What is the initial dosing strategy for starting insulin basal therapy in gestational diabetes?

From the Guidelines

The initial dosing strategy for starting insulin basal therapy in gestational diabetes should begin with 10 units per day or 0.1-0.2 units/kg per day, as recommended by the most recent guidelines 1. When initiating insulin basal therapy, it is essential to set a fasting plasma glucose (FPG) goal and choose an evidence-based titration algorithm, such as increasing the dose by 2 units every 3 days to reach the FPG goal without hypoglycemia 1. Key considerations for insulin dosing include:

• Starting dose: 10 units per day or 0.1-0.2 units/kg per day 1
• Titration algorithm: increase dose by 2 units every 3 days to reach FPG goal without hypoglycemia 1
• Monitoring: assess adequacy of insulin dose at every visit and evaluate for clinical signals of overbasalization, such as elevated bedtime-to-morning and/or postprandial-to-preprandial differential, hypoglycemia, or high glucose variability 1 The most recent guidelines from 2025 1 provide the best approach for initiating insulin basal therapy in gestational diabetes, and their recommendations should be prioritized over older guidelines, such as those from 2022 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initial Dosing Strategy for Insulin Basal Therapy in Gestational Diabetes

• The initial dosing strategy for starting insulin basal therapy in gestational diabetes is not explicitly stated in the provided studies, but it can be inferred that a personalized approach is necessary due to individual heterogeneity in defects of insulin secretion or sensitivity 2.
• A patient-led, daily insulin dose titration algorithm can be used to improve fasting glycemic control in gestational diabetes, with a recommended daily four-unit dose increase after every fasting glucose value ≥5.0 mmol/mol (90 mg/dl) 3.
• Insulin analogues, such as detemir and aspart, have been shown to be safe and effective in pregnancy, and can be used as an alternative to human insulin 4, 5.

Factors to Consider When Initiating Insulin Basal Therapy

• Individual patient characteristics, such as glycemic profiles, nutritional intake, physical activity, and cultural habits, should be taken into account when initiating insulin basal therapy 2.
• The type of insulin used and the method of insulin administration should be carefully considered, with options including human insulin, analogue insulins, and continuous subcutaneous insulin administration (CSII) or intensive insulin injection therapy (MDI) 5.
• The risk of hypoglycemia should be carefully monitored and managed, particularly during the first trimester and after delivery, especially in women who breastfeed 5.

Glycemic Control and Outcomes

• Tight glycemic control is essential to achieve the best possible outcome of a pregnancy complicated by diabetes, and can be achieved through a combination of insulin therapy, dietary changes, and lifestyle modifications 2, 6, 5.
• Studies have shown that metformin can be an effective alternative to insulin in achieving glycemic control and improving obstetrical and perinatal outcomes in women with gestational diabetes 6.
• Patient-led daily insulin titration can lead to higher insulin dose use, lower fasting glucose, and improved glycemic control, without causing significant hypoglycemia 3.