Finding the Right Balance with Insulin Therapy

Friday, October 10, 2014 at 2:00 pm

LAS VEGAS—When a patient with diabetes has become comfortable with oral medications, the idea of initiating insulin therapy can be a little intimidating—not only for the patient, but sometimes for the physician as well.

After this afternoon’s session, “Initiating Insulin Regimens,” presenter Steven Milligan, MD, of the Centura Family Care Center in Pueblo, CO, hopes that “attendees will feel more comfortable using insulin and not relegate it to the last resort in treating diabetes.”


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He and Ben Taylor, PhD, PA-C, of Georgia Regents University in Augusta, GA, will discuss targets for glycemic control and how to tackle common obstacles to insulin initiation, treatment, and adherence. They will also describe various recommendations for when and how to start or transition patients with type 2 diabetes who are not meeting treatment goals to more intensive and effective insulin regimens.

When is it time to start considering insulin? When initial A1c is >9% or diabetes is uncontrolled despite optimal oral hypoglycemic therapy, according to guidelines from the American College of Endocrinology and the American Association of Clinical Endocrinologists.1

If the patient is reporting any of the following signs, it could be an indication that oral medications are no longer getting the job done:

• Increasing blood glucose levels

• Persistently elevated A1c

• Unexplained weight loss

• Traces of ketonuria

• Poor energy level

• Sleep disturbances

• Polydipsia unresolved with therapy

Presenting a case study to illustrate how this decision-making process might unfold in a clinical setting, Milligan and Taylor will look at common factors and special considerations that come into play when deciding if insulin therapy is appropriate as a next step for the patient. First and foremost, they say it’s key to ensure strict diet control before taking any additional steps.

“Dietary management is important with all diabetics at all times,” the presenters said. “It’s important to keep meal timings regular with 6 hours between the 3 meals, and keep the number of calories during the meals the same from day to day. The quantity and quality of diet should be the same with the same timing.”

They emphasize that insulin regimens should be designed taking lifestyle and meal schedules into account. One size doesn’t fit all when it comes to insulin therapy. While the A1c goal for the general population is <7%, treatment must be individualized.

When determining the most effective insulin regimen, Milligan said the physician must also consider the patient and his or her comfort level in using insulin, the cost of insulin compared to the cost of other agents, and the patient’s blood glucose patterns.

It may take some time and effort to find the right balance with insulin therapy, but the benefits can be long-lasting and life-saving. 

Colleen Mullarkey


1. Handelsman Y, Mechanick J, Blonde L, et al. American Association of Clinical Endocrinologists.  medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. American Association of Clinical Endocrinologists. 2011;17(Suppl 2):1-53.