also is treated for hypertension and osteoarthritis and admits to unreliable adherence to his daily regemin of pills. He has an erratic daytime schedule as a retail store manager and is not as careful as he "should be" about eating breakfast and lunch or following his dietary guidelines.

metformin, 1000 mg twice daily

After a discussion of the pros and cons of insulin therapy, the patient agrees to start.

Which of the following would be the best choice for him at this time?

A. Continue metformin; initiate insulin detemir 10 units QHS, and insulin asparte 4 units TID with meals
B. Continue metformin; initiate premixed Novolin 70/30 6 units BID
C. Stop metformin; initiate insulin glargine 10 units daily, follow-up in 1 month
D. Continue metformin; initiate insulin glargine 10 units QHS with self-titration to glucose goals
E. Continue metformin; initiate NPH insulin 10 units twice daily
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