From the Guidelines
For a patient taking 880 units of insulin daily with only 6% time in range, despite not being a large person, I strongly recommend a thorough reevaluation of their insulin therapy to identify potential causes of extreme insulin resistance, as their basal dose likely exceeds 0.5 units/kg/day, indicating possible overbasalization 1. To approach this patient, consider the following steps:
- Verify insulin administration technique and storage to ensure proper injection and insulin integrity.
- Evaluate for insulin antibodies, endocrine disorders like Cushing's syndrome, acromegaly, or thyroid dysfunction, which can cause severe insulin resistance.
- Assess medication interactions, particularly glucocorticoids, and evaluate for intercurrent illness or infection.
- Consider genetic syndromes of extreme insulin resistance, although rare, as part of a comprehensive evaluation.
- Adjust therapy by considering the addition of insulin sensitizers like metformin or pioglitazone, or GLP-1 receptor agonists, which may help reduce insulin requirements, as suggested by the standards of care in diabetes-2024 1. Given the patient's high insulin dose and poor glycemic control, it is crucial to investigate these potential causes to tailor therapy to their individual needs and improve their time in range, ultimately enhancing their quality of life and reducing morbidity and mortality associated with poorly controlled diabetes.
From the FDA Drug Label
The time course of LEVEMIR action may vary in different individuals or at different times in the same individual and is dependent on site of injection, blood supply, temperature, and physical activity Adjustment of dosage of any insulin may be necessary if patients change their physical activity or their usual meal plan. Insulin requirements may be altered during intercurrent conditions such as illness, emotional disturbances, or other stresses.
The patient's high insulin dosage and low time in range suggest insulin resistance. However, the FDA drug label does not provide a clear explanation for why a patient may be resistant to insulin.
- Possible factors that may contribute to insulin resistance include:
From the Research
Insulin Resistance and Time in Range
- The patient is taking 880 units of insulin per day, but still has a time in range of only 6% 3.
- This suggests that the patient may be experiencing insulin resistance, which can be caused by a variety of factors, including severity of illness, medications, and inconsistent dietary intake 4.
- Insulin resistance can make it difficult to achieve optimal glycemic control, even with high doses of insulin.
Factors Contributing to Insulin Resistance
- The patient's size is not necessarily a determining factor in insulin resistance, as other factors such as medication use, dietary habits, and underlying medical conditions can play a larger role 5.
- The use of certain medications, such as steroids, can contribute to insulin resistance 4.
- Inconsistent dietary intake and poor glucose control can also contribute to insulin resistance 3.
Alternative Treatment Options
- GLP-1 receptor agonists, such as semaglutide, have been shown to be effective in improving glycemic control and reducing insulin resistance 5, 6, 7.
- These medications can be used in combination with insulin therapy to improve glycemic control and reduce the risk of hypoglycemia 7.
- Oral semaglutide has been shown to be effective in reducing HbA1c and body weight, with a low risk of hypoglycemia 7.
Considerations for Treatment
- The choice of treatment should be individualized based on the patient's specific needs and medical history 3.
- The use of computer decision support systems can help reduce the risk of insulin infusion rate calculation errors and standardize insulin therapy 4.
- Communication with the primary care physician is an important part of discharge planning and ensuring continuity of care 4.