A man with poorly controlled diabetes (hemoglobin A1c 8.8%) was recently released from jail. The patient had never taken diabetes pills before and was put on insulin while incarcerated. He expressed a strong desire to be taken off insulin and started on oral medication. Is this prudent?—JULIA SEELEY, FNP-C, Lewes, Del.
The decision to stop insulin should be based on two important factors: (1) whether the patient has type 1 diabetes or type 2 diabetes; and (2) if it is type 2 diabetes, is there any remaining beta-cell insulin secretory capacity?
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Of course, if you’re dealing with type 1 diabetes, the patient needs lifelong insulin therapy. Knowing more about the events surrounding his diagnosis would be helpful. If he is overweight or obese, has a strong family history of type 2 diabetes, and is from an ethnic group that has a higher diabetes risk, this would suggest that he is more likely to have type 2 diabetes. If he is thin, has no family history of type 2 diabetes but has a family or personal history of autoimmune disorders (e.g., thyroid disease, asthma, atopic dermatitis), diagnosis occurred during childhood or adolescence, and diagnosis was associated with diabetic ketoacidosis or ketosis, this would suggest a tendency for type 1 diabetes. To clarify the diagnosis, measure glutamic acid decarboxylase antibodies and insulin antibodies.
If the patient has type 2 diabetes, the American Association of Clinical Endocrinologists medication titration recommendations suggest that a careful trial of oral medications would be reasonable (Endocr Pract. 2009;15:540-559). Remember that all oral medications for type 2 diabetes rely on the assumption that there is some endogenous beta-cell insulin production by the pancreas. The longer the duration of type 2 diabetes, the less likely this is to be the case. If the patient’s insulin requirements are high (>40 units daily), it is less likely that he would be able to meet glycemic goals without insulin. An insulin sensitizer such as metformin would be a good first step, and titrating the dose of metformin upward while titrating the insulin dose downward could be attempted as long as the patient appears to respond to the metformin by meeting glycemic goals. — Kathy Pereira, MSN, FNP-BC, assistant professor, co-coordinator, family nurse practitioner program, Duke University School of Nursing, Durham, N.C. (150-8)
