What is a reasonable starting dose of basal insulin for a patient with severe hyperglycemia (A1c of 16.1)?

From the Guidelines

A reasonable starting dose of basal insulin for a patient with severe hyperglycemia (A1c of 16.1%) is 0.1-0.2 units/kg of body weight per day, as recommended by the most recent guidelines 1. For example, a 70 kg patient would start with approximately 7-14 units of basal insulin daily.

• Insulin glargine (Lantus), insulin detemir (Levemir), or insulin degludec (Tresiba) are appropriate basal insulin options, typically administered once daily.
• Given the severely elevated A1c, consider also adding mealtime (bolus) insulin such as insulin lispro, aspart, or regular insulin at 0.1-0.2 units/kg/meal.
• Start with the lower end of the dosing range if the patient is elderly, has renal impairment, or is at high risk for hypoglycemia.
• The patient should monitor blood glucose levels at least 4 times daily initially and adjust insulin doses every 2-3 days based on patterns, as suggested by recent guidelines 1.
• Educate the patient about hypoglycemia symptoms and management, including having glucose tablets or juice readily available. This approach provides 24-hour insulin coverage while addressing the severe hyperglycemia, allowing gradual improvement in glycemic control while minimizing hypoglycemia risk, which is in line with the recommendations from the American Diabetes Association 1.

From the Research

Basal Insulin Dosing for Severe Hyperglycemia

To determine a reasonable starting dose of basal insulin for a patient with an A1c of 16.1, we must consider the available evidence.

• The provided studies do not directly address the specific dosing of basal insulin for a patient with an A1c of 16.1 2, 3, 4, 5, 6.
• However, the study by 6 investigated the initiation of basal insulin in patients with type 2 diabetes on oral antidiabetic treatment and outcomes in patients with varying levels of glycemic control at baseline.
• In this study, patients with a pre-insulin HbA1c >9% had the largest HbA1c reduction (-2.4%) after initiation of once-daily insulin detemir.
• The study does not provide a specific starting dose of basal insulin, but it suggests that patients with higher baseline HbA1c levels may require more aggressive insulin therapy.

Considerations for Basal Insulin Initiation

When initiating basal insulin in a patient with severe hyperglycemia (A1c of 16.1), the following considerations should be taken into account:

• The patient's current medication regimen and any potential interactions with insulin
• The patient's lifestyle, including diet and physical activity level
• The patient's ability to self-monitor blood glucose levels and adjust insulin doses as needed
• The potential for hypoglycemia and the need for close monitoring of blood glucose levels

Potential Starting Dose

While there is no specific guidance on the starting dose of basal insulin for a patient with an A1c of 16.1, a common starting dose for once-daily basal insulin is 10 units per day, with adjustments made based on the patient's response to therapy 6. However, this dose may need to be adjusted based on the patient's individual needs and response to therapy.

It is essential to consult with a healthcare professional to determine the best course of treatment for a patient with severe hyperglycemia.