From the Guidelines
The evening dose of long-acting insulin should be adjusted by changing the timing from bedtime to morning and titrating the dose based on fasting fingerstick glucose test results over a week, as recommended by the most recent guidelines 1. When the total daily dose of short-acting insulin exceeds the maximum recommended dose, it is essential to reassess the patient's insulin regimen to minimize the risk of hypoglycemia and improve glucose control.
- The goal is to achieve a fasting glucose level between 90-150 mg/dL (5.0-8.3 mmol/L) 1.
- If 50% of the fasting fingerstick glucose values are over the goal, the dose should be increased by 2 units 1.
- If more than 2 fasting fingerstick values per week are below 80 mg/dL (4.4 mmol/L), the dose should be decreased by 2 units 1. It is crucial to monitor blood glucose levels closely during the adjustment period, especially overnight, to prevent hypoglycemia and ensure consistent carbohydrate intake with meals.
- Blood glucose should be checked frequently during the titration period, particularly before meals, at bedtime, and occasionally during the night. By adjusting the long-acting insulin dose and timing, healthcare providers can help patients achieve better baseline glucose control, reduce the need for frequent correction doses, and minimize the risk of hypoglycemia and other complications.
- The use of noninsulin agents, such as metformin, may also be considered if the patient's eGFR is ≥45 mg/dL, and the dose should be increased every 2 weeks as tolerated 1.
From the FDA Drug Label
The dose of LEVEMIR should be adjusted according to blood glucose measurements. The dosage of LEVEMIR should be individualized based on the physician’s advice, in accordance with the needs of the patient. Dose and timing of concurrent short-acting insulins or other concomitant antidiabetic treatment may need to be adjusted
The FDA drug label does not provide specific guidance on adjusting the evening dose of long-acting insulin when the total daily dose of short-acting insulin exceeds the maximum recommended dose.
- Adjustment of long-acting insulin dose should be based on blood glucose measurements and individualized according to the patient's needs, as advised by a physician.
- Concurrent short-acting insulin doses may need to be adjusted, but the label does not specify how to adjust the long-acting insulin dose in this scenario 2.
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:
- The American Diabetes Association guidelines recommend a basal plus correction or basal insulin regimen for patients with type 2 diabetes mellitus (T2DM) receiving nothing by mouth (NPO) in the non-intensive care unit setting 3.
- Reducing the evening premeal short-acting insulin dose by 20% and increasing the bedtime basal NPH dose by 25% can improve evening and nighttime glycemic control 4.
- Administering the basal NPH dose before dinner at 1800 instead of at bedtime can result in higher nighttime and fasting glucose concentrations 4.
- Using a long-acting insulin analogue such as insulin glargine can provide a flatter time-action profile and reduce nocturnal hypoglycemia compared to NPH insulin 5.
- Aggressive titration of the insulin dose with either once-daily insulin glargine or NPH insulin combined with oral agents can achieve good glycemic control with less variability and nocturnal hypoglycemia 5.
Key Considerations
- The goal of adjusting the evening dose of long-acting insulin is to achieve optimal glycemic control while minimizing the risk of hypoglycemia.
- The choice of insulin regimen and dosage should be individualized based on the patient's specific needs and response to treatment.
- Regular monitoring of blood glucose levels and adjustment of the insulin regimen as needed is crucial to achieving optimal glycemic control 6, 7.