A sliding scale is good for fishing, but is it good for managing diabetes in outpatients?

This past month I have seen four adults with type 2 diabetes who have gained 40 lb or more in weight during a 12-month period and they all blamed it on their insulin therapy. Whether insulin therapy for diabetes results in weight gain continues to be a debated topic with many prescribers saying "no" and many patients saying "yes."

My recent experience with the four patients prompts me to say yes, but not because of the insulin per se but because of the way it had been prescribed. Each had been placed on a multiple insulin dosing schedule with different levels of complexity.

Case one was prescribed glargine in a dose of 102 units (yes, that was the prescribed dose) every evening, 10 units of lispro with each meal, and additional lispro on a sliding scale if the glucose was >200 mg/dL. That adds up to four injections per day and at least three finger sticks per day. He gave up after a while and decided to skip the finger sticks and just take 15 units of lispro with each meal. Not a bad idea until he started to feel "a little off" more often than he liked. His blood glucose on those occasions was always below 70 mg/dL and he felt better after he took a snack. Essentially he was chasing his hypoglycemia with more and more food and chasing his hyperglycemia with more rapid acting insulin. It should be no surprise that he blamed the insulin for his weight gain and was quite frustrated.

Case two was on a similar regimen but her basal regimen was twice-daily detemir 65 units each time. Her rapid acting insulin was aspart. The other two patients were on similar schedules of injections and glucose checking.

Don’t worry, oral therapies were included in the mix for each of them! And don’t think for one minute that they were not also on medication for hypertension and dyslipidemia.

Colleagues who know me and read these blogs (there are one or two) know that my background has focused on bone and mineral disorders and I don’t have the expertise of my colleagues who have devoted their clinical and academic careers to diabetes. But common sense should tell us that the above approaches are doomed to fail in many, probably most, patients.

Living with diabetes is not easy but we have an obligation to keep pharmacologic management to a minimum and spend as much time as we can find to teach and continually reinforce the benefits of lifestyle modification. Each of these four patients had been to classes to teach them about good eating habits, carbohydrate counting, etc., but there is a limit to what we can expect of our patients.

There is ongoing debate about the merits or otherwise of tight glycemic control in the inpatient setting but all are in agreement that wide fluctuations on blood glucose are best avoided. Surely the same must hold for outpatients. The cycle of chasing hyperglycemia with insulin and the resultant hypoglycemia with food can be avoided in most patients. We should not dilly dally in our attempts to control hyperglycemia but there is no mandate to overshoot morning noon and night!

I know that there are many colleagues and patients out there who have found a way around this issue. You would be helping a lot of us if you shared your successful approaches with us.