Moving Beyond Basal Insulin—Intensifying Type 2 Regimens
The American Diabetes Association (ADA) advises to advance treatment of diabetes without delay when treatment goals are not being met.1 Specific to type 2 diabetes (T2D), advancing treatment can include intensifying lifestyle behaviors (diet and exercise), adding non-insulin medication(s), and adding basal and prandial insulin. For a variety of reasons therapeutic inertia may exist which can have untoward effects on risk of complications.2 It is precisely for this reason treatment models such as the Identify, Configure, Collaborate (ICC) Framework has been developed as a call-to-action.2
One of the delayed treatment stages in T2D is advancing post-prandial medication coverage—either with GLP-1 agonist (if not already used) or prandial insulin.3,4 In an attempt to control hyperglycemia, basal insulin dose might be increased to a level that is beyond therapeutic and therefore puts patients at risk of hypoglycemia, especially during sleep hours. Providers might question when to add prandial insulin. To help address this clinical situation, researchers have studied the use of a simple calculation—to use as an assessment measure—called a “BeAM value.”5 The BeAM value is the number obtained after taking a bedtime blood glucose (Be) and subtracting the following prebreakfast (AM) blood glucose.
A three-part retrospective study by Zisman et al found, in subjects with T2D, the larger BeAM values correlated with a higher incidence of nocturnal hypoglycemia.5 This finding could identify poor post-prandial control (higher bedtime BG) and overbasalization (large drop in glucose overnight). Zisman et al say their data analysis suggests when the BeAM value is between 45-55 mg/dL a change in treatment should be considered5; simply stated ≥ 50 mg/dL.4 Researchers say prospective studies are needed. Other variables should be assessed such as missed medication doses, patient eating habits, and other pre to post-meal glucose patterns.
Prandial insulin is a treatment option warranted when maximum basal insulin is reached and overall glycemia remains elevated. A commonly believed maximum basal insulin dose is ~0.5 units/kg/day.1,4 Basal doses above this level have shown to increase risk of weight gain and hypoglycemia yet only have modest effect on glycemia.4 The ADA suggests starting prandial insulin by adding 4 units (or 10% basal dose) before one meal (largest meal or largest post-meal excursion). This same number of units can be subtracted from basal dose if A1C < than 8%.1
When using a connected insulin pen (CIP), such as the InPenTM system, ongoing assessment of the basal insulin dose can be done by using the long-acting assessment on the Insights Report (see below). This assessment can be made with or without use of continuous glucose monitor (CGM) data. In addition, prandial doses are automatically recorded to show units taken and timing of dose, which can greatly assist the safe and effective titration of prandial insulin.
For more information about InPen, or any Medtronic Diabetes product, contact your local representatives. Information also available at https://www.medtronic.com/us-en/healthcare-professionals/therapies-procedures/diabetes.html
1
American Diabetes Association Professional Practice Committee. 9. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes—2022. Diabetes Care 2022;45(Suppl. 1):S125–S143.
2
MacLeod, J., Scher, L., Greenwood, D., et al. Technology Disparities and Therapeutic Inertia A Call to Action for the Diabetes Care and Education Specialist. In Practice. 2021; Sept.34-41.
3
Khunti S, Khunti K, Seidu S. Therapeutic inertia in type 2 diabetes: prevalence, causes, consequences and methods to overcome inertia. Ther Adv Endocrinol Metab. 2019;10:2042018819844694. Published 2019 May 3.
4
Cowart K. Overbasalization: Addressing Hesitancy in Treatment Intensification Beyond Basal Insulin. Clin Diabetes. 2020;38(3):304-310.
5
Zisman A, Morales F, Stewart J, et al. BeAM value: an indicator of the need to initiate and intensify prandial therapy in patients with type 2 diabetes mellitus receiving basal insulin BMJ Open Diabetes Research and Care 2016;4:e000171.
Important safety information: InPenTM smart insulin pen
The InPenTM requires a prescription. It is a home-use reusable pen injector for single-patient use by people with diabetes under the supervision of an adult caregiver, or by a patient age 7 and older for the self-injection of a desired dose of insulin. The pen injector is compatible with Lilly Humalog® U-100 3.0 mL cartridges, Novo Nordisk Novolog® U-100 3.0 mL cartridges, and Novo Nordisk Fiasp® U-100 3.0 mL cartridges and single-use detachable and disposable pen needles (not included). The pen injector allows the user to dial the desired dose from 0.5 to 30 units in one-half (1/2) unit increments.
The InPenTM dose calculator, a component of the InPenTM app, is indicated for the management of diabetes by people with diabetes under the supervision of an adult caregiver, or by a patient age 7 and older for calculating an insulin dose or carbohydrate intake based on user entered data.
For an insulin dose based on amount of carbohydrates, a healthcare professional must provide patient-specific target blood glucose, insulin-to-carbohydrate ratio, insulin sensitivity parameters, and duration of insulin action to be programmed into the software prior to use as it is required for set up.
For an insulin dose based on fixed/variable meal sizes, a healthcare professional must provide patient-specific fixed doses/meal sizes to be programmed into the software prior to use.
For additional product and important safety considerations, see User Guide and http://bit.ly/InPenSafety.