What is the recommended initial insulin therapy regimen for patients with diabetes?

Initial Insulin Therapy for Patients with Diabetes

The recommended initial insulin therapy regimen for patients with diabetes is basal insulin at a starting dose of 0.1-0.2 units/kg/day or 10 units once daily for type 2 diabetes, with the addition of prandial insulin for type 1 diabetes. 1

Initial Insulin Regimen Selection

Type 2 Diabetes

• Starting dose: 0.2 units/kg or up to 10 units once daily 1, 2
• Administration timing: Once daily at any time of day, but at the same time every day 2
• Preferred insulin: Long-acting basal insulin analog (glargine, detemir, or degludec) 1
• Titration: Increase dose by 2 units every 3 days until fasting plasma glucose target is reached without hypoglycemia 1

Type 1 Diabetes

• Starting dose: Approximately one-third of total daily insulin requirements as basal insulin (typically 0.4-1.0 units/kg/day total, with higher doses often required following ketoacidosis) 1, 2
• Regimen structure: Multiple daily injections (MDI) combining basal and prandial insulin or continuous subcutaneous insulin infusion (CSII) 1
• Prandial insulin: Short-acting insulin must be used concomitantly with basal insulin 2

Basal Insulin Options

Long-acting insulin analogs are preferred due to:

• Lower risk of hypoglycemia compared to NPH insulin 1, 3
• More stable glucose levels with less pronounced peaks 3
• Once-daily dosing in most cases 1

Advancing Beyond Basal Insulin

If basal insulin has been titrated to an acceptable fasting blood glucose level (or if dose exceeds 0.5 units/kg/day) and HbA1c remains above target:

1. For mild hyperglycemia: Consider a basal-plus approach with a single dose of basal insulin (0.1-0.25 units/kg/day) along with corrective doses of rapid-acting insulin before meals 4

2. For more significant hyperglycemia: Implement a full basal-bolus regimen with:

   • Basal insulin once or twice daily
   • Rapid-acting insulin before meals
   • Correction doses for hyperglycemia 4, 1

3. Starting mealtime insulin: Begin with 4 units, 0.1 units/kg, or 10% of the basal dose 4

Important Considerations

• Avoid sliding scale insulin alone as it's ineffective, especially in type 1 diabetes 4
• Monitor for hypoglycemia risk, particularly in older patients (>65 years), those with renal failure, and those with poor oral intake 4
• Premixed insulin therapy (70/30) is generally not recommended for hospital use due to high hypoglycemia risk 4
• Injection technique: Administer subcutaneously into abdomen, thigh, or deltoid; rotate sites to prevent lipodystrophy 2
• Blood glucose monitoring: Check before breakfast daily during titration; additional checks before other meals may be considered 1

Special Situations

• Patients with decreased kidney function: Require more frequent monitoring (every 3-6 months) 1
• Patients on glucocorticoids: May need higher insulin doses, with 75% allocated to prandial insulin and 25% to basal insulin 4
• Patients with poor oral intake: Consider a basal-plus approach rather than full basal-bolus regimen 4

By following these guidelines for initial insulin therapy, clinicians can effectively manage hyperglycemia while minimizing the risk of hypoglycemia, ultimately improving morbidity, mortality, and quality of life outcomes for patients with diabetes.