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Case Series
Adjusting background insulin therapy in type 2 diabetes when initiating a glucagon-like peptide 1 receptor agonist: A case series
1 Clinical Professor, Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy; Auburn, Alabama, USA
2 Clinical Pharmacy Specialist, Baptist Family Medicine, Baptist Health System; Montgomery, Alabama, USA
3 Doctor of Philosophy Student, Department of Drug Discovery and Development, Auburn University Harrison College of Pharmacy; Auburn, Alabama, USA
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Heather P Whitley
4371 Narrow Lane Rd, Suite #100, Montgomery, Alabama 36116,
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Article ID: 100073Z09HW2023
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Whitley HP, Smith WD. Adjusting background insulin therapy in type 2 diabetes when initiating a glucagon-like peptide 1 receptor agonist: A case series. J Case Rep Images Med 2023;9(1):4–10.ABSTRACT
Introduction: Guidelines recommend preferential use of antihyperglycemic medications with proven cardiovascular benefit for the treatment of patients with type 2 diabetes with established atherosclerotic cardiovascular disease (ASCVD), high risk factors for ASCVD, kidney disease, or heart failure. However, current guidelines offer little to no practical recommendations for adding these therapies to a patient’s current regimen while avoiding hyperglycemia or hypoglycemia. Nevertheless, considering background therapy in a proactive effort to avoid undesirable glycemic excursions when initiating any new antidiabetic medication remains paramount.
Case Series: A six-patient case series investigates adjustments to background therapies and glycemic outcomes surrounding the initiation and titration of long-acting glucagon-like peptide 1 receptor agonists (GLP-1 RAs) to shed light on practical methods to manage patient care during this tenuous phase. Overarching findings regarding background therapy adjustments to avoid hypoglycemia when initiating a GLP-1 RA include: (1) safe continuation of metformin regardless of baseline A1C or concurrent glycemic background therapy; (2) continuation of background therapy when the baseline A1C is above 9%; (3) consideration of a proactive 15–20% basal insulin dose reduction when the baseline A1C is below 7.5%; (4) proactive bolus insulin dose reduction by 25% or complete discontinuation at the time of GLP-1 RA initiation.
Conclusion: No dose adjustments are necessary when A1C > 9%, and possibly >8%. When A1C is <7.5% and possibly <8%, discontinue or reduce bolus insulin by 25% and/or reduce basal insulin by 15–25%. Adjust background therapy using shared-decision making while considering fasting blood glucose, A1C, hypoglycemia risk, and chosen GLP-1 RA therapy.
Keywords: Diabetes mellitus, GLP-1 receptor agonists, Glucagon-like peptide 1 receptor agonists, Hypoglycemia, Insulin, Type 2
SUPPORTING INFORMATION
Author Contributions
Heather P Whitley - Substantial contributions to conception and design, Interpretation of data, Drafting the article, Final approval of the version to be published
Warren D Smith - Acquisition of data, Analysis of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guaranter of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
Copyright© 2023 Heather P Whitley et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
