Insulin is in the spotlight...and you can help answer questions.
Medicare Part D now caps insulin co-pays at $35/month. And manufacturers are rolling out their own co-pay caps...and lower prices.
Plus Rezvoglar (insulin glargine-aglr) will soon join Semglee as a lower-cost interchangeable biosimilar for Lantus.
Expect all of these changes to lead to more questions about how to use insulin for patients with type 2 diabetes.
When should insulin be started? Suggest basal insulin first-line in some cases...such as if A1c is over 10% or in patients with symptomatic hyperglycemia (polyuria, polydipsia, etc).
Or consider adding insulin if other med combos aren’t enough.
Recommend starting with 10 units or 0.1 to 0.2 units/kg once daily of a long-acting analog (glargine, etc) or NPH in most patients.
Suggest titrating by 1 to 2 units or 5% to 10% once or twice weekly...to meet fasting glucose goals.
How should other diabetes meds be adjusted when insulin is added? Recommend continuing GLP-1 agonists (Ozempic, etc), metformin, and SGLT2 inhibitors (Jardiance, etc).
Explain that continuing these meds may help limit weight gain...and allow patients to use lower insulin doses.
And point out that GLP-1 agonists or SGLT2 inhibitors may be used for their CV or kidney benefits in some patients.
It’s also okay to continue gliptins (Januvia, etc).
But caution about using insulin with pioglitazone...due to possible weight gain, edema, and heart failure.
Recommend stopping sulfonylureas once mealtime insulin is added...there’s little added benefit and possibly more hypoglycemia.
When should mealtime insulin be added? Suggest bolus insulin if patients have good fasting glucose but can’t reach their A1c goal...or are using over 0.5 units/kg/day of basal insulin.
Advise adding rapid-acting (lispro, etc) or regular insulin before the largest meal...then adding a dose before other meals if needed.
Think of premixed insulin (70/30, etc) for patients who need a simpler approach...but keep in mind that doses are harder to adjust.
See our resource, Tips to Improve Insulin Safety. And access our Diabetes Resource Hub for help with switching, monitoring, and more.
- Diabetes Care. 2023 Jan 1;46(Suppl 1):S140-S157
- Diabetes Care. 2022 Nov 1;45(11):2753-2786
- Checklist: Tips to Improve Insulin Safety
- Technician Tutorial: Dispensing Insulin and Other Injectable Diabetes Meds