What is the appropriate insulin dose?

From the Guidelines

Insulin dosing should be initiated at 10 units per day or 0.1-0.2 units/kg per day, with titration based on an evidence-based algorithm to reach the target fasting plasma glucose (FPG) goal without hypoglycemia. This approach is supported by the most recent guidelines, including the 2025 standards of care in diabetes 1. The initial dose can be adjusted by increasing 2 units every 3 days to reach the FPG goal. It is essential to assess the adequacy of insulin dose at every visit and consider clinical signals to evaluate for overbasalization and the need for adjunctive therapies.

For patients with type 2 diabetes, insulin therapy is often initiated with basal insulin, and the dose can be adjusted based on the patient's response. The American Diabetes Association recommends a starting dose of 10 units or 0.1 to 0.2 units/kg of body weight of basal insulin per day, with adjustments made to achieve the target fasting blood glucose level 1. However, the most recent guideline from 2025 should take precedence in clinical decision-making 1.

Key considerations in insulin dosing include:

• Starting dose: 10 units per day or 0.1-0.2 units/kg per day
• Titration: increase 2 units every 3 days to reach FPG goal
• Monitoring: assess adequacy of insulin dose at every visit and consider clinical signals for overbasalization
• Adjunctive therapies: consider GLP-1 RA or dual GIP and GLP-1 RA if A1C is above goal and patient is not already on these therapies.

Regular follow-up with healthcare providers is necessary to optimize insulin regimens as insulin needs change over time due to factors like weight changes, activity levels, and progression of diabetes. Blood glucose monitoring is essential for dose adjustments, with targets generally between 80-130 mg/dL before meals and less than 180 mg/dL after meals. Hypoglycemia risk increases with higher insulin doses, so patients should always have fast-acting carbohydrates available.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION LEVEMIR can be administered once- or twice-daily. The dose of LEVEMIR should be adjusted according to blood glucose measurements. The dosage of LEVEMIR should be individualized based on the physician’s advice, in accordance with the needs of the patient. For patients with type 1 or type 2 diabetes on basal-bolus treatment, changing the basal insulin to LEVEMIR can be done on a unit-to-unit basis. The dose of LEVEMIR should then be adjusted to achieve glycemic targets For insulin-naïve patients with type 2 diabetes who are inadequately controlled on oral antidiabetic drugs, LEVEMIR should be started at a dose of 0.1 to 0. 2 U/kg once-daily in the evening or 10 units once- or twice-daily, and the dose adjusted to achieve glycemic targets.

The insulin dose should be individualized and adjusted according to blood glucose measurements.

• For patients with type 1 or type 2 diabetes on basal-bolus treatment, the dose can be changed on a unit-to-unit basis.
• For insulin-naïve patients with type 2 diabetes, the initial dose is 0.1 to 0.2 U/kg once-daily or 10 units once- or twice-daily 2.

From the Research

Insulin Dose Considerations

• The initial insulin dose for patients with type 2 diabetes mellitus can be determined based on their weight, with a starting dose of 0.3 units per kg for augmentation therapy or 0.6 to 1.0 units per kg for replacement therapy 3.
• When using replacement therapy, 50% of the total daily insulin dose is given as basal, and 50% as bolus, divided up before breakfast, lunch, and dinner 3.
• The choice of insulin therapy should consider factors such as glucose control, adverse effects, cost, adherence, and quality of life 3.

Comparison of Insulin Therapies

• A study comparing premixed, bolus, and basal insulin found that hypoglycemia was more common with premixed and bolus insulin, and weight gain was more common with bolus insulin 3.
• Another study found that premixed insulin lispro was superior to insulin glargine at reducing glycosylated hemoglobin (HbA1c), but resulted in more weight gain and a higher risk of hypoglycemia 4.
• The use of a glucagon-like peptide 1 (GLP-1) receptor agonist in combination with premixed insulin and metformin has been shown to improve glycemic control and reduce insulin dose in patients with uncontrolled type 2 diabetes 5.

Titration and Adjustment of Insulin Dose

• Titration of insulin over time is critical to improving glycemic control and preventing diabetes-related complications 3.
• The dose of insulin glargine can be increased from 47 to 53 IU when used in combination with albiglutide, a GLP-1 receptor agonist 6.
• The cumulative daily insulin dose can be reduced by 33.3 units when using a combination of premixed insulin, metformin, and a GLP-1 receptor agonist 5.