TABLE 41–8 Examples of intensive insulin regimens using rapid-acting insulin analogs (insulin lispro, aspart, or glulisine) and NPH, or insulin detemir, glargine, or degludec in a 70-kg man with type 1 diabetes.1–3 1Assumes that patient is consuming approximately 75 g carbohydrate at breakfast, 60 g at lunch, and 90 g at dinner.
2The dose of rapid-acting insulin analogs can be raised by 1 or 2 U if extra carbohydrate (15–30 g) is ingested or if premeal blood glucose is >170 mg/dL. The rapid-acting insulin analogs can be mixed in the same syringe with NPH insulin. 3Insulin glargine or insulin detemir must be given as a separate injection.
reduced insulin requirement include newly diagnosed persons and those with ongoing endogenous insulin production, long-standing diabetes with insulin sensitivity, significant renal insufficiency, or other endocrine deficiencies. Increased insulin requirements typically occur with obesity, during adolescence, and during the latter trimesters of pregnancy. Table 41–8 illustrates regimens of rapidly acting insulin analogs and basal analogs that might be appropriate for a 70-kg person with type 1 diabetes. If the patient is on an insulin pump, he or she may require about a basal infusion rate of 0.6 units per hour throughout the 24 hours with the exception of 4:00 am to 8:00 am, when 0.7 units per hour might be appropriate (dawn phenomenon). The ratios might be one unit for 12 grams carbohydrate plus one unit for 50 mg/dL (2.8 mmol/L) of blood glucose above a target value of 120 mg/dL (6.7 mmol/L).
B. Type 2 Diabetes
Normalization of glucose levels can occur with weight loss and improved insulin sensitivity in the obese patient with type 2 diabetes. A combination of caloric restriction and increased exercise is necessary if a weight reduction program is to be successful. Understanding the long-term consequences of poorly controlled diabetes may motivate some patients to lose weight. For selected patients, medical or surgical options should be considered. Orlistat, phentermine/ topiramate, lorcaserin, naltrexone plus extended release bupropion, and high-dose liraglutide are approved weight loss medications for use in combination with diet and exercise. Bariatric surgery (Roux-en-Y, gastric banding, gastric sleeve, biliopancreatic diversion/duodenal switch) typically result in significant weight loss and can result in remission of the diabetes.
Nonobese patients with type 2 diabetes frequently have increased visceral adiposity—the so-called metabolically obese normal weight patient. There is less emphasis on weight loss in such patients, but exercise is important.
Multiple medications may be required to achieve glycemic control (Figure 41–6) in patients with type 2 diabetes. Unless there is a contraindication, medical therapy should be initiated with intensive lifestyle interventions (diet and exercise), diabetes self-management education, and metformin. If clinical failure occurs with metformin monotherapy, a second agent is added. Options include sulfonylureas, repaglinide or nateglinide, pioglitazone, GLP-1 receptor agonists, DPP-4 inhibitors, SGLT2 inhibitors, and insulin. In the choice of the second agent, consideration should be given to efficacy of the agent, hypoglycemic risk, effect on weight, adverse effects, and cost. In patients who experience * Step taken if needed to reach individualized HbA1c target after ~ 3 months.