Insulin Tresiba (Degludec) in combination with insulin Aspart is available as Insulin Ryzodeg. It is ultra-long-acting insulin administered as a once-daily injection without regard to meals and at any time of the day. However, the combination "Insulin Degludec + Insulin Aspart" is usually given one time daily before meal. Insulin Aspart is rapid-acting insulin with a short duration of action. It usually covers a single meal. It is given to reduce the post meals blood sugar spikes along with other medicines like metformin, sitagliptin, or SGLT-2 inhibitors. Synjardy is a combination of metformin and empagliflozin. It is available as:
- Xenglu-met and
- Diampa-M (among others in Pakistan)
Difficult Diabetic Patients - Uncontrolled Diabetes despite Insulin Tresiba, Aspart, and Synjardy ...
Let's see if we can help this patient ...
A 56 years of age male patient, diagnosed of Type 2 Diabetes Mellitus and hypertension for past 14 years. He is currently on the following regimen:
- Tab. Xenglumet 12.5/1000 mg (Synjardy) once daily after breakfast
- Insulin Novorapid (Insulin Aspart) 20 units in the morning and 20 units at lunch
- Insulin Ryzodeg (Insulin Aspart and Insulin Degludec) 40 units at dinner.
- For hypertension, he is taking Diovan 160 mg once daily
His blood sugars ranged in between 250 mg/dl to 350 mg/dl. His latest glycated hemoglobin is 9 % He has dyslipidemia and his urinary microalbumin levels are more than 300 mg/dl.
Recently, because of non-compliance to three injections, he was switched from Insulin Degludec and Insulin Aspart to the following regimen:
- Tab. Xenglumet 25/ 1000 mg in the morning
- Tab. Metformin XR 750 mg after dinner
- Insulin Novomix-30 36 units in the morning and 26 units in the evening
With this regimen, his blood sugars jumped to 422 mg/dl.
What should we do next?
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Should we resume the previous regimen and enhance the oral medications?
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Should we increase the dose of Novomix?
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Should we admit the patient, start insulin infusion, calculate the total insulin dose required per day, and then start him on a basal-bolus regimen?
Expert comments are needed to help this patient ...
I decided to admit the patient and control his blood sugars with insulin infusion after ruling out Diabetic ketoacidosis. Lowering the blood sugars with insulin infusion will reduce the effects of glucotoxicity that may result in better glycemic control. Plus, I plan to start him on a basal-bolus regimen if his insulin requirements are high.
