Titrating Insulin to Glycemic Target

Toolkit for Implementing the Chronic Care Model in an Academic Environment

On September 19, 2006, Judy Bowen, M.D., of the Oregon Health & Science University (OHSU), made a presentation during the Academic Chronic Care Collaborative (ACCC) site visit there, entitled Titrating Insulin to Glycemic Target.

This is the text version of the slide presentation. Select to access the PowerPoint Version [ Microsoft PowerPoint file - 82.5 KB] .

Slide 1

Titrating Insulin to Glycemic Target

Judy Bowen, MD

CIM Rotation

September 2006

Slide 2

Case 1

  • Mrs. G, 46 year old was diagnosed with Type 2 DM diagnosed 5 years ago (initially treated with diet and exercise, then glipizide XL 5 mg BID and metformin 1,000 mg BID) has these Hgb A1c values q 3 months over the past year:
  • 5.8%.
  • 6.3%.
  • 7.4%.
  • 7.8%.

Slide 3

Case 1 Continued

  • Her BMI is 33, BP is 126/72, micro-albumin is 9 on lisinopril 10 mg, LDL is 89 on Lipitor 10 mg.  She takes 81 mg ASA daily. Her eye exam is up-to-date and normal.  Monofilament exam is normal.  Your exam is normal except for her obesity.
  • Her fasting a.m. CBGs are 140-180.
  • What do you recommend?

Slide 4

Schematic of 24-hour glucose profile

Riddle M. AJM 2004; 116:3S-9S

The graph shows 0, 100, 200 on the left-hand side and 6 a.m., noon, 6 p.m., 12 a.m., and 6 a.m.

At the top of the graph beginning at below 200 on the left and spanning from 6 a.m. to 6 a.m is a straight line. Above the straight line is a wavy line that begins before 6 a.m. and rises to above 200 at 6 a.m., falls to the straight line before noon, rises to above 200 at noon, falls to the line right before 6 p.m.,, rises above 200 again before dropping and merging into the straight line before 12 a.m.

Below this part of the graph is another straight line beginning below 100 on the left and spanning from 6 a.m. to 6 a.m. is a straight line. Above the straight line is a wavy line that rises to above 100 at 6 a.m. and declines sharply down to noon. It rises again to above 100 after noon and falls to right before 6 p.m. It rises again over 6 p.m. and declines before 12 a.m.

Between the two straight lines is a red arrow beginning at the top line shortly after noon and reaching down so that the point touches the bottom straight line after noon.

Slide 5

Initiating basal insulin therapy

  • Add basal insulin therapy:
    • Start with 10 units insulin in most patients.
    • Use either NPH or glargine (both work).
    • NPH q HS, glargine either q HS or q AM.
    • Glargine was associated with less nocturnal hypoglycemia (Riddle et al, Diabetes Care 2003; 26:3080-3086).
  • Continue with oral agents.
  • Consider adverse effects.

Slide 6

Treat-To-Target

  • Goal:  near normal fasting CBGs (~100 mg/dl).
  • Adjust dose weekly:
    • Based on average of two previous fasting CGBs.
  • Titration:
    • If CBG >/= 180, increase insulin by 8 units.
    • If CBG 140-180, increase insulin by 6 units.
    • If CBG 120-140, increase insulin by 4 units.
    • If CBG 100-120, increase insulin by 2 units.
  • No increase if any hypoglycemia (CBG < 72) with or without symptoms.

Slide 7

Relationship of A1c to CBG.

Graph of a triangle. On the left side, beginning above the bottom line, is 10%, 9%, 8%, 7%, 6%, 5%, 4%. From each percentage an arrow extends across the triangle to number on the other side of the figure: 65 at the top, 100 below it, 135, 170, 205, 240, and finally 275.

Slide 8

Relationship of A1c to CBG.

This slide has the exact same graph as Slide 7, only the arrow extending from 7% to 170 is highlighted.

Slide 9

Case 1, continued

  • Mrs. G agrees to start bedtime glargine 10 units, and feels confident she can titrate using the "Treat to Target" instructions with RN follow up. Over the next 3 weeks, she achieves fasting CBGs in the 100-120 range with 20 units glargine at bedtime, and no symptoms of hypoglycemia. Her follow up Hgb A1c 3 months after starting insulin is 6.5%.

Slide 10

Case 2

  • Mr. M, a 65 year-old patient with Type 2 DM for 10 years is on metformin 1,000 mg BID and insulin:
    • NPH q a.m. 30 units + Regular 10 units.
    • NPH q p.m. (supper) 25 units + Regular 15 units.
  • His fasting CBGs are in the 120"s but his Hgb A1c is now 8.0%.  He wants better control.
  • What do you recommend?

Slide 11

Switching to Basal/Prandial Insulin

  • To switch to glargine:
    • Add up his current total insulin dose (80 units).
    • Reduce by 20% (64 units).
    • Give half as glargine (32 units).
    • Titrate using fasting CBGs and "treat-to-target."
  • To add lispro/aspart:
    • (Onset is 5-15 min, peak is 30-90 min, duration is 3.5 –5 hours).
    • Send to Diabetes Education to learn carb counting.
    • Give remaining "half" of total dose based on meals:
      • 10 + 10 + 12 depending on carb load.

Slide 12

Pearls

  • Insulin therapy is associated with weight gain.
  • Glargine doesn"t last 24 hours in every patient (nor is NPH predictable).
  • We usually wait too long to start insulin in Type 2 patients.
  • Early insulin therapy may be associated with better daytime prandial secretion from native pancreas.
  • Finger sticks are more painful than insulin shots.

Return to Document

Page last reviewed January 2008
Internet Citation: Titrating Insulin to Glycemic Target: Toolkit for Implementing the Chronic Care Model in an Academic Environment. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/chroniccaremodel/chronic4fa.html