What is the initial insulin dose for a patient with type 2 diabetes and a glucose level of 15.30 mmol/l?

Initial Insulin Dosing for Type 2 Diabetes with Severe Hyperglycemia

For a patient with type 2 diabetes and a glucose level of 15.30 mmol/l, the initial insulin dose should be 10 units of basal insulin or 0.1-0.2 units/kg of body weight. 1

Insulin Initiation Algorithm

Step 1: Determine Need for Insulin

• Glucose level of 15.30 mmol/l (276 mg/dl) exceeds the threshold of 180 mg/dl (10.0 mmol/l) for initiating insulin therapy 1
• This level indicates significant hyperglycemia requiring immediate intervention

Step 2: Select Insulin Regimen

• Basal insulin alone is the most convenient initial insulin regimen for type 2 diabetes 1
• Options include:
  • NPH insulin (more affordable option)
  • Long-acting analogs (glargine, detemir, degludec) with less hypoglycemia risk

Step 3: Calculate Initial Dose

• Starting dose options:
  • Fixed dose: 10 units daily 1
  • Weight-based: 0.1-0.2 units/kg daily 1
  • For example, for a 70kg patient: 7-14 units daily

Step 4: Titration Plan

• Increase dose by 10-15% or 2-4 units once or twice weekly until fasting blood glucose target is reached 1
• Target glucose range: 140-180 mg/dl (7.8-10.0 mmol/l) 1, 2
• More stringent goals of 110-140 mg/dl (6.1-7.8 mmol/l) may be appropriate for selected patients if achievable without significant hypoglycemia 1

Monitoring and Adjustment

• Monitor blood glucose regularly, ideally before meals and at bedtime
• Equip patient with self-titration algorithm based on self-monitoring of blood glucose (SMBG) to improve glycemic control 1
• If basal insulin alone doesn't achieve target A1C despite acceptable fasting glucose, consider advancing to combination therapy 1

Important Considerations

Concurrent Medications

• Continue metformin if not contraindicated 1
• Consider discontinuing sulfonylureas, DPP-4 inhibitors, and GLP-1 receptor agonists when more complex insulin regimens are used 1

Hypoglycemia Prevention

• Educate patient on hypoglycemia recognition and treatment
• Provide comprehensive education on SMBG, diet, and exercise 1
• Monitor for hypoglycemic events, especially when initiating insulin therapy

Common Pitfalls to Avoid

1. Relying solely on sliding scale insulin, which is strongly discouraged 2
2. Delaying insulin initiation when clearly indicated by severe hyperglycemia
3. Inadequate patient education on insulin administration and hypoglycemia management
4. Failing to adjust insulin doses based on glucose patterns

By following this structured approach to insulin initiation, the patient's severe hyperglycemia can be effectively managed while minimizing the risk of complications associated with prolonged hyperglycemia, such as diabetic ketoacidosis or hyperosmolar hyperglycemic state.