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The 30-Day Challenge: Oral Meds During the Day, Lantus at Night

Steven Edelman, MD

Apr 1, 2006

From the Spring Research Guide

Mary is a 64-year-old woman who has been diagnosed with type 2 diabetes for 14 years. She is obese at 220 pounds. Mary has been treated with a sulfonylurea (a medication that stimulates the pancreas to secrete insulin, such as glypizide and glyburide) for the past 10 years. Her glucose control for the past three or four years has not been good. A recent A1C was 9.5% (normal range is 4% to 6%, with a goal of 7%). Metformin (Glucophage) and rosiglitazone (Avandia) were added to her sulfonylurea. Both her pre-meal and post-meal glucose values improved and her A1C came down to 7.8%. However, her fasting blood glucose levels were in the upper 100 mg/dl to low 200 mg/dl range. She was afraid of “the needle” and did not want to start on insulin. In addition, Mary was recently diagnosed with early diabetic eye disease (retinopathy) and nerve disease (neuropathy).

Unfortunately, Mary’s story is a common one. The sulfonylurea has lost its effectiveness over time, and her blood glucose values have been excessively high for years. As a result, she is developing the classic complications of diabetes. The addition of Glucophage and Avandia helped, but she was still not at goal.

Mary does not have many other options in terms of oral medications. One very effective regimen is to add one injection of an intermediate (NPH) or long-acting (Lantus) insulin at night, in addition to taking her usual medications during the day. Mary was started on 10 units of Lantus at night, and she was taught to self-titrate her own dose upward depending on her blood glucose levels first thing in the morning. She was instructed to go up one unit every night until the morning levels were below 120 mg/dl. Her ultimate dose was 45 units of Lantus at bedtime; her A1C came down to 6.6%. She had no problems with hypoglycemia and only a 3-pound weight gain.

Mary did not want to start with injections, but I told her about my 30-day challenge: After one month she could stop the insulin if the injections hurt too much (this is usually not a problem with the very short ultra-fine needles), if the insulin did not bring down her numbers or if she felt it was not helping her. Later Mary thanked me, gave me a big hug and apologized, saying what a sissy she had been and how happy she is to now be in control.

Categories: A1c Test, Blood Glucose, Diabetes, Diabetes, Insulin, Lantus, Low Blood Sugar, Professional Issues, Type 2 Issues

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Apr 1, 2006

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