What is the recommended initial dose and regimen for initiating insulin therapy?

Initial Insulin Therapy Dosing and Regimen

For patients with type 2 diabetes requiring insulin therapy, basal insulin should be initiated at 10 units per day or 0.1-0.2 units/kg/day, depending on the degree of hyperglycemia. 1

Basal Insulin Initiation

• Basal insulin alone is the most convenient initial insulin regimen for most patients with type 2 diabetes 1
• Initial dosing options:
  • Fixed dose: 10 units per day 1
  • Weight-based dose: 0.1-0.2 units/kg/day 1, 2
• Basal insulin is typically prescribed in conjunction with metformin and possibly one additional non-insulin agent 1
• Preferred basal insulin options include long-acting analogs such as glargine, detemir, or degludec 1

Special Circumstances for Initial Insulin Regimen

• Consider starting insulin therapy when:
  • HbA1c is ≥9% 1
  • Blood glucose levels are ≥300-350 mg/dL (16.7-19.4 mmol/L) 1
  • HbA1c is 10-12% with symptomatic or catabolic features 1
• For severe hyperglycemia with symptoms, consider basal insulin plus mealtime insulin as the initial regimen 1

Titration of Basal Insulin

• Once insulin therapy is initiated, timely dose titration is important 1
• Adjustments should be based on self-monitored blood glucose (SMBG) levels 1
• Titration options:
  • Increase by 1 unit per day until target fasting glucose is reached 3
  • Increase by 2-4 units once or twice per week until target is reached 3
• Equipping patients with a self-titration algorithm improves glycemic control 1
• Target fasting glucose range is typically 80-130 mg/dL 3

When to Consider Adding Mealtime Insulin

• When basal insulin has been titrated to appropriate fasting blood glucose levels but HbA1c remains above target 1
• Options for adding mealtime coverage:
  • Add a GLP-1 receptor agonist 1
  • Add 1-3 injections of rapid-acting insulin (lispro, aspart, or glulisine) before meals 1
  • Starting dose for mealtime insulin: 4 units, 0.1 units/kg, or 10% of the basal dose 1
• Twice-daily premixed insulin analogues (70/30 aspart mix or 75/25 or 50/50 lispro mix) may also be considered 1

Medication Management with Insulin Initiation

• Metformin should generally be continued when initiating insulin 1
• When using more complex insulin regimens beyond basal insulin:
  • Sulfonylureas, DPP-4 inhibitors, and GLP-1 receptor agonists are typically discontinued 1
  • Thiazolidinediones or SGLT2 inhibitors may be continued to improve glucose control and reduce total daily insulin dose 1

Common Pitfalls to Avoid

• Delaying insulin therapy in patients not achieving glycemic goals 1
• Using insulin as a threat or describing it as a sign of personal failure 1, 4
• Overbasalization (continuing to escalate basal insulin dose beyond 0.5-1.0 units/kg/day without meaningful reduction in fasting plasma glucose) 4, 3
• Inadequate patient education on self-monitoring, diet, and hypoglycemia management 1, 4

Patient Education

• Comprehensive education regarding self-monitoring of blood glucose is critically important 1
• Provide guidance on diet and exercise 1
• Educate on recognition, prevention, and treatment of hypoglycemia 1, 4
• Explain the progressive nature of type 2 diabetes and the role of insulin therapy 1, 4

Remember that insulin therapy should not be delayed in patients not achieving glycemic goals, and timely dose titration based on blood glucose monitoring is essential for optimal outcomes 1.