How do you determine the insulin units for a patient diagnosed with Diabetes Mellitus (DM) type 2?

Determining Insulin Units for Type 2 Diabetes Patients

For patients diagnosed with type 2 diabetes, insulin therapy should be initiated at 10 units per day or 0.1-0.2 units/kg per day, with systematic titration of 2 units every 3 days until reaching fasting plasma glucose goals without hypoglycemia. 1

Initial Insulin Dosing

• Start basal insulin (long-acting) at 10 units per day OR 0.1-0.2 units/kg per day, depending on the degree of hyperglycemia 1
• Consider insulin as first injectable therapy when symptoms of hyperglycemia are present, A1C >10%, or blood glucose ≥300 mg/dL 1
• Basal insulin is typically prescribed with metformin and sometimes one additional non-insulin agent 1, 2

Titration Algorithm

• Set fasting plasma glucose (FPG) goal (typically 80-130 mg/dL) 1, 3
• Increase basal insulin dose by 2 units every 3 days until reaching FPG goal without hypoglycemia 1
• If hypoglycemia occurs, determine the cause; if no clear reason is found, reduce the dose by 10-20% 1, 2
• Assess adequacy of insulin dose at every visit 1

When to Add Prandial (Mealtime) Insulin

• If A1C remains above goal despite optimized basal insulin, consider adding prandial insulin 1
• Start with one dose with the largest meal or meal with greatest postprandial glucose excursion 1
• Initial prandial dose: 4 units per day or 10% of basal insulin dose 1
• Increase prandial dose by 1-2 units or 10-15% based on postprandial glucose readings 1
• If A1C <8% when starting prandial insulin, consider reducing basal insulin by 4 units or 10% 1

Full Basal-Bolus Regimen

• If A1C remains above goal with basal plus one prandial injection, proceed to full basal-bolus plan 1
• Total daily insulin dose is typically divided as 50% basal and 50% prandial 2
• Prandial insulin is usually split evenly between meals 2
• For hypoglycemia: determine cause; if no clear reason, lower corresponding dose by 10-20% 1

Alternative: Premixed Insulin

• Consider twice-daily premixed insulin as an alternative to basal-bolus regimen 1
• Typical distribution: 2/3 before breakfast, 1/3 before dinner 1
• Add 4 units of short/rapid-acting insulin to each injection or 10% of reduced NPH dose 1
• Main disadvantage: requires relatively fixed meal schedule and carbohydrate content per meal 1

Monitoring and Adjustment

• Self-monitoring of blood glucose is essential for insulin dose adjustments 2, 3
• Titrate each component of insulin regimen based on individual blood glucose patterns 1, 2
• Assess for overbasalization (elevated bedtime-to-morning glucose differential, hypoglycemia, high glucose variability) 1
• Consider GLP-1 receptor agonist in combination with insulin for patients not at goal 1

Special Considerations

• For newly diagnosed patients with A1C >9%, short-term intensive insulin therapy may induce remission 4
• Equipping patients with a self-titration algorithm improves glycemic control 1
• Consider cost when selecting insulin products, as there have been substantial price increases 1
• Prescribe glucagon for emergency treatment of severe hypoglycemia 1, 2

Remember that insulin therapy should be regularly reassessed and modified every 3-6 months to avoid therapeutic inertia and maintain optimal glycemic control 1, 3.