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Appropriate Use of Basal Insulins
EDUCATIONAL OBJECTIVES:
At the conclusion of the activity, the learner will be better able to:
1. Review guideline recommendations for basal insulin use, including when to start basal
insulin therapy;
2. Describe potential barriers to early initiation of insulin therapy;
3. Discuss aspects of currently available basal insulin products, including pharmacokinetic
parameters, dosing and administration, and adverse effects; and
4. Design an evidence-based medication regimen for a patient that involves appropriate
timing and use of basal insulin.
POST-TEST/RATIONALE
1.
Which of the following is an appropriate indication for insulin replacement therapy?
A.
B.
C.
D.
An individual in hyperglycemic crisis (e.g., diabetic ketoacidosis)
A person with a hemoglobin A1c greater than 9.0% who is symptomatic
A hospitalized individual receiving enteral nutrition
All of the above***
Correct Answer: D
Insulin replacement therapy is indicated in a variety of situations, including for patients who
have markedly elevated hemoglobin A1c who are symptomatic, for patients experiencing
hyperglycemic crises, and for patients who are hospitalized and unable to take oral medications.
2. According to the American Diabetes Association recommendations for antihyperglycemic
therapy in type 2 diabetes, which of the following is a true benefit of using basal insulin as a
second-line add-on therapy to background metformin when compared to other drug classes?
A.
B.
C.
D.
The addition of basal insulin has the highest level of efficacy***
The addition of basal insulin has the lowest risk of hypoglycemia
The addition of basal insulin has a neutral effect on weight
None of the above
Correct Answer: A
According to the American Diabetes Association recommendations for antihyperglycemic
therapy in type 2 diabetes, the addition of basal insulin as a second-line add-on therapy to
metformin has the highest level of efficacy, a relatively high risk of hypoglycemia, and is
associated with weight gain.
3.
All of the following are key patient barriers to the use of insulin therapy EXCEPT:
A. Fear of injections
B. Fear of weight gain
C. Fear of hyperglycemia***
D. Fear of a loss of independence
Correct Answer: C
There are a variety of patient barriers to starting insulin. Some of the most common barriers
include fear of injections, fear of weight gain, fear of hypoglycemia, and a fear that starting
insulin injections will lead to a loss of independence.
4. All of the following are appropriate strategies to overcoming key barriers to insulin therapy,
EXCEPT:
A.
B.
C.
D.
Avoid using insulin as a “threat”
Use insulin pens and regimens that offer maximum regimen flexibility
Give an injection in the office or clinic to dispel injection fears
Wait to use insulin until all other treatment approaches have failed***
Correct Answer: D
A variety of approaches can be used to minimize and overcome barriers to insulin therapy. Some
approaches that can be helpful include: avoiding using insulin as a “threat,” using insulin pens
and regimens that offer maximum flexibility, giving patients a limited trial of insulin, and giving
patients an injection in the office or clinic to dispel injection fears.
5. Which of the following basal insulin products is considered an “ultra-long-acting” basal
insulin?
A.
B.
C.
D.
Insulin degludec***
U-100 insulin glargine
Insulin detemir
NPH insulin
Correct Answer: A
There are a variety of insulin products available that can be used to cover basal insulin needs.
The 2 insulin products that last longer than 24 hours and are considered “ultra-long-acting” basal
insulins are U-300 insulin glargine and insulin degludec.
6. All of the following statements about the concentrated insulin products U-300 insulin
glargine and U-200 insulin degludec are true, EXCEPT:
A. These concentrated insulins are only available in pre-filled pens to minimize the risk of
dosing errors
B. Due to their longer duration of action, these concentrated insulins are associated with
higher rates of hypoglycemia than U-100 insulin glargine***
C. These concentrated insulin products allow for a smaller volume of insulin injection than
U-100 insulin products
D. When administering a dose of insulin with concentrated insulins, the dose is simply
dialed on the insulin pen (i.e., no dose conversion is needed)
Correct Answer: B
The concentrated ultra-long-acting basal insulins (U-300 insulin glargine and U-200 insulin
degludec) are only available in pre-filled insulin pens to minimize the risk of dosing errors.
When administering a dose, the dose is dialed on the insulin pen and no dose conversion is
needed. These concentrated insulin products allow for a smaller total volume of insulin with a
given dose, and they have the potential advantage of slightly lower rates of hypoglycemia
compared to U-100 insulin glargine.
7. According to the prescribing information for U-300 insulin glargine, if a patient is currently
taking 10 units of U-100 insulin glargine once daily, what is the recommended starting dose if
she is switched to U-300 insulin glargine?
A.
B.
C.
D.
8 units of U-300 insulin glargine
10 units of U-300 insulin glargine***
12 units of U-300 insulin glargine
11 units of U-300 insulin glargine
Correct Answer B:
According to the manufacturer, when converting a patient from U-100 to U-300 insulin glargine,
the conversion can be made in a 1:1 ratio. If a patient is receiving 10 units of U-100 insulin
glargine, he or she can be started on 10 units of U-300 insulin glargine. It is important to monitor
the patient’s response and titrate the insulin to individualized needs.
8. Which of the following basal insulins is formulated in an acidic solution and, when injected,
forms microprecipitates in the subcutaneous tissue that allows for delayed absorption and a
protracted duration of action?
A.
B.
C.
D.
Insulin detemir
Insulin degludec
Insulin glargine***
Insulin glulisine
Correct Answer: C
Insulin glargine is formulated in an acidic solution. Once injected, insulin glargine
microprecipitates in the subcutaneous tissue. These microprecipitates then slowly dissolute and
are absorbed into the circulation. This process allows for delayed absorption and a protracted
duration of action.
9. TG is a 65-year-old man with type 2 diabetes. He weighs 100 kg. According to the
American Diabetes Association recommendations for the initiation of basal insulin, which of the
following options is an appropriate starting dose of basal insulin?
A.
B.
C.
D.
10 units per day
5 units per day
20 units per day
Both A and C would be appropriate options***
Correct Answer: D
According to the American Diabetes Association Standards of Care, an appropriate starting dose
of basal insulin is 10 units per day or 0.1 to 0.2 units/kg/day. Therefore, a reasonable starting
dose of basal insulin for TG would be 10 to 20 units/day.
10. After starting TG on 10 units of insulin daily, which of the following would be an
appropriate plan for titrating his basal insulin therapy according to the American Diabetes
Association standards of care?
A. Instruct TG to monitor his morning fasting blood glucose (FBG) and adjust his basal
insulin dose to reach his FBG target***
B. Instruct TG to monitor his postprandial glucose (PPG) and adjust his basal insulin dose
to reach his PPG target
C. Tell TG his insulin dose will be assessed when he is back in the office in 3 months
D. All of the above
Correct Answer: A
According to the American Diabetes Association Standards of Care, basal insulin should be
adjusted by 10% to 15% or 2 to 4 units once or twice weekly to reach the FBG target. The basal
insulin dose should also be decreased in response to recorded hypoglycemic events. Basal insulin
should not be titrated to address PPBG. Basal insulin should be actively titrated to achieve FBG
goals and avoid clinical inertia.