What is the appropriate insulin dose?

From the Guidelines

For type 2 diabetes, a safe and simple approach to initiate insulin therapy is to prescribe 10 units, or 0.1 to 0.2 units/kg of body weight, of basal insulin per day and advise to increase the dose 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 2025 standards of care in diabetes 1.

Key Considerations for Insulin Dosing

• Insulin dosing should be individualized based on a patient's weight, blood glucose levels, insulin sensitivity, and medical history.
• For type 2 diabetes, starting doses are often lower, around 0.1-0.2 units per kilogram daily.
• Mealtime insulin is typically calculated using an insulin-to-carbohydrate ratio (often 1 unit per 10-15g carbs) and a correction factor (typically 1 unit lowers blood glucose by 30-50 mg/dL).
• Regular blood glucose monitoring is essential for dose adjustments.
• Insulin requirements may increase during illness, stress, or with certain medications like steroids, and decrease with exercise or weight loss.
• Hypoglycemia risk increases with higher doses, so patients should always have fast-acting glucose available and know how to recognize and treat low blood sugar symptoms.

Adjusting Insulin Dose

• Assess adequacy of insulin dose at every visit and consider clinical signals to evaluate for overbasalization and need to consider adjunctive therapies.
• If A1C is above goal and the individual is not already on a GLP-1 RA or dual GIP and GLP-1 RA, consider these classes in combination and with insulin (may use fixed-ratio product, if available and appropriate) 1.

Important Notes

• Cost considerations are important when an insulin product is selected, particularly because of substantial price increases over the past decade.
• Although newer products cause less hypoglycemia, intermediate-acting insulin (neutral protamine Hagedorn [NPH]) may be a more affordable option for some patients 1.

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 based on the physician’s advice and the patient’s needs.

• 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, and then adjusted to achieve glycemic targets 2.

From the Research

Insulin Dose

• The initial insulin dose can be 10 units or 0.2 units/kg, and then increased by 2 units every 3 days until fasting levels are consistently in the target range 3
• If hypoglycemia occurs, the insulin dose can be reduced by 4 units 3
• The dose of insulin glargine can be titrated based on fasting blood glucose levels, with a target of <5.5 mmol/L (<100 mg/dL) to achieve glycosylated hemoglobin (HbA1c) <7% 4
• A simple titration regimen for insulin glargine can include increasing the daily dose by 0-2,4, or 6-8 IU if mean fasting plasma glucose over the 3 previous days is >or=5.6-<6.7, >or=6.7-<7.8, >or=7.8-<10.0 or >or=10 mmol/L (>or=100-<120, >or=120-<140, >or=140-<180, or >or=180 mg/dL), respectively, in the absence of plasma glucose <4.0 mmol/L (<72 mg/dL) 4
• Patient-managed dose titration of insulin glargine can result in greater reductions in HbA1c compared to clinic-managed titration, but may also increase the risk of hypoglycemia 4

Factors Affecting Insulin Dose

• The choice of insulin regimen, such as biphasic insulin aspart or insulin glargine, can affect the dose and frequency of insulin administration 5, 4
• The use of oral antidiabetic agents, such as metformin, can also impact the insulin dose required to achieve glycemic control 6, 7
• Patient factors, such as weight and glucose monitoring, can influence the insulin dose and titration regimen 3, 4

Clinical Efficacy and Safety

• Insulin therapy can be effective in achieving glycemic control in patients with type 2 diabetes, with a low risk of hypoglycemia 3, 7
• The use of insulin glargine and other basal insulins can provide a convenient and well-tolerated treatment option for patients with type 2 diabetes 5, 4
• The addition of prandial insulin or other glucose-lowering agents can be necessary to achieve optimal glycemic control in some patients 6