A practical approach for implementation of a basal-prandial insulin therapy regimen in patients with type 2 diabetes

Abstract

Basal-prandial insulin therapy is a physiologic approach to insulin delivery that utilizes multiple daily injections to cover both basal (ie, overnight fasting and between-meal) and prandial (ie, glucose excursions above basal at mealtime) insulin needs. While basal-prandial therapy with multiple daily injections is an important therapeutic option for patients with type 2 diabetes, there is a common perception that this therapy is difficult to initiate in the primary care setting. To address this issue, a panel of clinical experts convened to develop practical recommendations on how to initiate basal-prandial therapy in patients with type 2 diabetes, focusing on patient selection, simple dosing and titration, and monitoring. Patients with type 2 diabetes who are appropriate candidates for basal-prandial insulin therapy include those who: 1) are unable to achieve glycemic control on oral antidiabetic drugs, 2) are unable to achieve glycemic control on split-mixed/premixed insulin regimens, 3) are newly diagnosed but unlikely to respond to oral antidiabetic drugs alone (ie, the patient has severe hyperglycemia or a markedly elevated glycosylated hemoglobin A1C level for which oral antidiabetic drug therapy alone is unlikely to achieve goals), and 4) prefer this therapy due to socioeconomic or other individual considerations. Basal-prandial insulin can be initiated in a simple stepwise manner, starting first with the addition of basal insulin to the existing oral antidiabetic drug regimen, followed by the introduction of 1 prandial insulin injection to the basal insulin plus oral antidiabetic drug regimen (after basal insulin has been optimized). Subsequently, other injections of prandial insulin may be added when needed. Based on home glucose monitoring data, patients may be converted from split-mixed or premixed insulin regimens to basal-prandial regimens with similar ease. Basal-prandial therapy using newer insulin formulations, such as long- and rapid-acting insulin analogs, can be relatively simple to use in patients with type 2 diabetes and is an appropriate methodology for application by primary care clinicians.

Figure 1

24-hour glucose profiles for representative patients at different levels of glycemic control. Increasing A1C values reflect an elevated fasting or preprandial (basal) blood glucose level and elevated PPG excursions. At levels shown as "uncontrolled" A1C (9.0%), the culprit is predominantly loss of control of the FPG, whereas the difference between an A1C of upper normal (6.0%) vs "controlled" A1C (7.0%) predominantly reflects increased PPG. (PG = plasma glucose.) Copyright ^© 2002 From Rationale for and strategies to achieve glycemic control by Cefalu WT. In: Leahy JL, Cefalu WT (eds) Insulin Therapy. Reproduced by permission of Routledge/Taylor & Francis Group, LLC [41].

Figure 2

Type 2 diabetes treatment algorithm.

Figure 3

Basal-prandial insulin replacement profiles using (A) NPH plus regular human insulin and (B) insulin glargine plus a rapid-acting insulin. Reprinted with permission from DeWitt DE et al. JAMA 2003, 289:2254–2264 [14].