Case Studies on Insulin Initiation
Nicole McGrath
2013
Case 1
• 52 year old woman, type 2 diabetes for 10 yrs,
BMI 32 (87kg)
– On Metformin 850mg mane, 1700mg nocte;
Gliclazide 80mg bd
• Regularly picks up scripts; assures you she is taking
– Not testing BG
– HbA1c 70 mmol/mol
• What to do?
Case 1 Discussion
• Increase Gliclazide to 160mg bd
• Start home BG testing
• BG elevated:
– Fasting around 10
– Before evening meal 12
– 2 hours after evening meal 13
• What next?
Case Study 1 - Mrs J
Age 52. BMI 32 (87kg). HbA1c: 70mmol/mol
Currently on: Metformin 850mg mane, 1,700mg at dinner, Gliclazide 160mg
BD.
Blood glucose (mmol/L)
How would you start Mrs J. on insulin?
Case Study 1 - Mrs J.
• NZGG:
– Start Isophane 8-10 units at
bedtime.
– Continue orals – consider reduction
of Gliclazide to 80mg BD.
– Give the patient instruction to selfadjust insulin dose.
• Likely doses to achieve red line:
– Isophane 30-35 units nocte
– Gliclazide 160mg bd
– Metformin 850mg mane, 1700mg
evening meal
Case Study 2 – Mrs T:
Age 74. HbA1c 75mmol/mol (9%)
,
Currently on: Prednisone 5mg/day for Rheumatoid Arthritis and maximal
OHA therapy.
Blood glucose (mmol/L)
Case Study 2 – Mrs T.
As you can see… high glucose levels rising
during the day but dropping over
night.
Consider:
• 10 units of isophane at breakfast and
adjust the dose as required.
– Good fasting achieved with 15 units but….
Red line still suboptimal so change to
• 15 units of Pre-mixed insulin breakfast
– Penmix 30 / Humulin 30/70
.
Case 3: 66 yr old male with COPD
• On Metformin 1gm bd,
Glipizide 5mg bd;
– HbA1c 57 mmol/mol
• Needs course of
Prednisone for
exacerbation COPD
– Prednisone 40mg daily 5
days then 20mg 5 days
Fasting
Pre-lunch
Pre-dinner
6.8
12.6
17.2
7.1
13.8
18.0
PATHWAY FOR MANAGING HYPERGLYCAEMIA SECONDARY TO
STEROIDS FOR CLIENTS WITH COPD
(on HealthPoint)
• Whilst on 40 mg Prednisone
– Test BSLs at least tds
– OHAs –increase usual mane dose by 100% e.g. usual mane dose
Gliclazide 80mg –increase to 160mg
• If patient is maximised on OHAs:
– transient hyperglycemia can sometimes be tolerated for a short
period.
– Alternatively, a morning dose of Penmix 30/70 (usually 0.2 units/kg
body weight) can be given during steroid treatment.
– Some patients may need to be commenced on ongoing insulin
Case Study 4 - Mr L.
Age 62. BMI 27 (78kg) HbA1c 68mmol/mol. Currently on: maximal OHA
therapy.
Blood glucose (mmol/L)
Case Study 4 – Mr L.
High fasting and post-prandial BG:
basal insulin with current OHA will treat
fasting hyperglycaemia but not post
meal BG elevations
Suggest Premixed insulin:
As lunch not so much of an issue,
Novomix 30 or Humalog 25:
Start 15 units bd (0.2 units/kg/dose)
Stop sulphonylurea
Case Study 5 - Mr K.
Age 64. HbA1c 75mmol/mol (9%).
Currently on: maximal OHA therapy.
Blood glucose (mmol/L)
Case Study 5 – Mr K.
Mr K’s blood glucose is particularly high
after his main meal (dinner).
•Consider 10–12 units of premixed insulin (Humalog
Mix25 or Novomix30) at
dinner.
Case 6: 55 yr old male, BMI 35 (116kg), known
diabetes 4 yrs, Hba1c 85
• No home BG testing
• Long gaps between prescription requests
– Prescribed Metformin 1gm bd, Gliclazide 160mg
bd
• Microalbuminuria, background retinopathy,
hypertension
Case 6
• Option 1
– advice on diet, exercise, taking medication
– warn of possible adverse consequences;
– increase Metformin to 1500mg bd;
– Start BG testing and reporting back to nurse
Case 6
• Option 2: 3 month F/U HbA1c 76:
– Has achieved good reduction with compliance but
HbA1c still suboptimal and not testing much
• Fasting BG 10, Pre-dinner 13
• Glargine in addition to Metformin and
Gliclazide a reasonable option
– Starting dose: 0.2 units / kg / day:
– Weight 116kg: start 24 units daily (morning or night)
– Insulin self-adjustment in conjunction with weekly contact
with nurse
Case 6
• Option 3:
– Accept failure of OHA
– Prescribe pre-mixed insulin bd
• He eats 2 meals per day: brunch and dinner
– NovoMix 30 or Humalog Mix 25: 24 units bd
» Could well need to double that
– Stop sulphonylurea, continue Metformin
• Provide insulin self-adjustment handout or ask pt to
increase each dose by 2 units every 3 days until BG 4-8
– Hopefully practice nurse will be able to contact him weekly to
support/supervise
Case 7: 37 year old female, BMI 45 (weight
128kg); diabetes 3 years
• HbA1c 85
• Prescribed Metformin 1gm bd; Gliclazide
160mg bd and appears to be taking them
• Not testing BG
• Sleep Apnoea
Case 7
• Option 1
– Weight loss essential:
• Refer to dietitian for consideration of Optifast
• Refer for consideration Bariatric Surgery
– Pioglitazone in addition to Metformin and
Gliclazide
– Repeat HbA1c in 3 months
Case 7
• Option 2
– Accept weight loss/exercise not achievable
– Consider insulin, although insulin resistance will
mean large doses necessary
• Eats 3 meals per day and snacks in the evening
• Penmix 30 or Humulin 30/70: 26 units bd, stop
sulphonylurea
– Insulin self-adjustment: may need to increase by > 4 units
each time if BG remain very high
– Will probably need 60 units bd if she doesn’t change her
diet/weight
Case 8: 41 yr old male, BMI 27
• Diabetes 8 yrs, on Metformin 1500mg bd, Gliclazide 160mg
bd, Pioglitazone 45mg daily
• Truck driver
• HbA1c 62 mmol/mol
• Microalbuminuria, erectile dysfunction, retinopathy
• BG: fasting 9, pre-dinner 10
• Requires heavy traffic licence medical certificate
• Patient feels he is doing as much as he can re diet, exercise
Case 8
• Needs insulin but want to minimise effect on
driving
– Isophane at night 10 units
• Increase by 2-4 units every 3 days to achieve fasting BG
<7
– Continue OHA
• NB. LTSA do not generally require specialist
reports for type 2 patients on insulin