As a clinical pharmacist, you can help answer questions about how to use insulin for patients with type 2 diabetes.
Continue to start basal insulin first-line in some cases, such as if A1c is over 10% or in patients with symptomatic hyperglycemia (polyuria, polydipsia, etc). Or consider adding insulin if other medications combos aren’t enough. When initiating insulin prior to discharge, usually start with 10 units or 0.1 to 0.2 units/kg once daily of a long-acting analog (glargine, etc) or NPH. If adding insulin to a patient’s home regimen, evaluate if their other diabetes medications should be adjusted.
Consider continuing GLP-1 agonists (semaglutide, etc), metformin, and SGLT2 inhibitors (empagliflozin, etc) after discharge. Continuing these medications may help limit weight gain, and allow patients to use lower insulin doses. And GLP-1 agonists or SGLT2 inhibitors may be used for their CV or kidney benefits in some patients. It’s also okay to continue gliptins (sitagliptin, etc). But be cautious about using insulin with pioglitazone (Actos) due to possible weight gain, edema, and heart failure.
Stop sulfonylureas once mealtime insulin is added, there’s little added benefit and possibly more hypoglycemia. Before discharge, work with case management to overcome hurdles, such as payer preferences or patient assistance. Educate patients about their insulin regimen. And ensure patients also have discharge Rxs for supplies they’ll need (syringes, pen needles, etc).
REFERENCES
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2023. Diabetes Care. 2023 Jan 1;46(Suppl 1):S140-S157. Available at: https://diabetesjournals.org/care/article/46/Supplement_1/S140/148057/9-Pharmacologic-Approaches-to-Glycemic-Treatment
Davies MJ, Aroda VR, Collins BS, Gabbay RA, Green J, Maruthur NM, Rosas SE, Del Prato S, Mathieu C, Mingrone G, Rossing P, Tankova T, Tsapas A, Buse JB. Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2022 Nov 1;45(11):2753-2786. Available at: https://diabetesjournals.org/care/article/45/11/2753/147671/Management-of-Hyperglycemia-in-Type-2-Diabetes