Jay H. Shubrook, DO; Eric L. Johnson, MD

Disclosures

December 12, 2016

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Basal Insulin Dosing in Primary Care

Jay H. Shubrook, DO:I am Jay Shubrook, DO. I am a professor in the Primary Care Department at Touro University.

It is my great pleasure to introduce to you Eric Johnson, MD, my friend and colleague, who is the assistant medical director at the Altru Diabetes Medical Center and an associate professor in Family and Community Medicine at the North Dakota School of Medicine and Health Sciences in Grand Forks, North Dakota. Our topic today is getting our patients on the right dose of basal insulin. Dr Johnson, who is an expert in this area, is going to help us sort through this very important topic.

Eric, you have many patients on insulin. It's a great challenge in primary care to get the dose right. Could you share some ideas about how you start someone on basal insulin and how you know what dose they will need?

Eric L. Johnson, MD: We should be thinking about who are good candidates for basal insulin in type 2 diabetes. Sometimes, insulin is indicated right at the beginning of their diagnosis, if they are very symptomatic with high blood sugars and elevated A1c. Quite often, these patients have had diabetes for a while and now they are having some beta-cell decline with less insulin production. Maybe they have been on two or more noninsulin agents without achieving their goal.

The American Association of Clinical Endocrinologists and the American Diabetes Association (ADA) have guidelines describing the initiation and titration of basal insulin. There are a couple of ways to do it. The simplest way is to start the patient on 10 units. Pick a time of day that is convenient for the patient to administer the insulin. That might be bedtime or morning—whatever time that they can do it consistently. Then you can titrate 2 or 3 units every 3 days or so until you reach the predetermined goal for that patient. For those who need less stringent control, the goal might be a fasting blood sugar < 140 mg/dL, or lower when you are looking for tighter control. If the patient experiences hypoglycemia, you can either stop at that dose or back up a couple of units. That is a pretty simple way to initiate insulin.

Another method is weight-based dosing, using 0.1 unit to 0.3 units/kg of body weight to start out. Then you can do some averaging of blood sugars over 2 or 3 days to determine your next move. Then increase the dose 1 unit if the fasting blood sugar is > 180 mg/dL. Most patients can understand this, particularly if they have the right instruction.

Letting Patients Drive the Titration

Dr Shubrook: Do your patients titrate their own insulin?

Dr Johnson: Yes, quite often they do. We like them to see a nurse educator or a certified diabetes educator for insulin initiation and to learn the titration schedule. If we write the instructions down for them or provide printed instructions, and use either email or another messaging system, they understand how to make these changes safely every couple of days, and quite a few will do it. If they are not comfortable with it, we rely on calling them every 3-5 days to see how they are doing.

Dr Shubrook: That is important because I find that with many patients, I start them on a dose of insulin and recommend that they titrate it. Then I have them return as soon as possible, but that might be 3 months. I find that some patients are still on the initial dose or they have only advanced one step. How do you help your patients continue that titration process, particularly for busy physicians? Because that is a real challenge.

Dr Johnson: It is. I take a couple of minutes with the patient, first of all, to explain why we are doing this. I tell them that their body is probably making less of its own insulin and we want to replace that. Many patients understand that if we take that extra minute or two to explain it to them. Of course, many insulins come in easy-to-use pen devices. If you have a demo that you can show the patient, that sometimes helps quite a bit too. This is a good time to have them come in for some additional education with the nurse educator or certified diabetes educator, if available. If you have nurse educators or diabetes educators in your practice or your healthcare system, they are a tremendous resource that can save you a lot of time by educating your patients.

Resources for Diabetes Education

Dr Shubrook: What if clinicians do not have those resources? Many practices lack diabetes educators or dedicated staff to do this. Are there other tools that could help people?

Dr Johnson: Definitely. I often see this problem in the very rural environments that I encounter in North Dakota. Many places designate a nurse within the facility who can do some teaching. Sometimes, that is a nurse who has another role but is not busy all the time. For example, some of the smaller centers in North Dakota, in towns with a population of 3000-5000, might have nurses who are doing education on cardiac rehabilitation, but they are not doing that all day long. Maybe they can learn some of these simple insulin management tools that can help outpatients.

The ADA has some good tools that are available online. Many of the primary care journals, if you do a quick literature search, have this information as well. ADA has some print materials that can be given to patients. Some of the insulin companies also have some nice noncommercial-based sites that can help patients understand diabetes management.

Dr Shubrook: That's great, and very important. We need to provide some resources for our colleagues. What are some warnings? It's hard for many providers to get the patient up to the right dose. If I am going to start doing this in my practice more often, what factors should I pay attention to?

Anticipatory Guidance

Dr Johnson: First, talk to patients about what might go wrong. They might have a low blood sugar. They might start gaining weight. This is a good time to take that extra minute or two to say, "If you notice this, pay more attention to your meal cues. I do not expect you to have to tolerate a lot of low blood sugar levels. Let us know so that we can make sure you are on the right insulin dose." We tell patients to try to be consistent with increases in their insulin dose and not to jump all over the place. They might increase the dose by 10 units one day and then decide to back up by 6 units the next day. We want them to have consistent schedules for titrating their insulin dose. In a busy practice, if you can take the time to talk about this with the patient, quite a few of them are going to be able to do this without a great deal of difficulty at home.

Dr Shubrook: Have you ever used a ceiling dose? I like to use weight-based dosing because I find that most of my patients are heavy and need to use a fair amount. I tell them, "You might start here, but I expect that you need this amount of insulin. Keep titrating up to that amount." Have you ever done that? Have you found it to be useful?

Dr Johnson: We do. We tell patients with type 2 diabetes that they typically might be on 50 or more units of basal insulin a day by the time they get to their ideal dose. We talk about safety with increasing in smaller increments, but for larger patients we use weight-based dosing of 0.2-0.3 units/kg to start. I tell them that they probably will eventually need 50 or more units. Once they get beyond about 60, 70, or 80 units, depending on their weight, and we are not achieving their A1c goal, we think about intensification with mealtime insulin. That is a separate topic and there are some good tools for that as well. Many patients are going to achieve or get close to their goal with effective use of basal insulin.

Dr Shubrook: I want to make sure we emphasize that we are talking about patients with type 2 diabetes. When we discuss a weight-based algorithm or when we are looking at using 50 units, we are specifically talking about their use in patients with type 2 diabetes.

Dr Johnson:The pens typically go up to doses of about 80 units, with one that goes higher. If we get to the maximum dose of a single injection on a pen, then we usually have a conversation about doing something else—perhaps mealtime insulin or some other strategy.

Gaining Experience With Basal Insulin Therapy

Dr Shubrook: These are very important points. Is there any other advice that you would give to our listeners who are trying to start insulin in patients with type 2 diabetes?

Dr Johnson: If you do not have a lot of experience in this area, start with patients who you think will succeed. That is going to help you, as a provider, learn to do this better. Patients who are likely to succeed are going to give you feedback that will be helpful when you want to move on to more complex or difficult patients. If you have a younger patient who is on a couple of noninsulin medications, without complications, and who is interested in better control, that is a prime patient to try to start on basal insulin with titration. When you have a couple of successes under your belt, you can feel pretty comfortable about this in your practice.

Dr Shubrook: Thank you so much for coming today. These are fabulous points. Enjoy your busy practice and we look forward to talking with you again.

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