Links And Excerpts: “#397: Insulin, Type 2 Diabetes, Fanny Packs, and Hypoglycemia with Dr. Jeff Colburn” From The Curbsiders

Today, I reviewed and link to and excerpt from The Curbsiders‘ #397: Insulin, Type 2 Diabetes, Fanny Packs, and Hypoglycemia with Dr. Jeff Colburn*.

*Valdez I, Colburn J, Williams PN, Watto MF. “#397: Insulin, Type 2 Diabetes, Fanny Packs, and Hypoglycemia with Dr. Jeff Colburn”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast May 29, 2023.

All that follows is from the show notes of the above outstanding resource.

Managing the Ups and Downs of Insulin from Start to Finish in Patients Living with Type 2 Diabetes

Don’t be scared of insulin or hypoglycemia anymore!  Our Kashlak Friend of the Pod Dr. Jeff Colburn gives us all the essentials you’ll need in your fanny pack for navigating the ups and downs of insulin in type 2 diabetes.

Claim free CME for this episode at curbsiders.vcuhealth.org!

Show Segments

• Intro
• Rapid fire questions/Picks of the Week
• Case #1: Starting insulin
• Types of basal insulin: glargine, detemir, NPH, 70/30 NPH/regular
• Glucose monitoring while on insulin
• Glucose targets  when taking insulin
• Overbasalization
• Adding additional agents to basal insulin
• Case #2: Deescalating insulin
• Insulin use in the geriatric population
• Hypoglycemia Rule of 15
• Glucagon how-to
• Outro

Insulin, Type 2 Diabetes, Fanny Packs, and Hypoglycemia Pearls

1. Starting insulin does not mean the patient failed to do what they were supposed to do, but instead it means their beta cells are failing to do what they’re supposed to do
2. Insulin could be started when other treatments are cost-prohibitive or if the HbA1c is over 10%
3. Start basal insulin at 0.1U – 0.2U/kg/day or at 10U/day and increase basal insulin by 2 units every three days until morning fasting glucose is consistently 90 to 130 mg/dl
4. NPH and pre-mixed insulin should be dosed twice a day with two-thirds of the insulin during the day and one-third in the afternoon/evening.
5. It is OK to dose basal insulin in the morning; determir is a basal insulin that should be dosed twice a day
6. In the US, big box retailers have $25 regular and NPH insulin available to patients when cost is an issue (google where to find)
7. Recognize overbasalization; suspect it if the patient is using ~50 units of basal insulin a day or ~0.5U/kg/day; review the daily blood sugar patterns with the patient to adjust basal insulin or add another agent
8. Decrease basal insulin when adding other agents such as mealtime insulin, GLP-1 RA, or SGLT2-1.
9. Mealtime insulin doses should approximately total the basal insulin in patients that approach absolute insulin deficiency and require complete replacement of insulin
10. The Rule of 15 for hypoglycemia: Teach patients and caregivers to identify hypoglycemia and  treat it with 15gm of glucose every 15 minutes until corrected. Prescribe glucagon to patients starting multiple daily insulin injections (they are at higher risk of hypoglycemia)

Links

1. ADA Standards of Care in Diabetes – 2023 App
2. American Diabetes Association Standards of Care in Diabetes—2023 
3. American Association of Clinical Endocrinology Practice Guidelines -202
4. #387 Diabetes Updates 2023 New Tools for the New Rules
5. #296 Diabetes FAQ 2021 with Dr. Jeff Colburn
6. #168 Diabetes Update 2019 with Dr Jeff Colburn