What is the initial dosing strategy for insulin in patients with Type 2 Diabetes Mellitus (Type 2 DM)?

From the Guidelines

Insulin therapy for type 2 diabetes should be initiated with a basal insulin, such as insulin glargine, at a starting dose of 10 units once daily or 0.1-0.2 units/kg/day, as recommended by the most recent guidelines 1. When starting insulin therapy, it is essential to consider the individual's body weight, insulin sensitivity, and carbohydrate intake to determine the optimal dose. The initial dose can be adjusted by 2-4 units every 3-7 days until the target fasting glucose of 80-130 mg/dL is achieved. If basal insulin alone does not control postprandial glucose spikes, consider adding mealtime rapid-acting insulin, starting at 4 units or 10% of the basal dose before meals 1. Alternatively, premixed insulin formulations combining intermediate and short-acting insulins can be used twice daily. It is crucial to educate patients about hypoglycemia recognition and management, proper injection technique, and the importance of consistent carbohydrate intake when using mealtime insulin 1. Insulin requirements may vary, and individualization is essential to achieve optimal glycemic control. The most recent guidelines recommend a stepwise approach to intensifying insulin therapy, considering self-mixed or premixed insulin plans, and adjusting the dose based on individual needs 1. By following these guidelines and considering the individual's specific needs, healthcare providers can help patients with type 2 diabetes achieve optimal glycemic control and improve their quality of life. Key considerations include:

• Starting with a basal insulin and adjusting the dose as needed
• Adding mealtime rapid-acting insulin if necessary
• Educating patients about hypoglycemia recognition and management
• Individualizing insulin therapy based on body weight, insulin sensitivity, and carbohydrate intake
• Considering self-mixed or premixed insulin plans to simplify dosing regimens.

From the FDA Drug Label

1. 3 Initiation of Insulin Glargine Therapy Recommended Starting Dosage in Patients with Type 2 Diabetes The recommended starting dosage of Insulin Glargine in patients with type 2 diabetes who are not currently treated with insulin is 0.2 units/kg or up to 10 units once daily.

The recommended starting dosage of insulin glargine for type 2 diabetes is 0.2 units/kg or up to 10 units once daily 2.

• Key considerations:
  • The dosage should be individualized based on the patient's metabolic needs and blood glucose monitoring results.
  • The patient should be closely monitored for glucose control during the initial weeks of therapy.
  • Dosage adjustments may be needed based on changes in physical activity, meal patterns, or renal or hepatic function 2.

From the Research

Initiating Insulin Therapy for Type 2 Diabetes

• Insulin therapy is often necessary for patients with type 2 diabetes who have not achieved target glycemic goals with oral antidiabetic agents 3, 4, 5, 6, 7.
• The American Diabetes Association suggests using long-acting (basal) insulin to augment therapy with one or two oral agents or one oral agent plus a glucagon-like peptide 1 receptor agonist when the A1C level is 9% or more 4.
• Basal insulin is usually initiated at a conservative dose of 10 units/day or 0.1-0.2 units/kg/day 3, 5, 6.

Titration and Adjustment of Insulin Dose

• The dose of basal insulin should be titrated regularly based on patients' self-measured fasting plasma glucose to achieve an individualized target (usually 80-130 mg/dL) 3, 4, 5.
• A simple rule is to gradually increase the initial dose by 1 unit per day (NPH, insulin detemir, and glargine 100 units/mL) or 2-4 units once or twice per week (NPH, insulin detemir, glargine 100 and 300 units/mL, and degludec) until FPG levels remain consistently within the target range 3.
• Insulin dose can be increased as required up to approximately 0.5-1.0 units/kg/day in some cases 3.

Patient Education and Support

• Patients require education for blood glucose monitoring, healthy diet, exercise, and identifying and responding to hypoglycemia 5, 6, 7.
• Insulin initiation requires a specific educational program for the acceptance of injection and to learn insulin injection, capillary blood glucose test, and adjustment of insulin regimens 6.
• The diabetes nurse practitioner should encourage patients to initiate insulin when appropriate and help patients overcome barriers, including fears of injection pain, public embarrassment, and hypoglycemia risk 7.