From the Guidelines
A reasonable approach to writing a regimen for mealtime and basal insulin involves using a combination of long-acting insulin for basal coverage and rapid-acting insulin for mealtime needs, with adjustments based on blood glucose levels and the pharmacodynamic profile of each formulation, as recommended by the 2017 American Diabetes Association standards of medical care in diabetes 1.
Key Considerations
- For basal insulin, start with once-daily insulin glargine (Lantus), insulin detemir (Levemir), or insulin degludec (Tresiba) at 0.1-0.2 units/kg/day, typically administered at bedtime.
- For mealtime coverage, use rapid-acting insulins like insulin lispro (Humalog), insulin aspart (NovoLog), or insulin glulisine (Apidra) starting at approximately 0.05-0.1 units/kg per meal or 1 unit per 10-15 grams of carbohydrates consumed.
- Adjust the basal dose by 10-20% every 2-3 days based on fasting glucose readings, aiming for 80-130 mg/dL.
- Mealtime insulin should be adjusted based on pre-meal and 2-hour post-meal glucose values, targeting less than 180 mg/dL post-meal.
Adjustments and Intensification
- Dose titration is important, with adjustments necessary in both mealtime and basal insulins based on blood glucose levels and the pharmacodynamic profile of each formulation.
- 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.
- Providers should consider regimen flexibility when devising a plan for the initiation and adjustment of insulin therapy for patients with type 2 diabetes, taking into account the advantages and disadvantages of different approaches, as discussed in the 2017 American Diabetes Association standards of medical care in diabetes 1.
Monitoring and Management
- Regular monitoring of blood glucose, carbohydrate counting, and consideration of physical activity are essential for successful management.
- Hypoglycemia risk increases with insulin therapy, so patients should always have fast-acting glucose available and understand how to recognize and treat low blood sugar.
- The goal of therapy is to achieve optimal glycemic control while minimizing the risk of hypoglycemia and other adverse effects, as recommended by the 2017 American Diabetes Association standards of medical care in diabetes 1.
From the FDA Drug Label
Instruct patients to follow healthcare provider recommendations when setting basal and meal time infusion rate. Individualize the dosage of Insulin Aspart based on the route of administration, the patient’s metabolic needs, blood glucose monitoring results and glycemic control goal. Generally use Insulin Aspart (administered by subcutaneous injection) in regimens with an intermediate- or long-acting insulin.
A reasonable approach to writing a regimen for mealtime insulin and basal insulin is to:
- Individualize the dosage based on the patient's metabolic needs, blood glucose monitoring results, and glycemic control goal.
- Use Insulin Aspart in regimens with an intermediate- or long-acting insulin.
- Follow healthcare provider recommendations when setting basal and meal time infusion rates.
- Consider factors such as physical activity, meal patterns, renal or hepatic function, and acute illness when adjusting the dosage regimen 2.
From the Research
Approach to Writing a Regimen for Mealtime Insulin and Basal Insulin
To write a regimen for mealtime insulin and basal insulin, several factors must be considered, including the type of diabetes, the patient's lifestyle, and their individual insulin needs.
- The regimen should be tailored to the patient's specific needs, taking into account their diet, physical activity level, and other health factors.
- Basal insulin, which is typically administered once or twice a day, should be adjusted to achieve a target fasting blood glucose level 3.
- Mealtime insulin, which is administered before meals, should be adjusted based on the patient's blood glucose levels, the amount of carbohydrates they consume, and their physical activity level 3.
Initiating and Titrating Basal Insulin
When initiating basal insulin, a conservative dose of 10 units/day or 0.1-0.2 units/kg/day is recommended, with titration based on the patient's self-measured fasting plasma glucose levels 4.
- The goal of titration is to achieve an individualized target fasting plasma glucose level, usually between 80-130 mg/dL 4.
- The dose of basal insulin should be increased as needed, up to approximately 0.5-1.0 units/kg/day in some cases, while avoiding overbasalization 4.
Choosing the Right Basal Insulin
The choice of basal insulin depends on several factors, including the patient's lifestyle, their ability to administer injections, and their individual insulin needs.
- Insulin glargine and insulin detemir are two commonly used basal insulins, which have been shown to be effective in achieving glycemic control in patients with type 1 and type 2 diabetes 5, 6, 7.
- The administration of basal insulin can be flexible, with options for once-daily or twice-daily administration, depending on the patient's needs and the specific insulin used 5, 6, 7.
Adjusting Mealtime Insulin
Mealtime insulin should be adjusted based on the patient's blood glucose levels, the amount of carbohydrates they consume, and their physical activity level.