Comment

An alternative for insulin intensification beyond basal therapy might be a switch to premixed insulin, which has been given twice daily or before every meal in some studies.5 Although premixed insulin usually results in lower HbA1c concentration than does basal insulin therapy, some studies have compared it with basal bolus insulin replacement. A recent meta-analysis6 that included three such studies concluded that a basal bolus approach was more effective in getting patients to target HbA1c concentrations than premixed insulin therapy, with no difference in weight gain or risk of hypoglycaemia.6 Nevertheless, in the real world setting, intensification with a premixed insulin preparation might be suitable for patients with a consistent lifestyle schedule who do not need as strict control, or who might be overwhelmed by a basal bolus approach. These trials of stepwise approaches to intensifying insulin therapy with a basal bolus regimen2–5 do provide the clinician with some practical approaches to intensification of treatment beyond basal insulin. First, the clinician needs to understand when basal insulin is insufficient to achieve or maintain desired glycaemic goals. This might be the case when the patient’s HbA1c concentration remains elevated despite reasonable fasting plasma glucose concentrations or a basal insulin dose in excess of 0·5 units per kg per day.1 Second, once the decision to initiate prandial insulin is made, the patient can be asked to identify the largest (carbohydrate) meal of the day. At that meal 4–6 units of a rapid-acting insulin analogue could be started (ideally injected 10–15 min before eating) and the dose adjusted on a weekly or twice-weekly basis so that the next prandial or bedtime glucose reading is at target (less than 7·2 mmol/L [130 mg/dL] based on standards from the American Diabetes Association and the European Association for the Study of Diabetes). After optimising

the first prandial insulin dose and allowing sufficient time for the HbA1c concentration to stabilise, if the repeat HbA1c remains above target range a second prandial dose could be added, using a similar process to that used for the pirst prandial insulin injection. A third dose can eventually be added as—and if—needed. Clinicians should be aware that every addition of a prandial dose of insulin to a patient’s daily regimen increases the risk of hypoglycaemia, and therefore should be weighed against potential benefits of intensifying therapy. Luigi F Meneghini Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA [email protected] I have been a member of the advisory board or panel of Novo Nordisk, Halozyme, and Boehringer Ingelheim/Lilly; a consultant for Novo Nordisk and Sanofi Diabetes; and I have received grants or research support from MannKind, Pfizer, Boehringer Ingelheim/Lilly, Biodel, and Sanofi-Aventis. 1

2

3

4

5

6

7

Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2012; 55: 1577–96. Meneghini L, Mersebach H, Kumar S, Svendsen AL, Hermansen K. Comparison of 2 intensification regimens with rapid acting insulin aspart in type 2 diabetes mellitus inadequately controlled by once-daily insulin detemir and oral antidiabetic drugs: the step-wise randomized study. Endocr Pract 2011; 17: 727–29. Raccah D, Haak, TJ, Huet D, et al. Comparison of stepwise addition of prandial insulin to a basal-bolus regimen when basal insulin is insufficient for glycaemic control in type 2 diabetes: results of the OSIRIS study. Diabet Metab 2012; 38: 507–14. Davidson MB, Raskin P, Tanenberg RJ, Vlajnic A, Hollander P. A stepwise approach to insulin therapy in patients with type 2 diabetes mellitus and basal insulin treatment failure. Endocr Pract 2011; 17: 395–403. Rodbard HW, Visco VE, Andersen H, Hiort LC, Shu DHW. Treatment intensification with stepwise addition of prandial insulin aspart boluses compared with full basal-bolus therapy (FullSTEP Study): a randomised, treat-to-target clinical trial. Lancet Diabetes Endocrinol 2013; published online Sept 25. http://dx.doi.org/10.1016/S2213-8587(13)70090-1 Garber AJ, Wahlen J, Wahl T, et al. Attainment of glycaemic goals in type 2 diabetes with once-, twice-, or thrice-daily dosing with biphasic insulin aspart 70/30 (The 1-2-3 study). Diabetes Obes Metab 2006; 8: 58–66. Giugliano D, Maiorino MI, Bellastella G, Chiodini P, Cerielle A, Esposito K. Efficacy of insulin analogs in achieving the hemoglobin A1c target of

Can we predict diabetes remission after weight-loss surgery?

Can we predict diabetes remission after weight-loss surgery? - PDF Download Free
113KB Sizes 1 Downloads 3 Views