From the Guidelines
The evening dose of long-acting insulin should be adjusted based on fasting fingerstick glucose test results, with a goal of achieving a fasting glucose level between 90-150 mg/dL. When the total daily dose of short-acting insulin exceeds the maximum recommended dose, it may indicate inadequate basal insulin coverage. To adjust the evening dose of long-acting insulin, I recommend the following steps:
- Change the timing of the basal insulin from bedtime to morning, as suggested by 1 and 1.
- Titrate the dose of basal insulin based on fasting fingerstick glucose test results over a week, increasing the dose by 2 units if 50% of the fasting fingerstick glucose values are over the goal, and decreasing the dose by 2 units if more than 2 fasting fingerstick values per week are less than 80 mg/dL, as recommended by 1 and 1.
- Consider adding noninsulin agents, such as metformin, if the patient's eGFR is 45 mg/dL or higher, and titrate the dose every 2 weeks as tolerated, as suggested by 1 and 1.
- Monitor blood glucose levels frequently, particularly for nocturnal hypoglycemia, and have a hypoglycemia treatment plan in place, as recommended by 1 and 1. The goal of these adjustments is to achieve better baseline glucose control with the long-acting insulin, reducing the need for frequent correction with short-acting insulin, as supported by the most recent and highest quality study 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Adjusting Evening Dose of Long-Acting Insulin
When the total daily dose of short-acting insulin exceeds the maximum recommended dose, adjustments to the evening dose of long-acting insulin may be necessary. The following points should be considered:
- There is no direct evidence from the provided studies on how to adjust the evening dose of long-acting insulin when the total daily dose of short-acting insulin exceeds the maximum recommended dose.
- However, studies have compared the efficacy and safety of different long-acting insulin analogues, such as glargine and detemir, in the management of hyperglycemia and diabetes 2, 3.
- These studies suggest that glargine and detemir have similar effects on glycemic control, but may differ in terms of dosing frequency and weight gain 2, 3.
- The use of short-acting insulin analogues, such as aspart or lispro, may also be considered to improve postprandial glucose control and reduce hypoglycemia 4.
- In general, the adjustment of insulin doses should be individualized based on the patient's specific needs and response to treatment, and may involve a combination of basal and prandial insulin therapy 5, 6.
Key Considerations
- The choice of long-acting insulin analogue and dosing frequency may depend on the patient's lifestyle and preferences 3.
- The use of computer decision support systems and communication with the primary care physician can help optimize insulin therapy and reduce the risk of errors 6.
- Regular monitoring of blood glucose levels and adjustment of insulin doses as needed can help achieve optimal glycemic control and minimize the risk of hypoglycemia 4.