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 basal insulin needs.
- The goal is to achieve better baseline glucose control with the long-acting insulin, reducing the need for frequent correction doses.
- The patient's fasting goal should be set between 90–150 mg/dL (5.0–8.3 mmol/L), and the dose of basal insulin should be titrated accordingly.
- If 50% of the fasting fingerstick glucose values are over the goal, the dose should be increased by 2 units, and 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, as suggested by the guidelines 1.
- Additionally, noninsulin agents such as metformin can be added to the treatment regimen if the patient's eGFR is ≥45 mg/dL, and the dose can be increased every 2 weeks as tolerated 1. It is crucial to monitor blood glucose levels closely during this adjustment period and educate the patient about recognizing and treating hypoglycemia.
- The patient's insulin regimen should be individualized based on their specific needs and response to treatment.
- The guidelines also recommend using a simplified sliding scale for prandial insulin and stopping the sliding scale when it is no longer needed daily 1. By following these recommendations and closely monitoring the patient's response to treatment, it is possible to achieve optimal glucose control and minimize the risk of hypoglycemia and other complications.
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 in the provided studies to support a specific method for adjusting the evening dose of long-acting insulin when the total daily dose of short-acting insulin exceeds the maximum recommended dose.
- However, studies suggest that basal-bolus insulin therapy, which includes a long-acting insulin component, is preferred over sliding-scale insulin for managing hyperglycemia 2.
- The adjustment of basal insulin doses may depend on the type of diabetes and the prior treatment regimen, as shown in a study on switching from glargine or detemir to degludec 3.
- Factors that can complicate glycemic control, such as the severity of illness and inconsistent dietary intake, should be taken into account when adjusting insulin doses 2.
- The use of computer decision support systems can help standardize insulin therapy and reduce errors in insulin dose calculations 2.
- Blood glucose monitoring is essential for effective insulin therapy, and fasting plasma glucose values should be used to titrate basal insulin, while both fasting and postprandial glucose values should be used to titrate mealtime insulin 4.
Considerations for Insulin Therapy
The following considerations should be taken into account when adjusting insulin doses:
- The type of diabetes (type 1 or type 2) and the individual patient's needs and response to insulin therapy 4.
- The potential benefits and risks of different insulin regimens, including the risk of hypoglycemia and the potential for improved glycemic control 5, 6.
- The importance of individualizing insulin therapy and avoiding wide fluctuations in glucose levels 4.