Targeting Insulin Doses in Type 2 Diabetes

The difference between the bedtime and morning blood glucose values (BeAM value) is a simple, easy way to identify patients with type 2 diabetes mellitus (T2DM) using basal insulin who need targeting of postprandial control rather than advancing basal insulin dose, according to a new study.

“We propose that bedtime (or 2 hour post-dinner) values, which are conveniently measured by patients at home, roughly reflect cumulative daytime postprandial excursions, and fasting or pre-breakfast values, which are also conveniently measured at home, provide insights into possible basal insulin overutilization,” state the authors, led by Dr. Ariel Zisman of The Endocrine Center of Aventura, Aventura, FL. “As such, BeAM value may represent a more suitable and accurate indicator than total daily basal insulin dose or fasting blood glucose (FBG) alone of the need to address postprandial control in patients on combination oral antidiabetic drugs (OADs) and undergoing optimization of basal insulin with FBG approaching target.”

Timely initiation of single-dose basal insulin treatment is a convenient, effective strategy that has become an acceptable option readily implemented by primary care physicians, the authors state. Several provider-driven or patient-driven algorithms, mostly focusing on a specific FBG target, promote easy upward titration of basal insulin doses.

However, “primary providers may continue up-titration of basal insulin to reduce A1C and/or FBG levels, causing inadvertent overinsulinization,” they state. “A simple and convenient, evidence-based and clinically relevant measure is needed to assist primary care providers in deciding when titration of basal insulin should cease.”

They devised a study to investigate the relationship between the BeAM value and A1C, FBG, and hypoglycemia events in patients undergoing basal insulin titration. For exploratory (1699 patients) and main (492 patient) analyses, data were pooled from phase 3 trials in adults with T2DM adding basal insulin to OADs. The main analysis included only patients who did not reach A1C ≤7.0% (53 mmol/mol) at week 24. The proof-of-concept analysis used pooled data from phase 3 trials in 299 adults with T2DM adding insulin glargine and a single insulin glulisine injection to oral antidiabetic drugs.

In patients undergoing basal insulin titration, BeAM value increased over 24 weeks in the exploratory and main analyses. In patients with T2DM who were undergoing targeted basal insulin titration, there was a doubling of the BeAM value after 24 weeks of treatment. There were significant correlations between week 24 BeAM value and postprandial contribution to hyperglycemia in these analyses, they state.

When postprandial glucose was targeted in the proof-of-concept analysis, the BeAM value reduced from 77.0 to 40.4 mg/dL, they state.

The authors conclude: “Despite the well-documented progressive nature of type 2 DM and the clinical consequences of elevated post-prandial glucose, there is currently no clear definition of the point at which a basal insulin regimen may be considered optimized and prandial insulin should be added. Our analyses suggest that use of the BeAM value could provide a simple, easy-to-calculate indicator of the need for treatment intensification targeting prandial glucose excursions in patients who have not reached treatment goals on basal insulin.”

Reference: Zisman A, et al. BeAM value: an indicator of the need to initiate and intensify prandial therapy in patients with type 2 diabetes mellitus receiving basal insulin. BMJ Open Diab Res Care  2016;4:e000171.