Case Reports
Initiation of Biphasic Insulin Aspart in a Patient Failing Basal Insulin Treatment
Janusz Gumprecht Professor, Department of Internal Diseases, Diabetology and Nephrology, Medical University of Silesia
Abstract
This case illustrates insulin intensification from insulin glargine to biphasic insulin aspart 30 (BIAsp 30), reviews supporting clinical literature and discusses alternative therapeutic approaches. PL, a 56-year-old male with an eight-year history of type 2 diabetes, needed to intensify his insulin glargine treatment as he was not achieving appropriate blood glucose targets and recurrent hypoglycaemia limited
further dose titration. With insulin glargine, his glycosylated haemoglobin (HbA1c) was 7.8 %, his fasting plasma glucose (FPG) ranged from 7.2 mmol/l to 8.0 mmol/l and his postprandial glucose (PPG) ranged from 8.9 mmol/l to 10.6 mmol/l, being especially high after dinner.
At four months after the switch to BIAsp 30, his HbA1c was 6.9 % and his FPG and PPG levels were at goal. The patient had not experienced any hypoglycaemic episodes. By addressing both PPG and FPG, intensification with BIAsp 30 provided improved glycaemic control without the hypoglycaemia experienced with insulin glargine.
Keywords Biphasic insulin aspart 30 (BIAsp 30), fasting plasma glucose (FPG), insulin, insulin glargine, postprandial glucose (PPG), type 2 diabetes
Disclosure: Janusz Gumprecht has participated in advisory boards and speakers’ bureaux for Novo Nordisk. Acknowledgements: Medical writing support was provided by Watermeadow Medical Ltd, funded by Novo Nordisk. Received: 2 September 2011 Accepted: 7 September 2011 Citation: European Endocrinology, 2011;7(2):127–8 Correspondence: Janusz Gumprecht, Department of Internal Diseases, Diabetology and Nephrology, Medical University of Silesia, Zabrze, Poland. E:
jgumprecht@sum.edu.pl
Support: The publication of this article was funded by Novo Nordisk A/S, Denmark. The views and opinions expressed are those of the author and not necessarily those of Novo Nordisk A/S, Denmark.
Premix insulin analogues such as biphasic insulin aspart 30 (BIAsp 30) offer a convenient and simple way to intensify basal insulin therapy once the basal insulin is no longer able to control glycosylated
haemoglobin (HbA1c). Simple treatment algorithms are available for intensifying patients on once- or twice-daily basal insulin to BIAsp 30 twice daily, or for patients on once- or twice-daily BIAsp 30 who require twice- or three-times-daily BIAsp 30.1
By switching to BIAsp 30
twice daily, patients can provide coverage of their fasting plasma glucose (FPG) as well as postprandial glucose (PPG) at their two main meals and the addition of a third daily dose provides an easy way to intensify therapy further.1–3
Case Report
PL is a 56-year-old male with a body mass index (BMI) of 29 kg/m2 and an eight-year history of type 2 diabetes. He has an active occupation but is minimally physically active in his free time and has irregular eating habits. He has non-proliferative diabetic retinopathy, concomitant hypertension and dyslipidaemia and, in addition to his diabetes medication, is receiving ramipril 10 mg/day, simvastatin 40 mg/day and acetylsalicylic acid (aspirin) 75 mg/day.
Prior Diabetes Therapy In contrast, while basal insulins provide a
simple way to initiate insulin, they fail to address PPG and therefore insulin intensification is more complicated. Patients either have to switch to a basal–bolus approach requiring two insulin devices, more invasive glucose monitoring and the difficulties of titrating both the basal and prandial components of therapy, or they can intensify therapy using a premix insulin. A basal–bolus approach may suit patients with very variable daily routines and mealtimes, those with good cognitive and physical function, those with a willingness to closely monitor their disease and those with a good support structure. Many patients, however, will prefer a simpler approach with a premix insulin that allows them to provide FPG and PPG control with a single insulin pen and an easy dose-titration algorithm. The following case report examines insulin intensification from insulin glargine to BIAsp 30 and reviews alternative treatment options.
© TOUCH BRIEFINGS 2011
The patient was receiving metformin 1,000 mg twice daily and glimepiride 4 mg/day, which was not providing adequate control of his
HbA1c (8.8 %, 73 mmol/mol), FPG (8.9–10.6 mmol/l) or PPG (8.9–12.2 mmol/l). Insulin initiation had been discussed three months earlier; however, the patient refused because of fear of injections and hypoglycaemia. It was decided to address the patient’s concerns regarding insulin initiation by explaining the benefits of insulin and the need to control hyperglycaemia in order to minimise the risks of diabetes complications. In response to discussions about lifestyle modification, the patient indicated that he would try to increase his physical activity but that it would be impossible to change his irregular eating habits. He was prescribed once-daily insulin glargine. Following insulin initiation, metformin was continued but the patient was advised to discontinue glimepiride. The patient was advised to continue ramipril, simvastatin and acetylsalicylic acid. The starting dose was 14 units of
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