What is the appropriate adjustment for insulin (intravenous/injected anti-diabetic medication) dosage?

From the Guidelines

The amount to increase insulin should be based on an evidence-based titration algorithm, such as increasing 2 units every 3 days to reach the FPG goal without hypoglycemia, as recommended by the 2025 standards of care in diabetes 1. When adjusting insulin doses, it is essential to consider individual factors such as weight, activity level, stress, illness, and concurrent medications, as these can significantly affect insulin requirements.

• For basal insulin, a common starting dose is 10 units per day or 0.1-0.2 units/kg per day, with adjustments made based on fasting plasma glucose (FPG) levels and the presence of hypoglycemia 1.
• If hypoglycemia occurs, the dose should be lowered by 10-20% to prevent further episodes 1.
• Regular blood glucose monitoring is crucial when adjusting insulin doses to ensure safety and effectiveness, and to assess the adequacy of the insulin dose at every visit. Key considerations when adjusting insulin doses include:
• Clinical signals to evaluate for overbasalization and the need for adjunctive therapies, such as elevated bedtime-to-morning and/or postprandial-to-preprandial differential, hypoglycemia, and high glucose variability 1.
• The potential benefits and risks of adding other medications, such as GLP-1 receptor agonists or SGLT-2 inhibitors, to improve blood glucose control and reduce insulin doses 1.

From the FDA Drug Label

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

The amount to increase insulin is not explicitly stated in the label.

• Dose adjustment should be based on blood glucose measurements and individualized according to the patient's needs.
• The label recommends adjusting the dose to achieve glycemic targets, but does not provide specific guidance on how much to increase the dose. 2

From the Research

Insulin Adjustment Guidelines

• The amount of insulin increase is dependent on various factors, including the patient's current glucose levels and insulin dosage 3.
• A study found that a 44% to 100% increase in total daily dose (TDD) was significantly more likely to achieve the primary outcome of average blood glucose (BG) ≤160 mg/dL without subsequent hypoglycemia, compared to a TDD increase of 10% to 22% 3.
• When adding a GLP-1 receptor agonist to basal insulin, the dose of basal insulin should be decreased by 20% in patients with an HbA1c ≤8% 4.

Combination Therapy

• Basal insulin and GLP-1 receptor agonists are frequently used to treat type 2 diabetes, and evidence supports their combined use 4, 5.
• The combination of basal insulin and a GLP-1 receptor agonist can reduce HbA1c and body weight, with less hypoglycemia compared to the addition of meal-time insulin to basal insulin 4.
• New combination injectable products that combine basal insulins with GLP-1 receptor agonists in single pen-injector devices have been approved, offering a convenient treatment option for patients with type 2 diabetes 5.

Hospital Setting

• Hyperglycemia in the hospital setting can be managed with insulin, but recent evidence suggests that not all patients require complex insulin regimens 6.
• Incretin-based agents, such as GLP-1 receptor analogs, may be a safe alternative to complicated insulin regimens in appropriately selected hospitalized patients 6.
• Further studies are needed to confirm the safety and efficacy of different treatment options, including dipeptidyl peptidase-4 (DPP-4) inhibitors and older oral agents, in the hospital setting 6.