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Stick to what works! Overcoming challenges with insulin therapy in older patients
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A 65-year-old man presents for follow-up consultation for management of type 2 diabetes. He was diagnosed with diabetes in 2005 and has been reasonably well controlled on oral medication until he received a kidney transplant 2 months prior to this visit. He was started on a basal-bolus insulin regimen at that time.
The patient is reliably testing his blood glucose three times a day. Fasting blood sugars are elevated in the 200s, as are his bedtime blood glucose levels. He reports adherence to his prescribed medical regimen at home but admits that he will frequently snack outside his usual mealtimes when he is out and about and then not take an insulin bolus. “I just never remember to bring my insulin pen,” he said. Further questioning brings out that the patient is feeling self-conscious about having to inject insulin in public.
Ronald Tamler
The patient has a medical history of hypertension, arthritis, coronary artery disease requiring CABG, kidney transplant and delayed wound healing.
Family history includes diabetes in his father and hypertension in his mother. He reports that he has never smoked, does not drink alcohol or use illicit drugs.
Medications include:
- Mycophenolate mofetil (CellCept, Roche Palo) 500 mg tablet 1,000 mg by mouth two times a day;
- Insulin glargine (Lantus SoloStar, Sanofi-Aventis) 100 unit/mL (3 mL) pen 30 units subcutaneously at bedtime;
- Insulin aspart (NovoLog FlexPen, Novo Nordisk) 100 unit/mL (3mL) pen 8 units subcutaneously with meals;
- Tacrolimus (Prograf, Astellas) 1 mg capsule 2 mg by mouth every 12 hours;
- Carvedilol 6.25 mg oral tablet, 1 tablet by mouth two times a day with meals.
- Sulfamethoxazole-trimethoprim (Septra, Monarch Pharms) 400/80 mg oral tablet; one tablet by mouth daily;
- Valganciclovir (Valcyte, Hoffmann-La Roche) 450 mg oral tablet; one tablet by mouth daily; and
- Aspirin 81 mg oral chewable tablet; one tablet by mouth daily.
Physical exam remarkable for normal-appearing white male; blood pressure 125 mm Hg/68 mm Hg; pulse 55; resp 16; 5’9” tall and 175 lb; BMI 26; otherwise pretty unremarkable except for scars from CABG and renal transplant.
Labs are unremarkable except for HbA1c of 8.5%. His creatinine had fluctuated but is now normal.
Case Discussion
Which of the following is most likely going to improve the patient’s glycemic control?
A. Explain to the patient that food intake without insulin will lead to hyperglycemia and admonish him to inject himself with insulin aspart every time he eats something. If he eats 10 times per day, he needs to inject 10 times per day.
B. Advise the patient that he can never eat anything outside the house and must stick to three square meals a day (all at home), no matter what the circumstances. He should avoid social engagements that serve food.
C. Given that he has elevated fasting blood glucose levels, increase insulin glargine by 10 units to 40 units daily.
D. Try a disposable insulin delivery device that will adhere to the skin. It should infuse 30 units of insulin per day and deliver a bolus at the push of a button.
Answer: D.
We frequently see patients like the one presented here, older patients with type 2 diabetes who are overwhelmed by the challenges that come with basal-bolus insulin treatment.
Overly strict medication recommendations will alienate the patient with the following possible side effects:
(A) Turning him into a hermit may lead to depression and adverse health (and life) outcomes;
(B) Increasing basal insulin to account for insufficient bolus insulin may carry the risk for hypoglycemia and frequent “hunger attacks”; and
(C) While other patients may have an opportunity to combine basal insulin with orals or use an insulin-mix regimen twice a day, this patient’s irregular eating habits, lifestyle and history were not compatible with such options.
Many patients also report a feeling of shame when they have to inject insulin with meals in public, and they may semi-intentionally forget to bring along their prandial insulin.
Our NP-CDE, Cynthia Esrig, suggested a trial of the V-Go insulin delivery device (Valerias). In this case, we suggested the V-Go 30, which delivers 30 units of rapid-acting insulin over 24 hours and 2 units of insulin with the push of a set of buttons. The device adheres to the skin under the clothing and is exchanged every day. The technology is less customizable, but also far less complex than other insulin infusion systems. Our patient’s wife sent a glowing thank you letter a few weeks after the transition.
Let’s hope the improvement will be reflected in the patient’s HbA1c!
For more information:
- Ronald Tamler, MD, PhD, MBA, is clinical director of the Mount Sinai Diabetes Center in New York. He also is an Endocrine Today Editorial Board member. Disclosure: The author and Esrig report no relevant financial disclosures.