Basal insulin therapy is a critical part of effective type 2 diabetes (T2D) management for many patients, yet its initiation and titration are often delayed or avoided. Aversion to basal insulin therapy contributes to unnecessary hyperglycemia and poorer outcomes for patients. Primary care physicians often make decisions regarding the initiation of basal insulin in T2D, as they work closely with patients and are well placed to discuss and manage the transition to basal insulin therapy. However, many primary care clinicians hesitate to initiate basal insulin due to concerns regarding time or effort needed to educate patients, doubts about patient acceptance or ability to manage titration or injection, or patient fears of hypoglycemia. Resistance to basal insulin therapy is often linked to the outdated perception that the need for insulin represents a failure to control the disease, or that insulin is dangerous or toxic. Time concerns can be addressed via group classes and mobile technology and by working with diabetes educators in the community. Hypoglycemia or weight gain can be minimized with proper titration and use of second-generation basal insulins. This article reviews strategies for the initiation of basal insulin therapy, with an emphasis on the characteristics and titration of second-generation basal insulins, introducing current guidelines and offering suggestions for recognizing and overcoming barriers to insulin therapy in the management of T2D. (J Am Board Fam Med 2019;32:431-447.)

Myxedema coma is a rare but highly fatal condition with reported mortality >40%-50%. Early recognition and prompt treatment are critical for survival. Here we describe a case of possible postoperative myxedema coma after subacute neck hematoma evacuation after hemithyroidectomy in a patient on concurrent amiodarone therapy. Symptoms included somnolence, hypothermia, and prolonged QTc with torsades de pointes resistant to magnesium therapy requiring defibrillation and overdrive pacing. Consideration of the possible diagnosis of myxedema coma resulted in prompt therapy and symptom resolution within 48 hours. Thyroid disorders, although rare, should be considered in the postoperative setting.

Background: The transition from intravenous to subcutaneous insulin is a complicated process often associated with poor glycemic control. Our academic medical center has protocols for guiding providers through this transition. Our protocols have previously been shown to improve glycemic control. We sought to assess protocol utilization and whether it continues to produce successful insulin transitions. Methods: Data was collected through retrospective chart review of all transitions from intravenous to subcutaneous insulin completed at our medical center from April 2015 through June 2015. A successful transition was defined as one in which the insulin drip was not restarted, mean blood glucose was less than 180 mg/dL for the first 48 hours after transition, and there was no hypoglycemia (blood glucose less than 70 mg/dL). Results: In total, 267 transitions from intravenous to subcutaneous insulin occurred at our medical center over the study period, and 211 were included in the analysis. For the group of patients with diabetes and transitioned to long acting subcutaneous insulin, 25 out of 1(23.1%) were transitioned using either our paper or computer protocol, and 82 out of 1(75.9%) were not transitioned via protocol. Of the 25 patients transitioned via protocol, 15 (60%) were successfully transitioned from intravenous to subcutaneous insulin. Of the 82 patients transitioned without using the protocol, 39 (47.6%) were successful. Among patients without a history of diabetes, 62 out of 65 patients (95.4%) were successfully transitioned from intravenous to subcutaneous insulin. The majority of these patients maintained good glycemic control with correctional insulin only. Conclusions: Our protocol is effective in producing successful transitions from intravenous to subcutaneous insulin, however it is underutilized in our academic medical center. Disclosure L. Vincent: None. K. Box: None. K. Kulasa: None.