Basal Insulin Recommendations for Patients with Diabetes
For patients with diabetes, long-acting basal insulin analogs (U-300 glargine or degludec) are recommended as they confer a lower hypoglycemia risk compared to older insulins while providing effective glycemic control. 1
Types of Basal Insulin Options
Preferred Options:
- Longer-acting basal analogs:
- Insulin glargine U-300
- Insulin degludec
Alternative Options:
- Standard long-acting analogs:
- Insulin glargine U-100
- Insulin detemir
- Intermediate-acting:
- NPH insulin (human)
Advantages of Newer Basal Insulins
The newer, longer-acting basal insulin analogs (U-300 glargine and degludec) offer several advantages:
- More stable glucose-lowering effect with less variability
- Reduced risk of hypoglycemia, especially nocturnal hypoglycemia 1
- More physiologic basal insulin coverage with no pronounced peak 2
- Greater flexibility in timing of administration
- Once-daily dosing for most patients
Initial Dosing and Titration
When initiating basal insulin:
- Starting dose: 0.1-0.2 units/kg/day or 10 units daily 1
- For patients with type 2 diabetes, basal insulin can be added to metformin and other oral agents 1
- For patients with type 1 diabetes, approximately 50% of total daily insulin should be basal insulin 1
Titration should be individualized based on fasting blood glucose levels, with gradual increases of 2-4 units once or twice weekly until target fasting glucose (typically 80-130 mg/dL) is achieved 3.
Special Considerations
Type 1 Diabetes
- Basal insulin should be combined with prandial insulin
- Long-acting analogs are preferred over NPH due to reduced hypoglycemia risk 1
Type 2 Diabetes
- Can start with basal insulin alone added to oral medications
- If A1C remains above target despite optimized basal insulin, consider advancing to combination injectable therapy 1
Hospitalized Patients
- For patients receiving enteral/parenteral nutrition, NPH insulin every 8 or 12 hours may be appropriate 1
- For patients on glucocorticoids, NPH insulin may be preferred when using intermediate-acting steroids due to its peak action matching steroid effect 1
Common Pitfalls to Avoid
Overbasalization: Continuing to escalate basal insulin dose without meaningful reduction in fasting glucose. Consider adding prandial insulin or other agents instead 3.
Inappropriate timing: Failing to adjust administration time based on individual response patterns. Some patients may benefit from morning rather than bedtime administration.
Ignoring hypoglycemia risk factors: Older adults, those with renal insufficiency, or patients with inconsistent oral intake require lower initial doses 4.
Cost barriers: Consider cost implications when selecting insulin type. NPH insulin is significantly less expensive than analog insulins but has higher hypoglycemia risk 1.
Cost Considerations
According to 2021 pricing data, there are significant cost differences between basal insulin options 1:
- NPH human insulin: $133-165 per vial
- Glargine follow-on products: $118-261
- Glargine (brand): $272-340
- Detemir: $296-370
- Degludec: $325-407
For patients with cost concerns, NPH insulin remains a viable option despite its less favorable pharmacokinetic profile.
By selecting the appropriate basal insulin based on patient characteristics, risk factors, and treatment goals, optimal glycemic control can be achieved while minimizing hypoglycemia risk.