Glargine insulin (Lantus Insulin) is a long-acting insulin. It is used as basal insulin in combination with other drugs or short/ rapid-acting insulins. The onset of action of Insulin glargine is about 3- 4 hours and the duration of action may last from 24 to 30 hours. Mixtard insulin is a combination of short-acting regular insulin and NPH insulin. This combination provides basal insulin cover and post-meals cover. Basal Insulins like Glargine, Detemir, or Degludec are not usually given with twice daily Mixtard insulin. Sitagliptin (Januvia, Tagip, Sita) is a DPP-IV inhibitor. Sitagliptin is used as an anti-diabetic medicine because of the following actions:
- Increase insulin synthesis and release from pancreatic beta cells and
- Decrease glucagon secretion from pancreatic alpha cells.
- Delay gastric emptying and suppress appetite
- Decreased gluconeogenesis
- Decrease Beta-Cells apoptosis
Case scenario of our patient with uncontrolled blood sugars:
A 60 years of age female patient, a diagnosed case of ischemic heart disease and scheduled for CABG because of TVCAD, presented with uncontrolled blood glucose. She was currently on the following regimen:
- Inj. Mixtard 70/30 52 units before breakfast and 48 units before dinner.
- Inj. Lantus (Glargine) 26 units at bedtime.
- Tab. Tagip (Sitagliptin) 50 mg twice daily.
Metformin was stopped by her cardiologist because of ischemic heart disease.
Should she stop metformin?
Her blood sugars were in the range of 180 - 240 mg/dl in the fasting state and 220 to 300 mg/dl in the prandial state. Glycated hemoglobin of the patient was 9.6%.
What is wrong with the above prescription?
Should she continue Insulin Glargine with Mixtard insulin?
Insulin Mixtard contains Regular insulin and NPH insulin. NPH insulin should not be combined with insulin glargine.
How I modified her prescription ...
I counseled her about the benefits of metformin, regular exercise, and a diabetic diet. Insulin Glargine was stopped. She was advised the following prescription:
- Tab. Xenglu-met (Synjardy, Empagliflozin + Metformin) 12.5/1000 mg once daily after breakfast
- Tab.Tagipmet-XR (Janumet, Sitagliptin + metformin) 50/500 mg after dinner.
- Inj. Mixtard insulin 54 units before breakfast and 48 units before dinner.
Her blood sugars in the fasting state were recorded on several occasions ranging from 80 - 109 mg/dl. Her postprandial blood sugars did not cross 155 mg/dl. Her insulin was reduced by 2 units twice daily. Her glycated hemoglobin will be repeated after three months.
Do you think she benefitted from Empagliflozin or Metformin?
Read More ...
How to switch from Insulin Glargine to Toujeo and NPH?
