From the Guidelines
For a patient with an HbA1c of 13% and fasting blood sugar of 220 mg/dL, I recommend starting insulin 70/30 at a dose of 10 units or 0.1 to 0.2 units/kg of body weight, divided as 2/3 before breakfast and 1/3 before dinner, as this approach is supported by the American Diabetes Association standards of medical care in diabetes 1. The patient's significantly elevated HbA1c and fasting glucose indicate severe insulin deficiency, requiring prompt intervention to reduce glucose toxicity and improve metabolic control.
- The 70/30 insulin regimen provides both basal and prandial insulin coverage, with the 70% NPH component providing intermediate-acting coverage and the 30% regular insulin addressing mealtime glucose excursions.
- The dose can be adjusted by 10% to 15%, or 2 to 4 units, once or twice weekly until the fasting blood glucose target is met, as recommended by the American Diabetes Association 1.
- Close monitoring of blood glucose is essential, particularly before meals and at bedtime, with dose adjustments made accordingly.
- The patient should be educated about hypoglycemia symptoms and management, including keeping fast-acting carbohydrates available. This approach is consistent with the recommendations outlined in the American Diabetes Association standards of medical care in diabetes, which emphasize the importance of individualizing insulin therapy and adjusting doses based on patient response 1.
From the Research
Insulin Dosing for Patient with HbA1c 13 and FBS 220mg/dl
- The patient's HbA1c level is 13 and FBS is 220mg/dl, indicating poor glycemic control.
- The patient is starting insulin 70/30, which is a premixed insulin containing 70% intermediate-acting insulin and 30% short-acting insulin.
- The starting doses for before breakfast and before dinner are not explicitly stated in the provided studies 2, 3, 4, 5, 6.
- However, the studies suggest that the dosing of insulin detemir and glargine, which are long-acting basal insulin analogs, can be adjusted based on the patient's glycemic control and insulin requirements 2, 3, 4, 5, 6.
- For example, a study found that patients with type 2 diabetes who were treated with insulin detemir required higher total daily basal insulin doses compared to those treated with glargine 4.
- Another study found that the glycemic control of type 1 diabetes patients with multiple daily injections was similar regardless of basal insulin, glargine, or detemir 6.
- However, the studies do not provide specific guidance on the starting doses for before breakfast and before dinner for a patient with HbA1c 13 and FBS 220mg/dl starting insulin 70/30.
Considerations for Insulin Dosing
- The patient's insulin dose should be individualized based on their specific needs and glycemic control.
- The dose of insulin 70/30 can be adjusted based on the patient's blood glucose levels, insulin sensitivity, and other factors.
- It is recommended to consult with a healthcare professional to determine the appropriate starting dose and adjustment of insulin 70/30 for the patient.