Transitioning to non-insulin therapy in a patient receiving high dose insulin. J Am Assoc Nurse Pract 2020 Jun;32(6):469-475
Date
04/14/2020Pubmed ID
32282568DOI
10.1097/JXX.0000000000000403Scopus ID
2-s2.0-85086284192 (requires institutional sign-in at Scopus site)Abstract
In people with type 2 diabetes with evidence of obesity-related insulin resistance, use of insulin to treat hyperglycemia has not been shown to reduce macrovascular complications, despite widespread use for many years. However, newer classes of diabetes medications, designed to address the prevalent pathophysiologic defect of type 2 diabetes, have emerged. Consequently, in many patients, reduction of insulin doses or even total elimination is possible after the addition of these newer agents. The authors suggest a cautious approach in which people with type 2 diabetes and established cardiovascular disease who are on high insulin doses (>1.0 unit/kg/day) be treated with diabetes medications that showed evidence of cardiovascular benefit (such as glucagon-like peptide-1 receptor agonists [GLP-1RAs]), on whom close monitoring is crucial because they may be at particular risk for developing hypoglycemia. This approach can be labor intensive and may be challenging for busy primary care providers for who may have limited time to evaluate and follow the patient. The authors present a case report of adding a GLP-1RA to high insulin doses. If the hemoglobin A1c is <8.0% when GLP-1RA is added, insulin doses should be reduced by 20%. Patients should be monitored at least every 4 weeks initially until it is confirmed there is no hypoglycemia risk. If glycemic targets (defined as fasting or preprandial glucose level between 80 and 130 mg/dl) are consistently achieved, providers may consider proactively reducing insulin doses by 10-20% to avoid hypoglycemia. The authors recommend creating appropriate goals and expectation before initiating this process.
Author List
Mishriky BM, Cummings DM, Mendez CE, Patil SP, Powell JRAuthor
Carlos Eduardo Mendez Castrillo MD Associate Professor in the Medicine department at Medical College of WisconsinMESH terms used to index this publication - Major topics in bold
Diabetes Mellitus, Type 2Humans
Hypoglycemic Agents
Insulin
Insulin Resistance
Male
Middle Aged
