The Latest on Insulin Therapy and Blood Glucose Monitoring from Pri-Med East 2010
by ben kozak
Late last month in Boston, the diaTribe team had the opportunity to join primary care physicians from around the country at this year’s Pri-Med East conference. While the conference included discussions on a variety of healthcare topics ranging from osteoarthritis of the knee to circadian rhythms, several of the diabetes field’s brightest stars were in attendance to deliver talks. Quite encouragingly, we often found ourselves struggling to find seats (or even standing room for that matter) in some of the diabetes-related talks, a strong indication in our view that primary care doctors appear to recognize, maybe more so than ever before, the importance of addressing the diabetes and obesity epidemics.
Insulin therapy was a dominant theme of this year’s Pri-Med East conference with the notable Dr. Jeff Unger, Dr. Joseph Tibaldi, and Dr. Mary Ann Banerji presenting. All were in agreement that the goal of most initial insulin regimens for individuals with type 2 diabetes is to first gain control over elevated fasting blood glucose levels. How to best achieve this result is up to both the healthcare provider and the patient as studies have shown that basal insulins, bolus insulins, and pre-mixed insulins (insulins that contain a set ratio of both a basal and a bolus insulin) are equally effective at reducing blood glucose levels. However, as Dr. Banerji highlighted, basal insulins may be the safest way to start, given that these insulins are associated with less weight gain and a lower incidence of hypoglycemia. Regardless of how insulin therapy is initiated, Dr. Unger emphasized that the insulin regimen will likely need intensification over time since type 2 diabetes is a progressive disease. Besides fasting plasma glucose levels, addressing rising post-prandial glucose levels will become increasingly important. He underscored the urgency of this concern by revealing that four consecutive hours of blood glucose levels above 180 mg/dl causes blood vessel inflammation for the next seven days. He said that this relates to the seven-year reduction in life expectancy for individuals with type 2 diabetes. Dr. Tibaldi outlined two strategies for intensifying therapy to address both fasting and post-prandial glucose levels: pre-mixed insulin and basal-bolus therapy, likening the choice to that between a Chevrolet and a Cadillac. A pre-mixed insulin regimen (Chevy) might be better for patients who prefer fewer injections, who have a fixed daily routine, or who are hesitant to intensively monitor their blood glucose. Compared to pre-mixed insulin, basal-bolus dosing (Cadillac) requires more upkeep (more shots) but allows you to “do fancier things” (titrate or adjust each insulin based on your exact insulin needs).
Blood glucose monitoring was also discussed at length. In front of a packed audience, Dr. Martin Abrahamson stressed his belief that no individual with diabetes “should ever stop checking their blood glucose.” Rather than a task or chore that must be done to appease a healthcare provider, Dr. Abrahamson emphasized that blood glucose monitoring is a very valuable tool for individuals with diabetes to use to improve their diabetes self-management. More specifically, active monitoring can help individuals understand the effects of specific meals on blood glucose levels, the effects of different daily activities (such as exercise) on blood glucose levels, and how much insulin they require before meals.
