What alternative therapy can be used for a patient on insulin (fast-acting/long-acting insulin) and metformin (biguanide) who wants to stop insulin due to travel?

Alternative Therapy for Patient on Insulin and Metformin During Travel

For a patient on insulin and metformin who wants to stop insulin due to travel, the most appropriate alternative therapy is to add a thiazolidinedione (TZD) such as pioglitazone while gradually tapering the insulin dose. 1

Assessment and Planning for Insulin Discontinuation

• Evaluate the patient's current glycemic control before making any medication changes; this is crucial to determine if insulin discontinuation is feasible 1
• Consider the patient's overall health status, duration of diabetes, and current insulin requirements to determine the likelihood of successful transition 1
• Patients with HbA1c <8.5% are better candidates for insulin discontinuation compared to those with higher values 2

Recommended Alternative Therapy Options

First-line Option: Add Pioglitazone (Thiazolidinedione)

• Start pioglitazone at 15 mg or 30 mg once daily while continuing metformin 3
• Gradually reduce insulin dose by 10-25% if the patient reports hypoglycemia or if plasma glucose concentrations decrease to less than 100 mg/dL 3
• Further adjustments should be individualized based on glucose-lowering response 3
• Pioglitazone can be taken once daily without regard to meals, making it convenient for travel 3
• Clinical studies have shown that adding pioglitazone to insulin therapy can reduce insulin requirements by 6.0-9.4% while maintaining glycemic control 3

Alternative Options if TZDs are Contraindicated

• Consider adding a DPP-4 inhibitor (especially linagliptin in patients with reduced renal function) as they have minimal risk of hypoglycemia 1
• For patients who were on basal insulin, consider using 70% of the total insulin dose as basal only in the morning, then gradually tapering while adding non-insulin agents 1

Monitoring and Follow-up During Transition

• Monitor blood glucose more frequently during the transition period, especially during travel 1
• Ensure the patient has access to glucose tablets or other glucose-containing foods to treat potential hypoglycemia 1
• Instruct the patient to check blood glucose before meals and at bedtime during the transition period 1
• Target fasting glucose levels of 90-150 mg/dL during the transition period 1

Important Precautions and Considerations

• Do not abruptly discontinue insulin therapy as this may lead to rebound hyperglycemia 1
• Patients with type 1 diabetes should never discontinue insulin, even temporarily 4
• For patients with marked hyperglycemia (blood glucose ≥250 mg/dL, A1C ≥8.5%), continuing some form of insulin therapy is strongly recommended 2
• Patients with history of diabetic ketoacidosis should not discontinue insulin 1

Special Travel Considerations

• Provide the patient with a carry-along meal plan and medication schedule to maintain glycemic control during travel 1
• Ensure the patient has adequate supplies of all medications and blood glucose monitoring equipment for the duration of travel 1
• Advise the patient to carry medical identification indicating their diabetes status 1
• If traveling across time zones, provide specific guidance on medication timing adjustments 1

Follow-up After Return from Travel

• Schedule a follow-up appointment after the patient returns from travel to reassess glycemic control 1
• Be prepared to adjust therapy based on the patient's experience during travel 1
• Consider reinstating insulin therapy if glycemic control deteriorates significantly 1

Remember that this approach is only suitable for patients with type 2 diabetes who have some residual beta-cell function. Patients with type 1 diabetes must continue insulin therapy at all times 4.