What is the recommended initial insulin dosing regimen for a type 2 diabetic patient?

From the Guidelines

The recommended initial insulin dosing regimen for a type 2 diabetic patient typically starts with basal insulin, usually 0.1-0.2 units/kg/day of long-acting insulin such as insulin glargine, insulin detemir, or insulin degludec, as this approach has been shown to effectively control blood glucose levels while minimizing the risk of hypoglycemia 1.

Key Considerations

• The initial dose of basal insulin should be estimated based on body weight and the degree of hyperglycemia, with individualized titration over days to weeks as needed 1.
• The patient should monitor fasting blood glucose levels daily and adjust the insulin dose by 2-4 units every 3-7 days until the target fasting glucose is achieved 1.
• Long-acting basal analogs, such as U-100 glargine or detemir, have been demonstrated to reduce the risk of level 2 hypoglycemia and nocturnal hypoglycemia compared with NPH insulin 1.
• Clinicians should be aware of the potential for overbasalization with insulin therapy and monitor for clinical signals such as basal dose greater than 0.5 units/kg or high bedtime-to-morning or preprandial-to-postprandial glucose differential 1.

Additional Insulin Therapy

• As diabetes progresses, additional mealtime (prandial) insulin such as insulin lispro, insulin aspart, or regular insulin may be needed, typically starting at 4 units or 0.1 units/kg before meals 1.
• Premixed insulin products containing both basal and bolus insulin are another option for patients who may benefit from simpler dosing, but require a relatively fixed meal schedule and carbohydrate content per meal 1.

Important Reminders

• Comprehensive education regarding self-monitoring of blood glucose, diet, and the avoidance of and appropriate treatment of hypoglycemia are critically important in any patient using insulin 1.
• Cost considerations are important when an insulin product is selected, particularly because of substantial price increases over the past decade 1.

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 initial insulin dosing regimen for a type 2 diabetic patient is 0.2 units/kg or up to 10 units once daily, as stated in the Insulin Glargine drug label 2.

• Key points:
  • The dosage is individualized based on the patient's metabolic needs and glycemic control goal.
  • Dosage adjustments may be needed with changes in physical activity, meal patterns, or renal or hepatic function.
  • The patient's blood glucose monitoring results should be used to adjust the dosage under medical supervision.

From the Research

Initial Insulin Dosing Regimen for Type 2 Diabetic Patients

The recommended initial insulin dosing regimen for type 2 diabetic patients can vary depending on several factors, including the patient's current glucose levels, weight, and other health conditions.

• The starting dose of insulin can be around 0.15 units per kg per day for augmentation or 0.5 units per kg per day for replacement, as suggested by 3.
• Another approach is to initiate basal insulin at a conservative dose of 10 units/day or 0.1-0.2 units/kg/day, and then titrate the dose based on the patient's self-measured fasting plasma glucose levels, as recommended by 4.
• The goal of insulin therapy is to achieve a target glycated hemoglobin A1c (HbA1c) level, which is typically < 7.5% for most patients, as stated by 5.

Factors to Consider When Initiating Insulin Therapy

When initiating insulin therapy, several factors need to be considered, including:

• The patient's current glucose levels and HbA1c level
• The patient's weight and body mass index (BMI)
• The presence of any other health conditions, such as kidney or liver disease
• The patient's lifestyle and dietary habits
• The potential risks and benefits of insulin therapy, as discussed by 6 and 7.

Titration of Insulin Dose

The insulin dose should be titrated based on the patient's glucose levels, with the goal of achieving a target HbA1c level.

• The dose can be increased by 1 unit per day (for NPH, insulin detemir, and glargine 100 units/mL) or 2-4 units once or twice per week (for NPH, insulin detemir, glargine 100 and 300 units/mL, and degludec), as suggested by 4.
• The patient's self-measured fasting plasma glucose levels should be used to guide the titration of the insulin dose, as recommended by 5.