What is the recommended approach for insulin management in patients with diabetes?

Insulin Management in Diabetes

The recommended approach for insulin management in diabetes is a basal-bolus regimen, with basal insulin providing 50% of the total daily insulin requirement and prandial insulin covering the remaining 50%, adjusted based on individual needs. 1

Initial Insulin Dosing

Type 1 Diabetes

• Total daily insulin requirement: 0.4-1.0 units/kg/day 1
• Starting dose for metabolically stable patients: 0.5 units/kg/day 1
• Distribution: 50% basal insulin, 50% prandial insulin 1

Type 2 Diabetes

• For insulin-naive patients: 0.3-0.5 units/kg/day 1
• For patients already on insulin (≥0.6 units/kg/day): Reduce total daily dose by 20% during hospitalization 1
• Starting basal insulin: 10 units/day or 0.1-0.2 units/kg/day 2

Insulin Regimen Selection

Basal Insulin Options

• Long-acting analogs (insulin glargine, insulin detemir, insulin degludec)
  • Advantages: Lower risk of hypoglycemia, more stable glucose levels 1
  • Dosing: Once or twice daily 1
• Intermediate-acting (NPH)
  • More variable absorption profile 1

Prandial Insulin Options

• Rapid-acting analogs (insulin aspart, insulin lispro, insulin glulisine)
  • Advantages: Quicker onset, better postprandial control, less hypoglycemia 1
  • Timing: 0-15 minutes before meals 3
• Short-acting (regular human insulin)
  • Slower onset and longer duration 1

Insulin Regimen Approaches

1. Basal-Bolus Regimen

• Most effective approach for achieving glycemic targets 1, 4
• Components:
  • Basal insulin once or twice daily
  • Rapid-acting insulin before meals
  • Correction doses for hyperglycemia
• Advantages: Better glycemic control, flexibility with meals 4
• Disadvantages: Multiple daily injections, higher risk of hypoglycemia (12-30%) 1

2. Basal-Plus Regimen

• Components:
  • Basal insulin once daily (0.1-0.25 units/kg/day)
  • Correction doses of rapid-acting insulin before meals 1
• Best for: Patients with mild hyperglycemia, decreased oral intake, or surgical patients 1
• Advantages: Similar glycemic control to basal-bolus with fewer injections 5

3. Premixed Insulin

• Not recommended for hospital use due to high risk of hypoglycemia 1
• May be considered for outpatient use in select patients requiring a simpler regimen 3

Insulin Titration and Adjustment

Basal Insulin Titration

• Adjust dose every 3 days based on fasting glucose levels 2
• Target fasting glucose: 80-130 mg/dL 2
• If fasting glucose above target: Increase dose by 2 units 2

Correction Insulin Doses

For high blood glucose levels:

• 150-200 mg/dL: Add 2 units rapid-acting insulin
• 201-250 mg/dL: Add 4 units rapid-acting insulin
• 251-300 mg/dL: Add 6 units rapid-acting insulin

• 300 mg/dL: Add 8 units and notify provider 2

Special Considerations

Elderly Patients

• Start at lower end of dosing range (0.1 units/kg) 2
• Titrate more cautiously 2
• Consider less stringent glycemic targets (HbA1c <8%) 2

Renal Impairment

• Increased risk of hypoglycemia due to decreased insulin clearance 2
• Adjust insulin requirements as needed 6, 7

Hepatic Impairment

• May require dose adjustments 6, 7

Insulin Administration Technique

• Use subcutaneous injection, avoid intramuscular administration 2
• Recommended sites: abdomen, thigh, buttock, upper arm 2
• Rotate injection sites to prevent lipohypertrophy 2, 7
• Use shortest needles available (4-mm pen needles) 2, 3

Hypoglycemia Management

• Primary risk of insulin therapy: hypoglycemia 6, 7
• Risk factors: renal impairment, hepatic impairment, poor oral intake, elderly 7
• Prevention strategies:
  • Regular blood glucose monitoring
  • Appropriate insulin dose adjustment
  • Patient education on recognition and treatment 2
• Treatment: Quick-acting carbohydrates; prescribe glucagon for emergency use 2

Common Pitfalls to Avoid

1. Using sliding scale insulin alone - Ineffective and associated with poor glycemic control 1
2. Abrupt discontinuation of oral medications when starting insulin - Risk of rebound hyperglycemia 3
3. Intramuscular injection - Risk of severe hypoglycemia, especially with long-acting insulins 3
4. Failure to adjust for decreased oral intake - Increased risk of hypoglycemia 1
5. Inappropriate storage of insulin - Should be refrigerated (36-46°F) when unopened 2

By following these guidelines for insulin management, clinicians can effectively control blood glucose levels while minimizing the risks of hypoglycemia and other complications, ultimately improving morbidity, mortality, and quality of life outcomes for patients with diabetes.