How to adjust insulin (insulin) glargine in type 2 diabetes mellitus with hyperglycemia?

Insulin Glargine Adjustment for Type 2 Diabetes with Hyperglycemia

For patients with type 2 diabetes experiencing hyperglycemia, insulin glargine should be initiated at 0.1-0.2 units/kg/day or 10 units once daily, with dose titration of 10-15% or 2-4 units once or twice weekly until target fasting blood glucose is achieved. 1, 2, 3

Initial Dosing Strategy

• For insulin-naïve patients with type 2 diabetes, start insulin glargine at 0.2 units/kg or up to 10 units once daily 3
• For patients with significant hyperglycemia (HbA1c ≥9% or blood glucose ≥300-350 mg/dL), consider starting insulin therapy immediately, especially when HbA1c is 10-12% with symptomatic hyperglycemia 2
• Administer insulin glargine subcutaneously once daily at any time of day, but maintain consistency in timing 3
• Continue metformin and possibly one additional non-insulin agent when initiating insulin glargine 1

Dose Titration Protocol

• Equip patients with a self-titration algorithm based on fasting blood glucose monitoring 2
• Increase basal insulin dose by 10-15% or 2-4 units once or twice weekly until the fasting blood glucose target is achieved 1, 2, 4
• For a more structured approach, consider the following titration algorithm based on fasting blood glucose (FBG) levels 4:
  • FBG ≥5.6-<6.7 mmol/L (≥100-<120 mg/dL): Increase by 0-2 units
  • FBG ≥6.7-<7.8 mmol/L (≥120-<140 mg/dL): Increase by 2 units
  • FBG ≥7.8-<10.0 mmol/L (≥140-<180 mg/dL): Increase by 4 units
  • FBG ≥10 mmol/L (≥180 mg/dL): Increase by 6-8 units

When to Intensify Therapy

• If basal insulin has been titrated to an acceptable fasting blood glucose level but HbA1c remains above target, consider advancing to combination injectable therapy 1, 2
• Options for intensification include:
  • Adding a GLP-1 receptor agonist 1, 2
  • Adding mealtime insulin (one to three injections of rapid-acting insulin analog administered just before eating) 1
  • Consider a basal-plus regimen (basal insulin with one mealtime injection) before advancing to a full basal-bolus regimen 1

Special Considerations

• For patients with renal insufficiency, consider starting with a lower dose (0.25 units/kg/day) to reduce hypoglycemia risk 5
• For elderly patients, use a more conservative starting dose (0.1 units/kg/day) and slower titration to minimize hypoglycemia risk 1
• During acute illness or changes in physical activity, more frequent monitoring and dose adjustments may be needed 3
• Watch for signs of overbasalization (basal dose >0.5 units/kg, high bedtime-morning glucose differential, hypoglycemia) 2

Monitoring and Safety

• Increase frequency of blood glucose monitoring during dose adjustments 3
• Monitor for hypoglycemia, especially within the first four weeks after initiating insulin glargine 6
• Insulin glargine provides relatively uniform insulin coverage throughout the day and night, with modestly less overnight hypoglycemia compared to NPH insulin 1, 7
• Do not mix insulin glargine with any other insulin products 3, 6

Common Pitfalls to Avoid

• Delaying insulin therapy in patients not achieving glycemic goals 2
• Using sliding scale insulin alone without basal insulin, which is less effective for glycemic control 1
• Failing to adjust doses frequently enough to reach glycemic targets 4
• Continuing sulfonylureas when using more complex insulin regimens, which increases hypoglycemia risk 2

By following this structured approach to insulin glargine adjustment, patients with type 2 diabetes experiencing hyperglycemia can achieve improved glycemic control with minimal risk of hypoglycemia.