Is 30 units of regular (short-acting) insulin twice a day, in addition to long-acting insulin with a sliding scale, an effective regimen for managing my blood glucose levels?

From the Guidelines

I strongly advise against using 30 units of regular insulin twice a day, in addition to long-acting insulin with a sliding scale, without consulting your healthcare provider to evaluate and adjust your current regimen based on your individual needs and glucose patterns. Insulin regimens must be tailored to each patient's specific situation, taking into account their weight, insulin sensitivity, meal patterns, activity level, and blood glucose patterns 1. The use of regular insulin, which has a slower onset and longer duration than rapid-acting analogs, may not be the most effective choice for managing blood glucose levels, especially when considering the potential for hypoglycemia and the importance of mimicking natural insulin patterns 1.

Key Considerations

• Regular insulin has a slower onset (30-60 minutes) and longer duration (6-8 hours) than rapid-acting analogs like lispro or aspart, which can make timing with meals challenging 1.
• Fixed twice-daily dosing may not accommodate varying meal sizes or timing, and may lead to inadequate blood glucose control or increased risk of hypoglycemia 1.
• Modern diabetes management often favors basal-bolus regimens that better mimic natural insulin patterns, and individualized regimens should be based on patient-specific factors such as weight, insulin sensitivity, and lifestyle 1.

Recommendations

• Consult your healthcare provider to evaluate your current regimen and determine if adjustments are needed for optimal blood glucose control and to minimize hypoglycemia risk 1.
• Consider using a basal-bolus regimen with rapid-acting analogs, which may provide more flexibility and better mimic natural insulin patterns 1.
• Use a simplified sliding scale, such as the one recommended in the 2024 standards of care in diabetes, which suggests giving 2 units of short- or rapid-acting insulin for premeal glucose >250 mg/dL (>13.9 mmol/L) and 4 units for premeal glucose >350 mg/dL (>19.4 mmol/L) 1.

From the FDA Drug Label

Type 1 Diabetes – Adult In one non-blinded clinical study (Study A, n=409), adult patients with type 1 diabetes were randomized to treatment with either LEVEMIR at 12-hour intervals, LEVEMIR morning and bedtime or NPH human insulin morning and bedtime. Insulin aspart was also administered before each meal Table 1: Efficacy and Insulin Dosage in Type 1 Diabetes Mellitus - Adult Daily Basal Insulin Dose (U/kg) Prestudy mean 0.360.39 End of study mean0.490.45 Daily Bolus Insulin Dose (U/kg) Prestudy mean0.400.40 End of study mean0.380. 38

The FDA drug label does not provide specific information about the effectiveness of a regimen consisting of 30 units of regular insulin twice a day in addition to long-acting insulin with a sliding scale. Key points to consider when evaluating insulin regimens include:

• Basal insulin dose: The label reports prestudy and end-of-study mean basal insulin doses in units per kilogram (U/kg) for patients with type 1 diabetes.
• Bolus insulin dose: The label also reports prestudy and end-of-study mean bolus insulin doses in U/kg for patients with type 1 diabetes. However, without direct information on the specific regimen in question, no conclusion can be drawn about its effectiveness. 2

From the Research

Insulin Regimen Effectiveness

• The effectiveness of an insulin regimen, such as 30 units of regular insulin twice a day in addition to long-acting insulin with a sliding scale, depends on various factors, including the individual's type of diabetes, lifestyle, and glucose monitoring results 3, 4.
• Studies suggest that a personalized approach to insulin therapy, taking into account the patient's specific needs and glucose patterns, is crucial for achieving optimal glycemic control 5, 6.
• The use of sliding scales, such as the 1500 or 1800 rule, can help patients adjust their insulin doses based on their blood glucose levels, allowing for more flexible and effective management of their diabetes 4.

Hypoglycemia Risk and Management

• Hypoglycemia is a common side effect of insulin therapy, and its risk can be increased with tight glucose control 5, 6.
• To minimize the risk of hypoglycemia, patients should be educated on how to recognize its symptoms, monitor their blood glucose levels regularly, and adjust their insulin doses accordingly 3, 4.
• The development of glucose-responsive insulin delivery devices may help mitigate the risk of hypoglycemia and improve patient compliance with insulin therapy 7.

Individualized Insulin Therapy

• Individualized insulin therapy, which takes into account the patient's lifestyle, diet, and physical activity, is essential for achieving optimal glycemic control 3, 4.
• Patients should be empowered to take an active role in their diabetes management by learning how to adjust their insulin regimen based on their glucose monitoring results and other factors 4.
• A team-based approach to diabetes care, involving healthcare providers, diabetes educators, and dietitians, can help patients develop a personalized insulin management plan that meets their unique needs 4.