Adapted from an Article by Don Zettervell
Submitted by Kathy Silliman, RN

There has always been a struggle in the management of patients with diabetes. How do we reach A1c goals of less than 7% and at the same time avoid hypoglycemia? Are we allowing fear of hypoglycemia let us get too comfortable with hyperglycemia? Most protocols for managing high blood sugars require contacting prescribers when glucose levels exceed 300 or even 400mg/dl. Since symptomatic hyperglycemia starts at glucose levels of 180mg/dl, allowing blood sugars to elevate to such levels proves the point that we are too comfortable with hyperglycemia. On the other hand, no one would suggest a prescriber be contacted every time blood sugars are above 180mg/dl.

There is also the problem of giving sliding scale insulin when blood sugars are deemed too high, especially when it’s being discouraged by AMDA, ADA, AACE and the State Operations Manual. Yet, 84% of patients entering a nursing facility from a hospital setting on sliding scale insulin remain on it for the duration of their stay and more than ½ of all patients using insulin have standing sliding scale orders. So what are we to do? There is a new approach that is rapidly becoming the treatment of choice. It comes from understanding how the body normally handles glucose and then applying those principles to insulin therapy. Simply put, it is physiologic insulin therapy. Since the body’s insulin needs change constantly, this means creating insulin protocols that provide consistent, yet flexible insulin dosing that can mimic normal physiology. This new approach has some very distinct advantages. Dosing flexibility can decrease unnecessary phone calls to prescribers, helps to minimize hypoglycemic episodes and most importantly improves glucose control in accordance to current standards of care. It all starts with understanding the basics of insulin physiology.

Physiologic Insulin Production

In the type 1 diabetes patient, it is the failure of the pancreatic beta cells that results in a total lack of insulin production. Treatment simply requires replacement of the missing insulin the way a normal pancreas would. In the type 2 patient, it’s more complicated. Insulin resistance leads to abnormalities in metabolism with decreased glucose uptake and increases in hepatic glucose production. Over time, beta cells gradually fail and insulin production declines. Since oral therapies depend on sufficient beta cell function to meet insulin demands their decline in effectiveness should be anticipated. When should insulin be added? A rule of thumb that is often used is that when glucose levels cannot be maintained at target levels using three or less oral agents then insulin is needed. Using insulin that matches the physiologic need clearly provides the most optimal glucose control and minimizes the risk of hypoglycemia. It’s all about when injected insulin activity peaks and how long it lasts. In other words, when the peaks in activity and duration of action do not match the physiologic need, wide fluctuations in glucose will result as with sliding scale methodology. When this is kept in mind, it’s easy to understand why NPH and regular insulin have given way to the more physiologic rapid and basal insulins as the therapy of choice.

Physiologic insulin therapy has arrived! Although we have been very comfortable with conventional insulin therapies, these therapies are a physiologic mismatch and the cause of most of the hypoglycemia problems we fear. It is the action duration mismatch that increases demands on staff and increases phone calls to prescribers. Embracing change is what is needed, starting with basal / prandial rapid insulin therapy. It’s a win-win situation: A1c values improve, there are less episodes of both hyper and hypoglycemia with more stable blood sugars. This will decrease the need for multiple finger sticks, eliminate the need for sliding scales and decrease demands on staff. In other words, it improves everyone’s quality of life! Watch for the change – physiologic insulin therapy is on its way.

For more information on basal insulin, consult the resource guide, Kindred Keys to Diabetic Management Using Basal Insulin. If you do not have a copy or wish to order another copy, contact United Graphics at 800.481.1677.