Best practice calls for discharge planning upon hospital admission.2 It is clear from the start of the consultation that the patient would not be returning home on the same outpatient antihyperglycemic regimen. The focus of the consult was to estimate his inpatient insulin requirements, and transition the patient to an improved regimen upon discharge.
From a patient-centered care perspective, the prescribed regimen was difficult to self-manage and had a high risk for error.
There were also patient-related factors to be considered, including patient’s compliance to his prescribed outpatient medication regimen and carbohydrate intake prior to hospitalization.
Medication adherence rates for patients with type 2 diabetes using insulin range from 60% to 80%. Factors of poor adherence include treatment regimen complexity, a patient’s understanding of regimen, perception of benefit, adverse effects, cost, and emotional well-being.4
Furthermore, there was a psychosocial aspect to this case as well. Individuals who are obese are more likely to underreport their energy intake.5 Patients with high social desirability (the tendency to respond to questionnaires or interviews with what is perceived to be a socially appropriate response as opposed to an objective or accurate response) are more likely to underreport on food frequency questionnaires for energy and protein.6
Additionally, there were medication factors that potentially contributed to the prescriber’s perceived need for a more complex regimen. Although insulin detemir is a basal insulin, it may not last 24 hours, which is why it is indicated for once- or twice-daily dosing.
This explained the need for premix insulin in the morning. It did not explain, however, why the premix insulin was prescribed three times daily. Liraglutide is limited in its ability to decrease postprandial glucose, thus requiring the use of rapid-acting insulin for nutritional coverage.
There were a few options to simplify the patient’s home regimen. The most optimal regimen maintained his glucose within a pre-established glycemic target with the least hypoglycemic event.
Treatment options included:
- Continue with a premix insulin and titrate accordingly, since the patient mainly eats only breakfast and dinner
- Basal bolus regimen using insulin glargine (Lantus) once daily and insulin aspart for nutritional coverage and correction
- Basal bolus with insulin detemir twice daily, and insulin aspart as described above
- A more concentrated insulin U-500 three times daily dosing
- A longer acting glucagon like peptide 1 agonist with once-weekly dosing can be added to any of the treatment options to improved satiety and decrease prandial insulin need if so desired
Annie D. Lu, ANP-BC, ADM-BC, practices at the Diabetes Foot and Ankle Center at New York University Langone Medical Center Hospital for Joint Diseases in New York City.
- Mayo Clinic Staff. (2012). Acanthosis nigricans. Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/acanthosis-nigricans/basics/definition/CON-200256
- American Diabetes Association. (2015). Standards of Medical Care in Diabetes. Diabetes Care. 2015; 38 (1): S1-S94
- Centers for Disease Control and Prevention. (2014). Medication Safety Program. Retrieved from http://www.cdc.gov/MedicationSafety/program_focus_activities.html
- Kenreigh C A, Wagner LT. (2005). Medication Adherence: A Literature Review. Medscape. Retrieved from http://www.medscape.com/viewarticle/514164
- Johansson L , Solvoll, K, Bjorneboe GA, Drevon CA. Under and overreporting of energy intake related to weight status sand lifestyle in nationwide sample. The American Journal for Clinical Nutrition. 1998; 68:266–74.
- Mossavar-Rahmani, Y. et al. Factors relating to eating style, social desirability, body image and eating meals at home increase the precision of calibration equations correcting self-report measures of diet using recovery biomarkers: findings from the Women’s Health Initiative. Nutrition Journal. 2013; 12:63