Key Factors of Insulin Intensification in Diabetes Care

Robert Hood, MD: With this increasing prevalence of obesity in our society, we’re seeing more and more patients requiring high doses of insulin. When you start reaching more than 200 units of insulin a day, the patient’s considered to be severely insulin resistant. Those patients really pose a significant challenge, because it often requires multiple injections to get insulin into the patient.

Now we have analog insulins that are great in a basal/bolus situation. Certainly, if you’re on more than 200 units a day, you should be on basal/bolus insulin therapy, not just 1 shot of basal insulin. But a lot of these patients don’t get to goal. You keep escalating therapy, the A1C doesn’t come down, the patient’s frustrated, and we’re frustrated. That’s the time that you think about maybe using U-500 insulin. If they’re getting to goal on more than 200 units a day without undue hypoglycemia with their other regimen, that’s great. U-500 is something to consider when you’re over 200 units a day and you’re just not getting the patient to goal.

With a patient on more than 200 units of insulin a day, it’s interesting to see what kind of insulin regimen they’re on. Sometimes we see people on just 1 shot or 2. It will be 2 shots of basal insulin at least, since an insulin syringe only holds 100 units, but basal insulin alone at that dose is very inappropriate. They should be on mealtime insulin. They might be on premixed insulin. But most of the patients will be on the gold standard basal/bolus therapy, where they’re getting a basal insulin, as well as mealtime insulin. That’s going to involve at the least 4 injections a day, sometimes even more, when you’re on more than 200 units of insulin a day.

It’s interesting that people consider different A1C cut points for different types of therapy. And really, I don’t think we should be doing that. We should certainly customize the A1C goals for the patient, but whatever is an appropriate A1C level for the patient should be the same trigger regardless of what you’re doing pharmacologically. For example, if your target A1C is 7% and it’s time for insulin, you should put someone on insulin. You shouldn’t wait until they’re 8%, 9%, or 10%. Likewise, if you’re not doing well on a current insulin regimen, we should not be waiting until patients are at 8%, 9%, or 10%. If they’re consistently above 7%, and that’s an appropriate goal for them, it’s time to think about doing something differently. If you are doing the same thing visit after visit with A1C climbing progressively, that patient’s doomed to fail, and you’re going to make it more difficult to regain glycemic control after you make a change in therapy.

Hypoglycemia is the main adverse event that makes us concerned about insulin therapy, not just us but the patients, as well. Patients fear hypoglycemia, and that promotes weight gain. We can minimize hypoglycemia by matching insulin, food, and exercise as well as possible. Now, the insulin analog therapy we have does a really good job of matching insulin requirements to what the body needs. But if you don’t eat at the right time, you take insulin and don’t eat, you get too much insulin, or you exercise more without making accommodations, all of these things can cause hypoglycemia to ensue. What’s more, there may be medications that make the patient not only more prone to hypoglycemia but also have difficulty perceiving hypoglycemia, such as noncardioselective beta blockers.

Transcript edited for clarity.