Can I introduce mealtime insulin (e.g. Novolog (insulin aspart) or Humalog (insulin lispro)) to a patient with type 2 diabetes mellitus (DM2) on Levemir (insulin detemir) 22 units daily and Metformin (metformin hydrochloride) 1000mg twice daily (BID), who was previously well controlled with a sodium-glucose cotransporter 2 (SGLT2) inhibitor but can no longer afford it?

Adding Mealtime Insulin to Basal Insulin for Type 2 Diabetes Management

Yes, you should introduce mealtime insulin (such as Novolog or Humalog) to this patient with type 2 diabetes who can no longer afford SGLT2 inhibitors despite having previously good control with this medication. 1

Assessment of Current Therapy and Need for Intensification

• The patient is currently on Levemir 22 units daily with morning fasting glucose <140 mg/dL and Metformin 1000mg twice daily 1
• Previous glycemic control was achieved with the addition of an SGLT2 inhibitor, which is no longer affordable due to coverage changes 1
• Other oral diabetes medications including DPP-4 inhibitors and GLP-1 receptor agonists are also not affordable options 1
• When basal insulin has been titrated to an acceptable fasting blood glucose level but HbA1c remains above target, combination injectable therapy should be considered 1

Rationale for Adding Mealtime Insulin

• When basal insulin alone is insufficient to achieve glycemic targets, mealtime insulin is recommended to address postprandial glucose excursions 1
• The American Diabetes Association guidelines recommend that when basal insulin has been optimized but glycemic targets are not met, mealtime insulin should be added to reduce postprandial glucose excursions 1
• Insulin therapy should not be delayed in patients not achieving glycemic goals 1

Recommended Approach for Initiating Mealtime Insulin

• Start with a single injection of rapid-acting insulin (insulin aspart or insulin lispro) before the largest meal of the day 1
• The recommended starting dose is 4 units, 0.1 U/kg per meal, or 10% of the basal insulin dose 1
• Consider decreasing the basal insulin dose (Levemir) by the same amount as the starting mealtime dose to avoid hypoglycemia 1
• Titrate the mealtime insulin dose based on self-monitored blood glucose levels, increasing by 1-2 units once or twice weekly until postprandial targets are achieved 2
• If glycemic targets are still not met with one mealtime injection, additional mealtime insulin injections can be added before other meals 1

Monitoring and Safety Considerations

• Continue metformin therapy alongside insulin 1
• Educate the patient on blood glucose monitoring, particularly before and after meals 1
• Provide comprehensive education about hypoglycemia recognition and treatment 1
• Monitor for hypoglycemia, especially during the initial titration phase 3
• Advise the patient to carry a source of quick-acting carbohydrates to treat potential hypoglycemia 1

Practical Implementation Tips

• Rapid-acting insulin analogues (lispro, aspart) are preferred over regular human insulin due to their faster onset of action and better postprandial glucose control 1, 4
• Insulin should be injected subcutaneously in the abdomen, thigh, or upper arm, with rotation of injection sites to prevent lipodystrophy 3
• Mealtime insulin should be taken before eating (within 15 minutes) 3
• If the patient later requires multiple mealtime injections, a basal-bolus regimen (basal insulin plus mealtime insulin at multiple meals) may be necessary 1

Potential Pitfalls and Considerations

• Avoid excessive basal insulin without adequate mealtime coverage, which can lead to hypoglycemia between meals while still having postprandial hyperglycemia 2
• Be aware that rapid increases in insulin doses could lead to hypoglycemia; incremental adjustments are safer 2
• The total daily insulin dose should eventually approach approximately 50% basal and 50% bolus when optimized 2
• If the patient was previously well-controlled on SGLT2 inhibitors, they may have had significant postprandial hyperglycemia that was being addressed by that medication 5, 6