From the Guidelines
Uncontrolled diabetes despite high insulin doses requires a comprehensive approach, prioritizing insulin therapy in combination with lifestyle intervention, as recommended by the American Diabetes Association and the European Association for the Study of Diabetes 1. To address this issue, several key steps should be taken:
- Evaluate for medication adherence issues, proper injection technique, and insulin storage problems to ensure that the insulin regimen is being followed correctly.
- Consider adding metformin to improve insulin sensitivity, starting at 500mg daily and increasing to 1000mg twice daily as tolerated.
- Other options include GLP-1 receptor agonists like semaglutide or SGLT-2 inhibitors like empagliflozin, which can help improve glycemic control.
- Lifestyle modifications are crucial, including:
- Aiming for 150 minutes of weekly exercise
- Reducing carbohydrate intake, especially refined carbs
- Maintaining consistent meal timing
- Achieving modest weight loss if overweight
- Monitor blood glucose more frequently, including post-meal readings, to identify patterns and adjust treatment accordingly.
- Underlying conditions like thyroid disorders, Cushing's syndrome, or infections may contribute to insulin resistance and should be investigated 1.
- Sleep apnea, stress, and certain medications (steroids, some antipsychotics) can also worsen glucose control and should be addressed.
- Regular follow-up every 2-3 months is essential to adjust treatment until control improves, with a goal of achieving an A1C level below 6.0% if possible, as suggested by the VA Diabetes Trial 1.
From the Research
Uncontrolled Diabetes Mellitus Despite High Insulin Dosage
- Uncontrolled diabetes mellitus despite high insulin dosage can be a challenging condition to manage, and several studies have investigated different treatment approaches 2, 3, 4, 5, 6.
- According to a study published in 1984, the treatment of severely uncontrolled diabetes mellitus requires careful attention to the patient's underlying illnesses and continuous clinical attention and laboratory monitoring 2.
- Another study published in 2011 recommends insulin therapy for patients with type 2 diabetes mellitus and an initial A1C level greater than 9 percent, or if diabetes is uncontrolled despite optimal oral glycemic therapy 3.
- A 2020 study suggests that adding new oral glucose-lowering drugs to insulin, such as DPP-4 inhibitors, can lead to a modest HbA1c reduction without weight gain and no increase in hypoglycemia 4.
- A retrospective review of patients with uncontrolled type 2 diabetes who received premixed insulin, a GLP-1 receptor agonist, and metformin found that the combination therapy improved glycemic control over 12 months, despite a decreased cumulative daily dose of insulin 5.
- A systematic review and meta-analysis of surrogate metabolic endpoints found that GLP-1RAs provide better glycaemic effects than SGLT-2is in patients with T2DM uncontrolled by metformin, albeit while increasing risk for hypoglycaemia and gastrointestinal adverse events 6.
Treatment Approaches
- Insulin therapy, including basal and bolus insulin, is a common treatment approach for uncontrolled diabetes mellitus 3, 4.
- The use of premixed insulin, GLP-1 receptor agonists, and metformin as combination therapy has been shown to improve glycemic control in patients with uncontrolled type 2 diabetes 5.
- GLP-1RAs and SGLT-2is are second-line treatment options for patients with type 2 diabetes mellitus, and the choice between these two treatments depends on various factors, including the patient's individual needs and medical history 6.
Key Considerations
- When managing uncontrolled diabetes mellitus, it is essential to consider the patient's underlying illnesses, medical history, and individual needs 2, 3, 4, 5, 6.
- The treatment approach should be tailored to the patient's specific needs, and the patient should be closely monitored to adjust the treatment plan as needed 2, 3, 4, 5, 6.