Transcript: Insulin Therapy in Type 2 Diabetes for New Nurse Practitioners

​Liz Rohr:

Well, hey there. It's Liz Rohr from Real World NP. And you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients.

So today, I'm talking about a super highly requested topic, which is insulin initiation in type two diabetes. And I have a couple of notes before I jump in. So number one, I have a cheat sheet down below this video. I would love to be able to share my screen and make a beautiful presentation like I usually do. But quarantine life is a little different right now and limited time to make these with my daughter at home. The second note is that the lab interpretation crash course for new nurse practitioners opens this Friday, which I'm so excited. I would love to have you. If you're struggling with labs, you're a new grad in primary care, or an experienced grad and you still don't like labs, it's CBC, CMPs, TSH, lipids, and all the main endocrine labs that I see in primary care, as well urinalysis.

And then my third note is that Kim Ellis, I want to give a shout out to her, is a nurse practitioner on YouTube as well and makes YouTube videos specifically about diabetes management. So definitely go check out her stuff if you haven't already, and you have more diabetes-related questions. And then definitely let me know if you have other questions and things you want me to talk about when it comes to diabetes.

So jumping right in, though, number one, who needs insulin in diabetes, in type two diabetes? So three main scenarios. One is that somebody comes in with severe hyperglycemia that is symptomatic. So they have things like weight loss, ketonuria, malaise, things like that, and their A1C is greater than 9% or their blood sugars are greater than 300 or so persistently.

And a quick note is that I have a video, a case study about hyperglycemia, where we talk a little bit more about the symptoms of hyperglycemia and differentiating between type one and type two. So I'll link down below this video to that if you want to check that out, if you haven't seen that one already.

Another scenario is that somebody has a persistent, severe hyperglycemia, meaning their blood sugars on average are typically greater than 300 and their A1C is greater than 9%. And they may or may not have symptoms. They may not have the weight loss or ketonuria and they might feel fine. Those patients, you can consider insulin therapy for them as well.

And then the other situation is if they are in either of those categories and you're not quite sure if they have type one or type two diabetes. Those patients should be on insulin as well. And again, I talk about that a little bit more in that video.

So I should back up and say that all of this is based on the AACE guidelines. And I don't have rights to share their stuff, and so on my presentation itself, I'm not able to reproduce it without permission. So I have it linked down below this video. I definitely encourage you to review that PowerPoint presentation that they have on their website and print out the slides that I'm going to be referencing to keep at your desk to make things a little bit easier.

And I keep looking down because I have my notes and I want to make sure I don't forget anything.

So just to back up a little bit, when it comes to the AACE guidelines, typically going from initial management all the way up to insulin is that somebody is diagnosed with diabetes when their A1C is 6.5 and above. And so from there, patients are typically started first-line on metformin if they don't have contraindications. And I'm not really going to get into all the nitty-gritty here. I'm doing really high level overview, because I could talk for hours. And this is really just to the quick and dirty of it. So making sure that they don't have contraindications to Metformin.

And then the next steps from there, depending on their A1C level, is if they want to do oral agents versus insulin. So do they do a second agent, a third agent? And once they get to three, then they have to progress to insulin if their A1C is still uncontrolled. However, you can always jump over that oral medication, the dual and triple therapy, to go right to insulin if the patient prefers.

So before I go any further into the nitty-gritty of it all, I want to make a really important point here, is that the most important thing is that you understand this well enough to explain it as plainly to your patients, because it might feel ... As a brand new grad, I remember feeling totally stressed out that someone's A1C was 13% and I needed to do all of the things for them right now. They didn't have their monofilament checked. They didn't have their microalbumin checked. They didn't have any education about the risks and benefits and side effects and all that stuff. And they needed all these medications. We had to get it done. They had to check the blood sugars. It was a lot of information.

And can you imagine how overwhelming that is for a patient? Maybe it doesn't mean that much to you, as somebody in healthcare. But my main takeaway, if you can, from this video, is to always include your patients. And it's okay to break it into smaller chunks because this is ... You don't have to fix them right now. This is a lifelong diagnosis and a lifelong challenge that they need to manage themselves. And the more you can explain and get buy-in from patients to manage their own care, the more successful they're going to be, and then you are going to be in helping them to achieve the goals that they want.

So when I ... Another thing to say about the management of type two diabetes according to the AACE guidelines is that diet and lifestyle always come first, which you know. But I have to say that each of the medications only lower A1C by about 1.5% maximum. So if you have one medication that lowered the A1C by 1.5% and their A1C is nine, it's not going to meet goal, right? And so knowing that ... And some of the medications are only 0.5%, right? So knowing that, even if you max out a triple oral therapy, you may need to add insulin. And dietary modification alone can drop somebody's A1C from 13 to six like that. It's not a hundred percent of the time. It's not a magic fix. But patients who are really motivated and able to consistently maintain those modifications, that is way more impactful than any medication you can give somebody.

So really, again, having those conversations and explaining that to patients, of, "Listen, you have control over this. You can do this and I can help you. And here are the ways that we can help you" is very impactful, versus, "Hey, your A1C is 13%. Here's my checklist of all the things I need to do for you. And here's this medication, and we need to titrate it this way."

So with all that said, I just want to jump into the actual nuts and bolts of probably why you're watching today. So when it comes to initiating insulin, you need to make that decision, share decision making with your patient. It's a pretty simple algorithm.

So what you start with is basal insulin, meaning it's just the longer acting insulin once or twice per day, depending on the specific type that you're choosing. And then it's a weight-based dosing. On average, it depends on the resource that you're looking at, but to keep it really simple, it's typically 0.1 To 0.2 units per kilogram per day is the total amount of their daily basal insulin. So those are things like insulin glargine or there's a couple of other ones. And really, the choice there depends on the insurance in my experience. The efficacies, I don't see a lot of differences between them. The most important thing is that they actually take them. So some of them are 12 hours and some of them are every 24 hour dosing. And so you just have to look at the particular medication that is covered for your patient and what they're willing to do. So that's the total amount.

The next step is that the patient needs to check their fasting blood sugar in the morning, every single morning, write them down, and then you titrate that dose of the total basal daily insulin dose based on that. And so if their blood sugar is greater than a 180 ... It depends. So the goal, it depends on the age of the patient, what their goal is. But typically, I tend to go on the higher side for my older patients, so greater than 180-ish. But the true normal fasting is less than 130 or less than 110, depending on how strict you're being. I typically go to 130, just because I tend to be a little bit cautious. But that's your goal for your fasting blood sugars in the morning.

And so every three days, the recommendations are to titrate up on the insulin. And so, for example, if somebody's basal insulin comes out to be 10 units, you can either do weight-based dosing or you can start with just 10 units. So starting with 10 units, you can do checking their fasting sugar. It's still not at goal. You increase it by two to four units, depending on how much higher it is.

So if you're feeling a little overwhelmed, can you imagine how your patients feel? So the way ... Again, print out the cheat sheet down below this video if you haven't already. But the main thing here is that it is complicated. And depending on the patient's health literacy, they might need a little bit more hand-holding. If someone has super high health literacy, they're very savvy with health-related things, they can do that, right? They can follow the directions, write it all down, go up and up and up and all that stuff. Then that's perfect. And once they get to their goal fasting blood sugar of less than 130 and they don't have hypoglycemia, they can chill at that dose.

However, what typically happens is that this is confusing for nurse practitioners and people who are not nurse practitioners. So what I do for patients is I'll talk about it with them, right? It would be great to get it down immediately. But again, this is the rest of their life, so they need to make that decision. And so there's a couple of options. So I can either ... As long as they feel comfortable checking their blood sugars and they have that skill down, they can go home and they can check it. They can come back in a week with me, two weeks, a month. They can come back with the nurse in a week or two weeks or a month. They can come in with the diabetes educator, if you have that luxury. And then you can just take it slow and go from there.

Most of the time, when I'm titrating up on insulin for patients in this manner, they need some hand-holding. So it's usually done in person and typically not even over the phone, because it's just such a new skill. It's so overwhelming. There's a lot to think about.

So a note about hypoglycemia, if patients have any hypoglycemic episodes, less than 70 is typically the cutoff for the blood sugar level, you can either decrease the daily basal dose by 10% or four units, whichever is greater, I believe. And it's, again, in those AACE guidelines. But typically, I'm scaling back by about four units at a time when patients are having those hypoglycemic episodes. And even if their fasting levels are high, I'd rather them not have hypoglycemia.

There are further steps to take. You can add prandial insulin, meaning mealtime, shorter acting insulin. You can add on more oral agents. It's getting a little bit outside of the scope of this video for today, but I'm happy to talk about that more if that's something that you're interested in.

But yeah, the moral of the story is print out the cheat sheet, walk your patients through it really slowly and easily for them, very clearly, and definitely getting their buy-in, watching out for hypoglycemia, making sure that they understand what signs of hypoglycemia are, checking their blood sugars, how to use it, and just giving them as much support as you can, because especially if this is a brand new diagnosis, that is incredibly overwhelming to them.

So I hope you liked this video. Definitely let me know if you have any questions or further topic requests when it comes to diabetes or otherwise. And definitely join us for the lab interpretation crash course for new nurse practitioners on Friday, if you feel so called. I'm super excited. It's at RealWorldNP.com/labs. Thank you so much for watching. Hang in there, and I'll see you soon.