What is the recommended insulin regimen for daytime insulin coverage?

From the Guidelines

The recommended insulin regimen for daytime insulin coverage typically involves rapid-acting insulin analogs such as insulin lispro, insulin aspart, or insulin glulisine, administered before meals, usually 0-15 minutes prior to eating, with dosing based on carbohydrate counting and pre-meal blood glucose levels. This approach is supported by the American Diabetes Association standards of medical care in diabetes, as outlined in the 2017 guidelines 1. The guidelines suggest that further options for treatment intensification include adding a single injection of rapid-acting insulin analogue before the largest meal, adding a GLP-1–receptor agonist, or stopping basal insulin and starting twice-daily premixed insulin.

Key Considerations

• Rapid-acting insulin offers greater flexibility in meal planning than premixed insulin, as noted in the guidelines 1.
• Basal insulin plus a GLP-1–receptor agonist is associated with weight loss and less hypoglycemia but may be more poorly tolerated and expensive than regimens using insulin alone 1.
• Patients should adjust doses based on pre-meal glucose readings, anticipated carbohydrate intake, planned physical activity, and other factors affecting insulin sensitivity, working with their healthcare provider to fine-tune their insulin-to-carbohydrate ratios and correction factors.

Administration and Dosing

• Administration is usually before breakfast and before dinner.
• A common starting point is 1 unit of insulin for every 10-15 grams of carbohydrates consumed, plus correction doses for elevated blood glucose (typically 1 unit for every 50 mg/dL above target).
• Rapid-acting insulins begin working within 15 minutes, peak in 1-2 hours, and last 3-4 hours, closely mimicking the body's natural insulin response to meals.

Benefits and Risks

• This physiologic profile helps prevent post-meal glucose spikes while reducing the risk of between-meal hypoglycemia.
• Regular insulin and 70/30 NPH/regular insulin mix are less costly alternatives to rapid-acting and premixed insulin analogues, respectively, but their pharmacodynamic profiles may make them suboptimal 1.

From the FDA Drug Label

Insulin Aspart starts acting fast. You should eat a meal within 5 to 10 minutes after you take your dose of Insulin Aspart. The recommended insulin regimen for daytime insulin coverage is to take Insulin Aspart exactly as your healthcare provider tells you to, with the insulin starting to act fast, and a meal should be eaten within 5 to 10 minutes after taking the dose 2.

• Key points:
  • Take Insulin Aspart as directed by your healthcare provider
  • Eat a meal within 5 to 10 minutes after taking Insulin Aspart
  • Monitor blood sugar levels as advised by your healthcare provider

From the Research

Daytime Insulin Coverage

• The recommended insulin regimen for daytime insulin coverage involves the use of rapid-acting or ultra-rapid-acting insulins to control postprandial glucose excursions 3, 4.
• Rapid-acting insulins, such as insulin aspart and insulin lispro, have an earlier onset of action and shorter duration of action compared to regular human insulin, resulting in lower postprandial glucose levels and reduced risk of late postprandial hypoglycemia 5, 6.
• Ultra-rapid-acting insulins, such as ultra-rapid lispro, have an even earlier onset of action and shorter duration of action, providing improved postprandial glucose control without increasing the risk of hypoglycemia 3, 4.
• The choice of insulin regimen for daytime coverage depends on individual patient factors, such as the type of diabetes, lifestyle, and personal preferences, and should be determined through shared decision-making with a healthcare provider 4.
• Insulin pump therapy using rapid-acting insulin analogues, such as insulin aspart, can also be an effective option for daytime insulin coverage, offering improved glycemic control and reduced risk of hypoglycemia compared to multiple daily injections 7.

Types of Insulins for Daytime Coverage

• Rapid-acting insulins:
  • Insulin aspart
  • Insulin lispro
  • Insulin glulisine
• Ultra-rapid-acting insulins:
  • Ultra-rapid lispro
  • Faster aspart
• Insulin pump therapy using rapid-acting insulin analogues, such as insulin aspart, can also be used for daytime coverage 7.

Clinical Implications

• The use of rapid-acting and ultra-rapid-acting insulins for daytime coverage can improve postprandial glucose control and reduce the risk of hypoglycemia 3, 4, 6.
• Insulin pump therapy using rapid-acting insulin analogues can offer improved glycemic control and reduced risk of hypoglycemia compared to multiple daily injections 7.
• The choice of insulin regimen for daytime coverage should be individualized based on patient factors and lifestyle, and should be determined through shared decision-making with a healthcare provider 4.