How should the evening dose of long-acting insulin be adjusted when the total daily dose of short-acting insulin, administered via a sliding scale regimen with meals, exceeds the maximum recommended dose?

From the Guidelines

When the total daily dose of short-acting insulin exceeds the maximum recommended dose, the long-acting evening insulin dose should be adjusted based on fasting fingerstick glucose test results. I recommend titrating the dose of basal insulin based on fasting finger-stick glucose test results over a week 1. If 50% of the fasting finger-stick glucose values are over the goal, increase the dose by 2 units 1. If more than 2 fasting finger-stick values/week are <80 mg/dL, decrease the dose by 2 units 1. The goal is to achieve a fasting glucose level between 90–150 mg/dL (5.0–8.3 mmol/L) 1. Key considerations include:

• Monitoring for hypoglycemia, especially overnight, and being prepared to further titrate the dose based on blood glucose patterns 1
• Considering the addition of noninsulin agents if the eGFR is ≥45 mg/dL, starting with metformin 500 mg daily and increasing the dose every 2 weeks as tolerated 1
• Adjusting the timing of basal insulin from bedtime to morning if necessary 1
• Being aware of the potential for overbasalization with insulin therapy and evaluating for clinical signals such as high bedtime-to-morning or preprandial-to-postprandial glucose differential, hypoglycemia, and high glucose variability 1

From the FDA Drug Label

1. 2 General Dosing Instructions Administer Insulin Glargine subcutaneously once daily at any time of day but at the same time every day. Individualize and adjust the dosage of Insulin Glargine based on the patient's metabolic needs, blood glucose monitoring results and glycemic control goal. Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), during acute illness, or changes in renal or hepatic function. Dosage adjustments should only be made under medical supervision with appropriate glucose monitoring [see Warnings and Precautions (5.2)].

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. However, it does recommend that dosage adjustments should be made under medical supervision with appropriate glucose monitoring. Key considerations for adjusting the dosage include:

• Metabolic needs
• Blood glucose monitoring results
• Glycemic control goal
• Changes in physical activity
• Changes in meal patterns
• Acute illness
• Changes in renal or hepatic function 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 study 3 recommends against using sliding-scale insulin due to its ineffectiveness and potential dangers, instead suggesting basal-bolus plus correction insulin therapy.
• According to 4, the preferred method of insulin initiation in type 2 diabetes is to begin with a long-acting (basal) insulin, and then add rapid-acting or short-acting insulin as needed to control postprandial glucose levels.
• The study 5 suggests that when adding glucagon-like peptide-1 receptor agonists to insulin therapy, the insulin dose may need to be reduced, particularly the bolus component.
• In terms of safety, 6 highlights the importance of validating insulin orders above certain thresholds to prevent errors, and 7 found that less intensive sliding scale insulin treatment did not significantly affect glycemic control in hospitalized patients with type 2 diabetes.

Key Considerations

• 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.
• The insulin regimen should be individualized and resemble a natural physiologic state as closely as possible, avoiding wide fluctuations in glucose levels 4.
• Blood glucose monitoring is an essential part of effective insulin therapy and should not be omitted from the patient's care plan 4.