Endocrinology nurse practitioner Brad Hise joins this episode of The Huddle to discuss all things related to basal insulin. Brad touches on how to titrate basal insulin, ensuring that a person's insulin injection technique is effective, and how to support people on insulin in persisting with their medication routine. Educational support for this episode is provided by Sanofi.
Endocrinology nurse practitioner Brad Hise joins this episode of The Huddle to discuss all things related to basal insulin. Brad touches on how to titrate basal insulin, ensuring that a person's insulin injection technique is effective, and how to support people on insulin in persisting with their medication routine.
Educational support for this episode is provided by Sanofi.
Jodi Lavin-Tompkins:
Hello and welcome to ADCES's podcast, The Huddle: Conversations with the Diabetes Care Team. In each episode, we speak with guests across the diabetes care space to bring you perspectives, issues, and updates that elevate your role, inform your practice, and ignite your passion. I'm your host, Jody Lavin-Tompkins, a board-certified nurse in advanced diabetes management and the director of accreditation and content development. at the Association of Diabetes Care and Education Specialists. Our guest today is Brad Hise, a nurse practitioner and certified diabetes care and education specialist who practices in Minnesota at the Endocrinology Clinic of Minneapolis. He is here to talk about starting patients on basal insulin and titrating to glycemic goal. I want to thank Sanofi for providing educational support for this podcast. Brad, welcome to The Huddle.
Brad Hise:
Hey, I'm honored and excited to be here with you on this podcast. Thanks for having me.
Jodi Lavin-Tompkins:
Sure. Before we get started, I'm wondering if you could tell our audience a little bit about your background.
Brad Hise:
Sure, what brought me into this field is that I was diagnosed with type 1 diabetes at 23 years old. Six years after my diagnosis, I became a diabetes educator and in 2021, I became a nurse practitioner. I started on this path after meeting a diabetes educator who was type 1 herself and ran a local support group. She had inspiring guests at her meetings including professional athletes like Team USA Ironman Jay Hewitt, who was type 1 and a type 1 Super Bowl winner from Pittsburgh Steelers. Inspirational type 1 stories like this motivated me to not let diabetes get in the way of any of my dreams and share that same perspective with the rest of the diabetes community. Some of my dreams I've done so far include scuba diving, hang gliding, and traveling around the world. I also took over that same support group in Minnesota that got my spark going in the first place. At my practice as a nurse practitioner in the endocrinology field, I see patients with type 1, type 2, and gestational diabetes. I'm slowly expanding on that and getting my sea legs with hypothyroidism and hypogonadism patients as well.
Jodi Lavin-Tompkins:
Well, thanks for sharing that interesting personal background. I think it really helps to set the stage for our conversation. I mean, you have such a depth of personal knowledge and personal experience. So we're here to talk about insulin, initiation, and titration. And when prescribing insulin, we know that the usual place to start per ADA guidelines is with basal insulin. So maybe you could share with our audience the factors that we should keep in mind when starting someone on basal insulin.
Brad Hise:
Sure. it's important to manage blood sugars. It's also important to help the patient reframe their perspective to dispel any myths or misperceptions they may have and align the diabetes medications you are using with your patient's goals. If a patient is looking to lose weight and also reduce postprandial blood sugars, it may be worth looking into a GLP-1 or a combination basal insulin and GLP-1 such as Saliqua. However, our discussion today focused primarily on basal insulin, which is one of the quickest and most effective medications in improving both fasting glucose and A1C.
Jodi Lavin-Tompkins:
Well, Brad, I've heard the term over-basalization being used when referring to basal insulin, and I'm wondering if you could elaborate for our audience on what that means exactly.
Brad Hise:
It's important to not increase the basal dose too much to cause hypoglycemia overnight or into the morning. This can lead to a distrusting relationship between provider and patient, or to the patient stopping the insulin altogether, although they may have needed just a slightly lower dose. I try to empower my patients by giving them a sense of control over their morning blood sugars. I stress the importance of them checking their fasting glucose so that they can change their numbers by adjusting their basal insulin dose accordingly. As a personal example, when the weather isn't freezing cold in Minnesota, I find myself more active in the summertime and therefore my blood sugars are lower on average and so my basal dose also needs to decrease. I also found myself decreasing my basal insulin dose by as much as 60% due to all the increased exercise while I was hiking in the Himalayan mountains. Since blood sugars don't remain too constant in our ever-changing lifestyles, hence our basal insulin dosing shouldn't remain stagnant or reliant solely on our vists with providers. As providers, we can empower patients to make slight changes in their dosing to keep them safe and in their target range.
Jodi Lavin-Tompkins:
When it comes to titrating basal insulin, I've actually seen some clinicians increase the basal dose but split it into BID dosing in order to decrease the volume the patient has to give. Do you think this is best practice or do you have other suggestions?
Brad Hise:
The best recommendation I share on titrating basal insulin is to set a range for target morning blood sugars such as 90-130. This target range can always be increased to say 100-140 for a patient at risk for falls if they were to become hypoglycemic. Then ask the patient to increase their dose by two units every two to three days they're higher than 130 until they're at that goal range. If they drop to below 90 for two mornings, then they should drop their dose by two units to help prevent low blood sugars. Since most basal insulins last for 24 hours, I let the patient choose whether the morning or the evening is the most convenient or consistent timeframe to take their insulin dose. Sometimes our lives are more chaotic in the morning or the evening, so it's best to choose a time when the patient is most likely to remember to take their insulin. Every once in a while you may find a patient that needs twice daily dosing since it may not last a full 24 hours for them. Others may just be on a BID basal insulin dosing because that's what the provider discharged them on from the hospital. More injections can occasionally lead patients to miss more of their doses or a higher likelihood of lipohypertrophy. To help eliminate twice daily dosing, I like to use or ultra long acting basal insulins such as Triseva and Tujeo that last longer and only need once daily dosing.
Jodi Lavin-Tompkins:
Okay, so you've introduced the concept of maybe switching to a concentrated insulin. So can you share with our audience if there are any differences in what they are between concentrated basal insulins and U100 basal insulins?
Brad Hise:
Sure, there are two concentrated basal insulins on the market known as Triseva and Tujeo. Their duration of action is 36 to 42 hours and longer than other U100 basal insulins. It's important to know that although their duration of action is longer than one day, there's no risk in stacking basal insulin levels when taken every 24 hours. I find using ultra long acting basal insulins can be great for my population of patients who have irregular schedules or often forget to take their basal insulin at a similar time. Triseva and Tujeo offer some flexibility with their dosing that if a patient forgets to take it at their normal time, they can still take it within 3 to 12 hours of their normal dosing time without losing background blood sugar coverage, depending on the name brand they take. Another minor difference to note is that concentrated insulins such as Triseva U200 will have 50% less volume. and Tujeo U300 will have 66% less volume than U100 Insulins.
Jodi Lavin-Tompkins:
Okay, well if you are titrating the basal insulin but it doesn't seem to be moving the glucose levels, what are your next steps?
Brad Hise:
This would mean it's a good time to check their insulin technique. Are they putting the needle on correctly and removing both needle caps? It sounds ridiculous, but I've had patients not remove the second needle cap before when giving their injection. Are they storing their insulin correctly? Or has it been exposed to extreme heat or cold? Are they properly absorbing the insulin or would some scars from surgery or lipohypertrophy be interfering? It's a good time to look closer at their injection sites to confirm. If a patient has titrated their insulin dose and their fasting glucose hasn't changed, that's a sign there's definitely something wrong with the insulin or their technique.
Jodi Lavin-Tompkins:
I would agree. I've seen that a lot in my own experience that a lot of people who take insulin either don't have the proper technique or they've developed lipohypertrophy. And the reason why I see this is because if you inject in the same area over and over and over again, it becomes numb. And that's exactly what they like about it. It's a place where they don't feel the injection. So I found that in my own practice since it was so common, I really did ask the person, first thing, show me where you give your injections. And oftentimes I would see lipohypertrophy and so their insulin being injected in that site is not getting absorbed. So the fix for that was to teach them more about where to move their injections to and to leave those sites alone because the absorption won't be as good. And also it's dangerous if they switch on their own from injecting into a site with lipohypertrophy and all of a sudden switching on the same dose to a fresh site, they may experience hypoglycemia. So this lipohypertrophy condition is really important to look for and to ask about. I'm glad you brought it up, Brad. Now moving on to how people can persist with taking their insulin long-term. What do you think causes people to stop taking their insulin?
Brad Hise:
So many patients have never had blood sugars high enough to cause symptoms of frequent urination or thirst, fatigue, and/or blurry vision. When A1Cs are below the 10% range, it's likely patients won't feel anything different with their body. Therefore, when patients on insulin are not checking their blood sugars, they may not feel like the insulin is doing anything or see the difference it is making in their blood sugar and stop taking it. Patients may not fully understand how or why the insulin is helping. This also includes patients who may have at one time taken too much insulin leading to hypoglycemia and therefore they stopped insulin. If they do not understand how to lower the basal insulin dose properly, this can lead them to stopping insulin altogether. When they stop the insulin, they may see the symptoms also stopped so they just don't take it. If you've ever seen a Snickers commercial before, you would know that you may not be the most pleasant person to be around when your glucose is low and your brain is demanding more sugar. It can be scary for the patient when adrenaline is coursing through your body telling you that you need to eat something or you may die. That's at least what it feels like to many people with a low blood sugar. So not understanding how insulin works and how to change the dose appropriately is therefore one of the biggest reasons for patients stopping their insulin. It can be very difficult to navigate healthcare and insurance. As a healthcare provider living with type 1 diabetes, it can take me four to eight hours each year to thoroughly review my insurance plan options so I can spend $1,000 to $4,000 less per year. I have a patient with a $3,000 deductible in which their current plan will not cover anything until they hit that deductible. So their insulin will cost around $900 early in the year. Some patients have an even bigger deductible than that. It becomes a lot more real and understandable that if you were short on finances that you might use that money for your rent, your car loan or electricity bill instead. Therefore, I think cost is a substantial factor in patients stopping their insulin. Thankfully many clinicians and diabetes care and education specialists know how to support patients in reducing medication costs if they are having trouble affording their medications. Also, through recent advocacy efforts, the costs of insulin have been coming down significantly.
Jodi Lavin-Tompkins:
Yes, and that is good news for everyone. And so, Brad, I think we're at the end of our conversation here. You've given us a lot of great information about basal insulin. I'm wondering if you have any final takeaways you'd like to share with our audience.
Brad Hise:
Sure. I try to teach patients that the ball is now in their court, that it's more important for them to check their morning blood sugars because they now have the power to change their morning blood sugars by titrating the dose by two units every two to three days that they are too high or too low. It's not just a provider's responsibility anymore and that gives the patient more ability to prevent high or low blood sugars as their activity levels change throughout the year. You can vary a patient's target range from 90-130 or 100-140, or whatever suits that patient's goal or comfort level when using basal insulin.
Jodi Lavin-Tompkins:
Well, Brad, thank you so much for taking the time to join us for this episode of The Huddle and for sharing your knowledge and experience with our audience. For me, as a diabetes care and education specialist, I know how useful this information is for practice, so I'm sure our listeners really appreciate hearing your first-hand experience.
Brad Hise:
Thanks again for your time and having me on your podcast today.
Jodi Lavin-Tompkins:
Sure, and thank you all for listening to this week's episode of The Huddle. To access the notes and resources from today's episode, head over to diabeteseducator.org forward slash podcast. And remember, ADCES membership gets you free access to resources, education, and networking that improve your practice and optimize outcomes for your clients. Learn more about what ADCES can do for you at diabeteseducator.org forward slash join. The information in this podcast is for informational purposes only and may not be appropriate or applicable to your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a healthcare professional. Please consult your healthcare professional for any medical questions.