Management of Obesity

Secondary drug failure can be due to progressive decrease in the beta cell function as a part of disease process, dietary non-compliance or because of weight gain.

Secondary drug failures can be treated as follows:

• Correct the cause if possible like diet or weight reduction
• Start insulin, and / or
• Add Metformin to sulphonylurea
• Sulphonylurea + Metformin and insulin.
• Insulin alone

Starting Insulin Therapy

Supplementation

• Continue with OHA, no change in dose.
• Start with 0.1unit/kg body weight of intermediate acting insulin at bed time or before breakfast.
• Increase dose by 2-4 units every 4 days, if necessary, until acceptable blood glucose levels have reached
• If the total dose exceeds 30-36 units, consider stopping OHA therapy and continue on insulin therapy alone.

Substitution

• Stop OHA.
• Begin once daily insulin treatment on the following day.
• Start 12-16 units of intermediate acting insulin before breakfast or at bed time.
• Increase insulin dose by 2-4 units every 4 days, if necessary, until acceptable blood glucose levels have been achieved.
• If the total dose exceeds 30-36 units, or the bedtime dose exceeds 20 units, divide the dose and inject 2/3 of the dose before breakfast and 1/3 of the dose before dinner or at bedtime.

If postprandial blood glucose levels are excessively high, premix insulins should be considered.

Hence to summarise it is very important to identify the obese Type 2 diabetes as a separate group for treatment of diabetes. Majority will have better glycaemic control if they lose weight which will improve insulin sensitivity. Exercise also helps to increase insulin sensitivity. Metformin has additional advantage in obese Type 2 diabetes. Whenever secondary drug failure occurs insulin has to be started with strict watch on weight.