Addition of Basal Insulin to Oral Antidiabetic Agents: A Goal-Directed Approach to Type 2 Diabetes Therapy

Louis Kuritzky, MD

Disclosures

November 15, 2006

Practical Suggestions for Combination Therapy

Factors Governing Choice of Oral Agent to Use in Combination With Basal Insulin

When oral therapy fails to attain or maintain glycemic goals, it is appropriate to add basal insulin to the regimen without discontinuing oral agents. Cessation of oral therapy while titrating insulin is less desirable, since the basal insulin is not targeted to be the primary modulator of postprandial glucose excursions. When initiating basal insulin, 10 U of either NPH insulin, insulin detemir, or insulin glargine is an appropriate beginning dose, titrated as discussed above. The average dose ultimately required to attain the A1C goal in a 100-kg person is generally around 40-45 U of basal insulin daily. Therefore, a generalized recommendation is 0.5 U/kg of body weight. Using typical titration schemes (eg, 2-U increments once or twice weekly until fasting glucose goals are reached), it can be anticipated that a duration of 4 months or longer may be required to reach the full therapeutic dose of basal insulin. Table 4 provides a summary of factors that may affect choice of oral agents and suggested choices for oral therapies.

There are many factors the physician should take into account when making clinical decisions regarding choice of basal insulin for combination therapy. These factors can include convenience, hypoglycemia incidence, control of postprandial glucose levels, avoiding weight gain, and achieving a more physiologic insulin profile. Convenience may be incorporated into insulin regimens by use of once-daily options.

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