Optimizing insulin use in type 2 diabetes: role of basal and prandial insulin in long-term care facilities

Approximately 25% of patients in nursing homes have diabetes, and it is the primary reason for 12% of nursing home admissions among residents 45 to 75 years of age. Glycemic control is important to reduce the risk of diabetic complications in this patient population. Management of diabetes in the long-term care setting is complicated, because many residents already have diabetic complications and other comorbidities. Data from several studies suggest that a significant number of nursing home residents receive suboptimal diabetes care. This review is intended to provide guidance for optimizing glycemic control in patients with type 2 diabetes in long-term care facilities. Oral antidiabetic drugs (OADs) represent first-line pharmacotherapy for diabetes. However, because of the progressive nature of type 2 diabetes, most patients will eventually require insulin. Adding a basal insulin analog, such as insulin glargine or insulin detemir, to an OAD is a simple, safe, and effective strategy for introducing insulin therapy. These long-acting insulin analogs provide effective glycemic control with a lower risk of hypoglycemia, a particular concern in the elderly, compared with NPH insulin. In patients whose insulin requirements have increased as a result of increases in post-prandial glucose excursions, prandial insulin should be added following a stepwise approach to therapy. Overall patient care and optimizing treatment of type 2 diabetes and its associated complications are vital services provided by the nursing staff at long-term care facilities.