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Includes art: Medical Caduceus

NOTE: If you have any questions for "Ask the Doctor," please send them to the Voice editorial office. The only questions Dr. Wilson (our regular writer) will be able to answer are the ones used in this column.

Christopher M. Corsi, M.D., our guest writer this issue, is an endocrinologist at Western Montana Clinic, in Missoula, Montana.

Q: I am a diabetes educator, working with a lot of older, “maxed-out” type 2 diabetics, who are either now injecting insulin, or should be. From what I have read about new Lantus insulin, it looks ideal for my clients. What do you think? What can you tell me about Lantus?

A: Becoming “maxed-out,” no longer receptive to oral diabetes medications, is an increasingly common problem. Type 2 diabetes is considered to be a “progressive disease, and recent evidence suggests the reason for this progression may be declining Beta cell function in the pancreas, resulting in reduced insulin secretion. Investigators are looking at new ways to treat patients, earlier in the course of their disease, with hopes of preserving this Beta cell function. If their research is successful, fewer patients will need to progress to insulin therapy.

When should someone switch from oral diabetes medications to insulin injection? When the oral meds can no longer keep the blood sugars down in the safe range. We used to do this when the patient showed persistent hemoglobin A1c levels over 8 percent, but now, endocrinologists and diabetologists are often initiating insulin therapy when hemoglobin A1c levels are over 7.0-7.5 percent on two successive measurements. There is, of course, a reasonable resistance on the part of many patients to move on to insulin, due to injections -- but it is important that, once insulin is needed, it should be initiated promptly, to avoid increasing the risk for long-term diabetes complications.

This is where Lantus insulin comes in. In most patients, Lantus has at least a 24-hour duration of action. Thus it can be used once a day, a much more acceptable situation (than multiple daily injections) for patients just getting used to the idea of needles. In many cases, a single injection of Lantus each day can allow patients to achieve their target A1c levels.

Beginning such therapy, physicians will often continue some of the oral medications, removing them at a later date. There may be advantages to continuing “insulin sensitizers” like Actos, Avandia, and Glucophage. Eventually, oral medications may be removed from the program.

One major hesitation, affecting both patient and physician, is the fear of hypoglycemia. Patients starting insulin therapy, it is feared, are more likely to experience low blood sugar. Lantus insulin appears to cause less hypoglycemia, especially in the middle of the night, the time when a hypoglycemic event is most feared.

When Lantus insulin first became available in the United States, recommended dosage was at bedtime. Recent studies suggest a single dose given in the morning might be better. Of course, insulin dosage needs to be tailored to the individual patient, and then titrated (adjusted) over time, in order to reach and maintain blood glucose targets. The best measurement of the effectiveness of Lantus therapy is the morning blood sugar.

There are times when a single injection of Lantus will not provide adequate blood sugar control. This most commonly occurs in a patient who has large increases in blood sugar following meals (postprandial hyperglycemia.) If this is happening, it is important to provide a “peak” of insulin action to cover those post-meal “spikes.” For instance, if a patient consumes most of his/her carbohydrates at supper time, the blood sugar will often go high after that meal. It may then be appropriate to add a quick-acting insulin at supper. If this problem (“spikes”) is occurring after all meals, a more detailed insulin program might be necessary. Sometimes, a mixed insulin (70/30 or 75/25) at breakfast and supper time will provide some peaking of insulin with each of these meals.

Lantus particularly shines in type 1 diabetes, where it is used as a “basal” insulin. In such a program, a short-acting insulin (Regular, Humalog, or Novolog) is also given with each meal, based on the blood sugar and the amount of carbohydrates going to be consumed at that meal. This is a very precise way to control blood sugars; it can be used in patients with type 2 diabetes who have need of insulin -- but of course these patients must be willing to take on the work of multiple injections and calculating doses. As usual with diabetes, patients are never exactly alike, and programs need to be tailored to their individual needs.