What is the recommended starting dose and brand of insulin (e.g. Lantus (insulin glargine), Levemir (insulin detemir), Humalog (insulin lispro), Novolog (insulin aspart)) for initiating insulin therapy?

Starting Insulin Therapy: Dosage and Brand Guidelines

The recommended starting dose for insulin therapy is 10 units per day or 0.1-0.2 units/kg/day of basal insulin, with subsequent dose adjustments of 2 units every 3 days until the fasting glucose target is reached without hypoglycemia. 1, 2

Initial Insulin Selection and Dosing

Basal Insulin Initiation

• Starting dose: 10 units/day or 0.1-0.2 units/kg/day 1, 2
• Timing: Usually administered at bedtime or with evening meal 3
• Titration: Increase by 2 units every 3 days until fasting glucose target is reached 1, 2
• Hypoglycemia management: If hypoglycemia occurs, reduce dose by 10-20% 1, 2

Brand Selection

Long-acting basal insulin analogs are preferred over NPH insulin due to:

• Lower risk of nocturnal hypoglycemia 2, 4
• More stable glucose profile with less pronounced peaks 4
• Options include:
  • Insulin glargine (Lantus): Once-daily dosing, relatively constant basal level 4
  • Insulin detemir (Levemir): Can be administered once or twice daily 3, 5
  • Insulin degludec: Longer duration of action in concentrated formulation (U-200) 1

Titration and Monitoring

Dose Adjustment Algorithm

1. Set fasting plasma glucose (FPG) target (typically 80-130 mg/dL) 2, 6
2. Patient should monitor blood glucose daily during titration phase 2
3. Increase dose by 2 units every 3 days until target is reached 1
4. If hypoglycemia occurs, determine cause and reduce dose by 10-20% 1

Signs of Overbasalization

• Watch for:
  • Basal dose exceeding 0.5 units/kg/day 1
  • Elevated bedtime-to-morning glucose differential 1, 2
  • Nocturnal hypoglycemia 2
  • High glucose variability 2

Advancing Insulin Therapy

When to Add Prandial Insulin

If A1C remains above target despite optimized basal insulin:

• Start with one dose with largest meal or meal with greatest postprandial glucose excursion 1
• Initial prandial dose: 4 units per day or 10% of basal dose 1
• Consider reducing basal dose by 4 units or 10% when adding prandial insulin 1
• Titration: Increase by 1-2 units or 10-15% twice weekly 1

Combination Injectable Therapy

• Consider GLP-1 receptor agonist before adding prandial insulin 1
• Maintain metformin when initiating insulin therapy 1
• Consider fixed-ratio combinations of basal insulin and GLP-1 receptor agonist if appropriate 1

Special Considerations

Cost Factors

• NPH insulin may be a more affordable option for some patients 1
• Consider cost when selecting basal insulin 1

Concentrated Insulin Products

• Available for patients requiring large insulin doses:
  • U-500 regular insulin: For patients requiring >200 units/day 1
  • U-300 glargine and U-200 degludec: Allow higher doses per volume 1

Common Pitfalls to Avoid

• Using insulin as a threat or describing it as a sign of personal failure 1
• Skipping comprehensive education on blood glucose monitoring and hypoglycemia management 1
• Failing to rotate injection sites, which can lead to lipohypertrophy 2
• Not adjusting insulin doses for exercise, which increases insulin sensitivity 2

By following these guidelines, insulin therapy can be safely initiated and titrated to achieve glycemic targets while minimizing the risk of hypoglycemia and other adverse effects.