Dr. Thiyagarajan. T
Diabetology
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Patient's Query
Hi doctor,
I would like your suggestion for a patient with type 2 diabetes. She has had diabetes for the past 50 years. Can she take tablet Repaglinide in conjunction with tablet Novolin 70/30? Currently injecting 10 to 15 units and taking tablet Repaglinide 4 mg before lunch. Is this ok? I am concerned about the interaction between Rapa (immunosuppressive agent rapamycin) and NPH (normal-pressure hydrocephalus) insulin. She is having trouble controlling post-meal units of sugar levels the blood. Routinely 200 to 250 units in 1 to 2 hours after meals are seen in her blood-sugar levels. She does not want to increase Novolin units. Would you recommend using inhaled insulin (freeze) in addition to Novolin 70/30 to control post-meal hike of blood-sugar levels? Can these two insulins be used together without adverse effects? Would inhaled insulin also be a solution for the dawn phenomenon? Please help. Thank you.
Hi,
Welcome to icliniq.com.
I suggest glucose monitoring while starting and titrating the dose up. Maybe start with a lower dose like 1 mg, see the response, and slowly titrate up. Tablet Repaglinide can be used at lunch to control post-lunch spikes in glucose. Yes, Afrezza (regular insulin inhalation powder) can be used to control the post-meal spikes. Quick in and out is perfect for this to be combined with other insulin. It is hard to say. Before suggesting, I would like to see the glucose profile like pre-dinner, post-dinner, or CGM (continuous glucose monitoring). If you want to take Afrezza in the morning, you need to check glucose before using it and then use it if higher than a specific value, say 180 mg/dL. CGM will be helpful in these situations. Why not switch from Novolin 70/30 to basal-bolus insulin-like Tresiba (Insulin degludec) one daily and Fiasp (Insulin aspart) three times daily? What is her most recent HbA1c (glycated hemoglobin)? What is her individualized glycemic goal? Any comorbidities like kidney or heart disease? Any Insulin issues in switching to the basal-bolus regimen? Please follow up with the above to guide you better. Thank you.
Patient's Query
Thank you doctor,
For a 50-year-old diabetic, her HbA1c has been very good. Maybe it is her age and general weakening, but the blood sugar control went haywire starting about two months ago. Glucose levels spike 200 plus post-meal and dawn phenomenon. She has used Novolin 70/30 for a very long time, and it gives a good effect (comfort, familiarity also) and wants to complement it to bring down post-meal spikes. Her reluctance to go to Tresiba stems from having tried it in the past (think like three years ago, involved four injections daily), which she was not responding well. Most other aspects of her health are good. Given that she knows where her numbers are with Novolin 70/30 and had good A1c with it, do you think it is ok to keep using it and add Afrezza whenever she needs it to control post-meal glucose spikes? She wants to use it between 1 to 2 hours after meals (Novolin for pre-meal as usual) as required. The idea of keeping everything the same and just taking a puff when she needs it. Or do you see the basal-bolus regimen (Tresiba and Fiasp) as the better route here and worth giving it another shot if insurance is fine? Please guide.
Hi,
Welcome back to icliniq.com.
According to the situation, I would suggest the following. Her HbA1c goal is 7%. It will be fine up to 7.5%. A lower HbA1c will not provide any extra benefit but significantly increase the risk for hypoglycemia. Avoiding hypoglycemia will be more important. I think given her familiarity and the convenience of just two injections a day, she can continue with Novolin 70/30 subcutaneous injection (70% NPH, Human Insulin Isophane Suspension, and 30% Regular, Human Insulin Injection). Instead of tablet Repaglinide, Afrezza (Insulin inhalation powder) is better for controlling the spikes. Like I said, Afrezza is quick in and quick out, so it will be perfect for this. But I will be cautious about using it for the dawn phenomenon again. I would like to ensure that she is not going hypoglycemic at midnight. I strongly suggest using a CGM (continuous glucose monitoring) for at least 14 days to see the trend throughout the day before deciding when to use Afrezza. Basal bolus regime (Tresiba and Fiasp or similar) is still possible if the above measures do not help have a controlled glucose level. I hope this helps. Thank you.
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Diabetology
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