What type of insulin do we start with?

Starting Insulin Therapy in Diabetes

Basal insulin is the most appropriate initial insulin therapy, starting at 10 units or 0.1-0.2 units/kg/day, depending on the degree of hyperglycemia. 1

Initial Insulin Selection and Dosing

• Basal insulin (such as insulin glargine, detemir, or degludec) is the most convenient initial insulin regimen for patients requiring insulin therapy 1
• Start with 10 units daily or 0.1-0.2 units/kg/day, typically administered at bedtime 1, 2
• Basal insulin should be prescribed in conjunction with metformin and possibly one additional non-insulin agent 1, 2
• Titrate the initial dose by approximately 2 units every 3 days to reach fasting plasma glucose goals without causing hypoglycemia 2
• If hypoglycemia occurs, reduce the dose by 10-20% 2, 3

Insulin Intensification When Needed

• If basal insulin has been titrated to an acceptable fasting blood glucose level but A1C remains above target, consider advancing to combination injectable therapy 1
• Options for intensification include:
  • Adding a GLP-1 receptor agonist to basal insulin 1
  • Adding prandial insulin, starting with a single dose at the largest meal 1
  • Initial prandial insulin dose should be 4 units or 10% of the basal insulin dose 1

Special Considerations for Different Patient Populations

• For patients with severely uncontrolled diabetes (A1C ≥10-12% or blood glucose ≥300-350 mg/dL), especially if symptomatic, consider starting with both basal insulin and mealtime insulin 1, 2
• For elderly patients (>65 years), consider starting at a lower dose of 0.1 units/kg/day to reduce hypoglycemia risk 3
• For insulin-resistant patients requiring large doses, concentrated insulin preparations (U-200, U-300, U-500) may be more comfortable and improve adherence 1

Monitoring and Adjustments

• Self-monitoring of blood glucose is essential for adjusting insulin therapy 2, 4
• Equip patients with an algorithm for self-titration of insulin doses based on self-monitoring results 1
• Adjust both basal and prandial insulins based on prevailing blood glucose levels and understanding of the pharmacodynamic profile of each formulation 1, 2

Common Pitfalls to Avoid

• Delaying insulin intensification when oral agents fail to achieve glycemic targets 2, 3
• Overbasalization (continuing to escalate basal insulin dose without meaningful reduction in fasting plasma glucose) 2, 4
• Not rotating injection sites, which can lead to lipodystrophy and variable insulin absorption 2
• Using sliding scale insulin alone in patients with type 1 diabetes 3

Practical Administration Tips

• Administer basal insulin subcutaneously into the abdominal area, thigh, or deltoid once daily at any time of day, but at the same time every day 5
• Do not dilute or mix with any other insulin or solution 5
• Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis 5
• Closely monitor glucose when switching to a different insulin and during initial weeks thereafter 5, 4