insulin titration case study william

Insulin Initiation and Titration for Family Physicians: Case Study #1: William Alice Y.Y Cheng, MD FRCPC Peter Lin, MD CCFP Case Study #1: William Patient history and presentation • • • • • 59-year-old male stockbroker Type diabetes x years Weight = 90 kg A1C = 7.9% He is on metformin, an insulin secretagogue and a TZD – he is at the maximum dose of all three oral agents • You have been proposing that he start insulin during the past few visits in the last year, and he is now becoming more agreeable to the idea William’s SMBG Logbook Breakfast Before After Lunch Before Dinner After Before After Bedtime Sunday 9.7 9.2 7.5 Monday 9.4 10.0 6.9 Tuesday 9.0 8.6 7.8 Wednesday 9.1 8.9 Thursday 8.8 8.5 7.5 Case Study #1: William (cont’d) Case review • William has suboptimal glycemic control, according to the guidelines • He is maxed out on oral agents • He continues to have high BG levels, particularly in the morning • What insulin regimen would you prescribe? Type Diabetes: Insulin Categories Basal Basal plus bolus Pre-mixed twice daily Case Study #1: William (cont’d) • The easiest insulin to start would be basal insulin at bedtime, which has the advantage of a single injection – so it is easy to remember • At this point, the TZD should be discontinued (to minimize risk of edema); however, the metformin and insulin secretagogue can both be continued CHOOSE AN INSULIN CATEGORY CHOOSE A BRAND DOSING SEE REVERSE FOR TIPS Basal Insulin Dosing and Titration 10 4.0–7.0 Case Study #1: William Three Years Later • William had achieved an A1C