Patients with diabetes may require insulin therapy at a certain point in their journey of living with diabetes. Insulin initiation is recommended when patient’s A1c is ≥7% even after 3 months of triple combination with oral anti-diabetes medicines (OAD) or if patient’s A1c levels are ≥10% (1). The American Diabetes Association recommends that insulin initiation should be done with the basal regimen, where a single daily dose of long-acting insulin is given to the patients. Based on patient response, this basal regimen can be intensified to either basal bolus regimen or the premixed twice-daily regimen (2). In the basal bolus regimen, in addition to the basal long-acting insulin, additional meal-time rapid-acting insulin is prescribed. Pre-mixed insulin has a combination of long and rapid-acting insulin.
The traditional approach to prescribing medications to patients with diabetes is a gradual step-wise increase is OADs with the final step of initiating Insulin. There are pros and cons to this approach and the final step of insulin initiation usually gets delayed due to patient as well as healthcare provider factors. Once insulin is initiated, it is equally important to optimally titrate insulin for better health outcomes of the patient.
Context of insulin titration:
Insulin’s primary affect is that it lowers blood glucose. Hence the dosing of insulin needs to be adjusted based on events that alter the patient’s blood glucose levels, namely: timing of food intake, content of food (glycaemia index of the foods consumed), pre-meal blood glucose and planned or completed exercise(3). Let us consider an example, If Ms. Anagha, who has diabetes is taking a certain dose of insulin with her regular meals and she plans to attend a party with a four-course meal for dinner, her insulin dose will have to be adjusted. Not adjusting or titrating the dose may lead to hyperglycemia. At another extreme, if she does strenuous exercise without titrating her insulin dose, she may experience hypoglycemia. Hence it is vital to optimally titrate insulin doses. Insulin titration is crucial in the first few months of starting insulin as well, when the patient is started on low doses and gradually the optimal level is achieved.
Hence insulin titration is essential during the following situations:
- Insulin initiation
- Change in jobs/ major changes in life/change in daily routine
- Periods of high stress
- During bouts of illness
- Holidays, Travel, festivals, events, weddings etc.
- When there are repeated hypoglycemia episodes
- When home blood glucose monitoring levels show consistently high or low levels.
How do patients benefit from optimal inulin titration?
The main goal of insulin titration is to achieve the target blood glucose levels relevant to the patient’s age and other characteristics. When blood glucose levels are consistently in the acceptable/target levels, the patient’s suffering is alleviated by prevention or reduction in (a) hypoglycemia episodes and in (b) long-term complications of diabetes. The morbidity and mortality are high in long-term complication of diabetes damage to retina (eyes), kidneys, nerves and heart. Maintaining a target glucose level is critical in reducing these long-term complications of diabetes(4).
Role of Digital Therapeutics in insulin titration:
Certain health centers educate patients to self-titrate their insulin based on the various factors discussed above. But patients may require help, especially in settings like India. In such a scenario, digital therapeutics (DTx) is a great solution. DTx would act as a bridge between the healthcare provider and the patient. All the pre-requisite information for titrating the insulin dose would be made available by the patient on the DTx platform. The blood sugar logs, physical activity tracking and digital food diary on DTx are vital keys to open the lock of insulin titration. Based on these values, either the healthcare provider can help the patient titrate the dose or if the patient is confident, self-titration could be done as well.
Wellthy CARE™, a pioneer DTx platform in India uses a combination of artificial intelligence, trained nutritionists and educational content nudges to assimilate the logs of the patient and provide real-time guidance on titrating the dose. The AI-driven technology has shown to reduce episodes of hypoglycemia and decrease in blood glucose variability as compared to people who did not use the app. Of the 282 patients with diabetes, those who used their DTx product had 1.95% lower instances of hypoglycemia over a period of 6 months with increase in glycemic control. This also helped patients to have lesser variability in their blood glucose levels from 32.83% to 19.69% over six months of use.
Hence, DTx is a great platform that can be leveraged to successfully titrate insulin among patients with diabetes.
- Swinnen SG, Hoekstra JB, DeVries JH. Insulin Therapy for Type 2 Diabetes. Diabetes Care. 2009 Nov;32(Suppl 2):S253–9.
- Chun J, Strong J, Urquhart S. Insulin Initiation and Titration in Patients With Type 2 Diabetes. Diabetes Spectr. 2019 May 1;32(2):104–11.
- Insulin Initiation and Titration in Patients With Type 2 Diabetes | Diabetes Spectrum [Internet]. [cited 2021 Jun 19]. Available from: https://spectrum.diabetesjournals.org/content/32/2/104
- Petznick A. Insulin Management of Type 2 Diabetes Mellitus. Am Fam Physician. 2011 Jul 15;84(2):183–90.