Easing into Meal-time Boluses for People with Type 2

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Adding bolus insulin to meals is a big deal for many people. You finally adjusted to taking one injection at night, but having to take three more injections during the day sounds like a real hassle. You have to take supplies with you to work, you have to remember to check your blood glucose before each meal and for many people you have to find a discrete place to take a pre-meal injection. That becomes burdensome and overwhelming.

One way to avert some of the anxiety of going from 1 basal dose of insulin to taking insulin four times a day may be to ease people into it. Normally, when bolus insulin is introduced to someone with type 2, they start with all three meals at once. This sometimes is overwhelming and can lead to adherence problems. But there isn’t any necessary reason to go from one injection to four overnight. Perhaps a graded approach to adjusting to mealtime insulin would help people figure out strategies to integrate mealtime injections into their lives.

A study published in Endocrine Practice in September 2011 compared two different ways to start people with type 2 diabetes on bolus insulin. Now these people were already taking once day basal insulin so they were comfortable with the concept of having to inject something into their bodies.

The study compared two step-wise approaches to starting bolus insulin in people with type 2. Both approaches started with one meal only. The first called SimpleSTEP had patients’ choose their largest meal, and the second called ExtraSTEP selected the meal that caused the highest rises in blood glucose levels post-meal as the meal with which they were going to begin bolus insulin use.

Each group started with 4 units of aspart at the chosen meal. The dose was titrated up or down each week based on the level of blood glucose either before the meal for the SimpleSTEP or after the meal for the ExtraSTEP. At the end of 12 weeks if the A1C was over 7.0, insulin at a second meal was added. The same process was repeated over another 12 weeks. At the end of the trial some people were taking bolus insulin only at one meal, some at two meals and some at three meals.

In turns out that both these approaches were similar in their ability to reduce A1C; however the post meal titration system turned out to be more cumbersome. This tells you two things: patient input is very important in determining insulin strategies. (The patients knew which meals were problematic) and in some situations pre-meal numbers are adequate for determining control in a population with type 2 diabetes. An interesting fact was that most of the reduction in A1C was due to the first two pre-meal injections. Both weight gain and hypoglycemic reactions were modest in each of the study arms.

The study was randomized and controlled, but not blinded. A second study comparing starting people with type 2 diabetes on three mealtime injections all at once to the SimpleStep procedure is in the works. That will be the real test in terms of patient satisfaction.

Adults who get type 1 diabetes don’t have much choice. There really isn’t a good way to ease people into taking insulin injections; rather, it’s a do or die situation. They are generally stuck with three or four injections from the get-go. But that isn’t what happens with people with type 2 diabetes. Type 2 diabetes is a slow, progressive disease that develops over time. That gives people and their health care providers the impetus to put things off. Nothing horrible will happen if a person with type 2 starts bolus insulin at meals tomorrow rather than today. It is when too many tomorrows build up that there is a problem.

Perhaps, as the 2011 study demonstrates, starting with one meal at a time will ease people into the regimen of taking insulin at meals. However, it would have been nice if the study had a third arm that compared the first two with starting insulin at all three meals at once.

If you needed to start bolus insulin would you rather do it all at once or start with the meal that was most problematic and only add insulin to additional meals as needed?

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