What is the appropriate dosing for initiating insulin therapy?

From the Guidelines

The appropriate dosing for initiating insulin therapy typically begins with 10 units per day or 0.1-0.2 units/kg per day of basal insulin, with adjustments made every 3 days to reach the target fasting blood glucose level. This approach is supported by the most recent guidelines, including those from the American Diabetes Association 1.

Key Considerations for Insulin Dosing

• For patients with type 2 diabetes, starting with a single daily dose of long-acting insulin at bedtime is often recommended.
• If mealtime coverage is needed, rapid-acting insulin can be added at 4 units or 10% of the basal dose before meals.
• The choice of insulin product should consider cost, as substantial price increases have occurred over the past decade, and intermediate-acting insulin (NPH) may be a more affordable option for some patients 1.
• Regular blood glucose monitoring is essential, with dose adjustments made based on the results to minimize the risk of hypoglycemia and achieve target glucose levels.

Adjusting Insulin Dose

• The dose should be increased by 2 units every 3 days to reach the fasting blood glucose goal without causing hypoglycemia, as recommended by recent standards of care in diabetes 1.
• Providers should assess the adequacy of the insulin dose at every visit and consider clinical signals to evaluate for overbasalization and the need for adjunctive therapies.

Special Considerations

• Concentrated insulin preparations, such as U-500 regular insulin, are available for patients requiring more than 200 units of insulin per day, offering both prandial and basal properties 1.
• Premixed insulin products containing both basal and bolus insulin can simplify dosing for some patients but require a relatively fixed meal schedule and carbohydrate content per meal.

From the FDA Drug Label

It delivers doses in 2-unit increments and can deliver up to 160 units in a single injection. It is recommended for patients requiring at least 20 units per day. The recommended starting dose of TOUJEO in insulin-naive patients with type 1 diabetes is approximately one-third to one-half of the total daily insulin dose The recommended starting dose of TOUJEO in insulin-naive patients with type 2 diabetes is 0.2 units per kilogram of body weight once daily. For patients currently on once-daily long or intermediate-acting insulin, start TOUJEO at the same unit dose as the once-daily long-acting insulin dose.

The appropriate dosing for initiating insulin therapy with TOUJEO is as follows:

• For insulin-naive patients with type 1 diabetes: approximately one-third to one-half of the total daily insulin dose, with the remainder given as short-acting insulin.
• For insulin-naive patients with type 2 diabetes: 0.2 units per kilogram of body weight once daily.
• For patients already on insulin therapy, the starting dose of TOUJEO depends on the current insulin regimen, with possible adjustments needed to lower the risk of hypoglycemia 2. Key points to consider when initiating insulin therapy with TOUJEO include:
• Starting with the correct dose based on the patient's metabolic needs and current insulin regimen
• Monitoring glucose daily, especially in the first weeks of therapy
• Titrating the dose no more frequently than every 3 to 4 days to minimize the risk of hypoglycemia or hyperglycemia.

From the Research

Initiating Insulin Therapy

The appropriate dosing for initiating insulin therapy can be determined based on several factors, including the type of diabetes, the patient's current medication regimen, and their individual needs.

• The starting dose of insulin can vary depending on the specific type of insulin and the patient's requirements, with a typical starting dose of 0.15 units per kg per day for augmentation or 0.5 units per kg per day for replacement 3.
• Insulin therapy can be initiated with either basal insulin, which is injected once or twice a day, or bolus insulin, which is injected before meals to cover mealtime carbohydrates and correct current glucose levels 3.

Types of Insulin

There are several types of insulin available, each with its own unique characteristics and uses.

• Basal insulin, such as neutral protamine Hagedorn (NPH), ultralente, and glargine, is injected once or twice a day to provide a steady background level of insulin throughout the day 3.
• Bolus insulin, such as regular, aspart, and lispro, is injected before meals to cover mealtime carbohydrates and correct current glucose levels 3.
• Insulin detemir is a long-acting insulin analogue that can be injected once or twice a day, and has been shown to be comparable to insulin glargine in providing glycaemic control over 24 hours in patients with type 2 diabetes 4.

Adjusting Insulin Doses

Insulin doses may need to be adjusted over time to achieve optimal glycaemic control.

• Adjustments should be made systematically, starting with the fasting, then the preprandial, and finally the postprandial glucose levels 3.
• The mealtime dose is the sum of the corrective dose plus the anticipated requirements for the meal and exercise 3.
• It is also important to note that switching from one type of insulin to another, such as from insulin glargine to insulin detemir, can result in changes to glycaemic control and may require adjustments to the insulin dose 5.

Clinical Trials

Several clinical trials have been conducted to compare the efficacy and safety of different types of insulin.

• A randomized trial comparing the addition of insulin glargine to conventional therapy with oral agents found that insulin glargine was more likely to achieve a lower HbA1c level than conventional therapy 6.
• A study comparing insulin detemir to NPH insulin found that insulin detemir was well tolerated and provided similar glycosylated hemoglobin values to NPH insulin 7.