What is a reasonable starting dose of Insulin (insulin glargine) for a patient with newly diagnosed Type 2 diabetes and a history of hemorrhagic stroke?

From the Guidelines

A reasonable starting dose of insulin glargine for a patient with newly diagnosed Type 2 diabetes and a history of hemorrhagic stroke is 0.1-0.2 units/kg/day, typically given once daily at bedtime. For example, a 70 kg patient might start with 7-14 units per day. This conservative approach is particularly important in patients with a history of hemorrhagic stroke, as hypoglycemia could potentially increase neurological risk 1. When initiating insulin therapy in this patient population, close blood glucose monitoring is essential, with self-monitoring recommended 1-2 times daily, particularly before breakfast to assess fasting levels. Dose adjustments should be made gradually, typically increasing by 2-4 units every 3-7 days until target fasting glucose levels of 80-130 mg/dL are achieved.

Some key considerations when managing hyperglycemia in patients with a history of stroke include:

• Avoiding hypoglycemia, which can have severe consequences in this patient population 1
• Monitoring glucose levels closely to adjust insulin doses as needed
• Educating patients about hypoglycemia symptoms and management, including keeping fast-acting carbohydrates readily available
• Considering a multidisciplinary approach involving endocrinology and neurology input to balance glycemic control with neurological safety in this high-risk patient.

It's also important to note that metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes, and insulin should be added to metformin if necessary, as stated in the standards of medical care in diabetes-2019 1. However, in patients with a history of hemorrhagic stroke, the primary concern is to avoid hypoglycemia while maintaining adequate glycemic control, making insulin glargine a suitable option when initiated at a conservative dose and closely monitored.

From the FDA Drug Label

2.3 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 starting dose of Insulin Glargine for a patient with newly diagnosed Type 2 diabetes is 0.2 units/kg or up to 10 units once daily. There is no specific guidance in the label regarding dose adjustments for patients with a history of hemorrhagic stroke, so the standard starting dose should be used with close medical supervision and monitoring for any potential issues. 2

From the Research

Insulin Glargine Starting Dose for Newly Diagnosed Type 2 Diabetes with Hemorrhagic Stroke

• The starting dose of insulin glargine for patients with newly diagnosed Type 2 diabetes and a history of hemorrhagic stroke is not directly addressed in the provided studies 3, 4, 5, 6, 7.
• However, study 3 compared three algorithms for initiation and titration of insulin glargine in insulin-naive patients with Type 2 diabetes mellitus, suggesting that simpler algorithms may result in lower rates of hypoglycemia.
• Study 4 investigated the effects of insulin glargine versus metformin on glycemic variability, microvascular, and beta-cell function in early Type 2 diabetes, but did not provide specific guidance on starting doses for patients with a history of hemorrhagic stroke.
• Study 5 examined the influence of fasting glucose levels on achieving glycemic targets in individuals with Type 2 diabetes, but did not address the specific population of interest.
• Study 6 demonstrated that chronic reduction of fasting glycemia with insulin glargine improves first- and second-phase insulin secretion in patients with Type 2 diabetes, but did not provide information on starting doses.
• Study 7 compared the impact of hyperglycemia on ischemic and hemorrhagic stroke incidence using fasting and 2-hour glucose criteria, but did not address insulin glargine starting doses.
• In general, the starting dose of insulin glargine is typically individualized based on the patient's specific needs and clinical characteristics, and may need to be adjusted over time to achieve optimal glycemic control 3, 4, 5, 6.
• It is essential to consider the patient's medical history, including their history of hemorrhagic stroke, when determining the starting dose of insulin glargine 7.