What is the initial insulin management regimen for patients with type 2 diabetes?

Initial Insulin Management for Type 2 Diabetes

Basal insulin alone is the most convenient initial insulin regimen for patients with type 2 diabetes, beginning at 10 units per day or 0.1-0.2 units/kg/day, depending on the degree of hyperglycemia. 1, 2

Initial Insulin Selection and Dosing

• Basal insulin is typically prescribed in conjunction with metformin and possibly one additional noninsulin agent 1, 2
• Long-acting insulin analogs (glargine, detemir, degludec) are preferred over NPH insulin due to lower risk of nocturnal hypoglycemia 2, 3
• For patients with severe hyperglycemia (A1C ≥10-12% or blood glucose ≥300-350 mg/dL) or with symptomatic/catabolic features, consider starting with basal insulin plus one mealtime insulin injection 1

Dose Titration Protocol

• Equip patients with a self-titration algorithm based on self-monitoring of blood glucose (SMBG) to improve glycemic control 1, 2
• Dose adjustments should be made based on fasting blood glucose patterns 2
• A common titration approach:
  • Increase dose by 2 units every 3 days until fasting glucose reaches target (typically 80-130 mg/dL) 2
  • If hypoglycemia occurs, reduce dose by 2-4 units 2
  • As glycemic targets are approached, make more modest and less frequent adjustments 4

When to Intensify Therapy

• 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:
  1. Adding a GLP-1 receptor agonist 1
  2. Adding mealtime insulin, consisting of one to three injections of rapid-acting insulin analog (lispro, aspart, or glulisine) before meals 1, 5
  3. Switching to premixed insulin (70/30 NPH/regular, 70/30 aspart mix, or 75/25 or 50/50 lispro mix) administered before breakfast and dinner 1

Medication Adjustments When Starting Insulin

• Continue metformin when initiating insulin therapy 1, 5
• Sulfonylureas, DPP-4 inhibitors, and GLP-1 receptor agonists are typically discontinued once more complex insulin regimens beyond basal are used 1, 5
• In patients requiring increasing insulin doses, adjunctive use of thiazolidinediones (usually pioglitazone) or SGLT2 inhibitors may help improve control and reduce insulin requirements 1

Monitoring and Safety

• Comprehensive education regarding SMBG, diet, exercise, and hypoglycemia management is critically important 1, 2
• Monitor for weight gain, which is often less with newer insulin analogs compared to NPH insulin 3, 6
• Be vigilant for nocturnal hypoglycemia, which occurs less frequently with long-acting insulin analogs than with NPH insulin 3

Common Pitfalls to Avoid

• Avoid using insulin as a threat or describing it as a sign of personal failure; explain the progressive nature of type 2 diabetes objectively 2, 5
• Avoid "overbasalization" (using higher than necessary doses of basal insulin) when A1C remains elevated despite normalized fasting glucose 2
• Don't overlook cost considerations when selecting insulin products, as prices have increased substantially 2, 5
• Don't delay intensification when basal insulin alone is insufficient to achieve glycemic targets 1