First-Line Insulin Therapy for HbA1c of 11.5%

For patients with an HbA1c of 11.5%, basal insulin plus metformin is the recommended first-line insulin therapy, unless contraindicated. 1, 2

Initial Treatment Approach

For patients with severely elevated HbA1c (>10%), immediate insulin therapy is strongly recommended to quickly reduce hyperglycemia and prevent metabolic decompensation 1, 2
Start with basal insulin (insulin glargine, detemir, or NPH) at an initial dose of 10 units per day or 0.1-0.2 units/kg per day 1
Metformin should be initiated or continued alongside insulin therapy unless contraindicated, as it improves insulin sensitivity and may reduce insulin requirements 2
Set fasting plasma glucose goals and choose an evidence-based titration algorithm (e.g., increase by 2 units every 3 days until reaching target without hypoglycemia) 1

Initial basal insulin dosing should be 10 units daily or 0.1-0.2 units/kg/day 1
Titrate insulin dose based on fasting blood glucose measurements, typically increasing by 2 units every 3 days until target is reached 1
For hypoglycemia, determine the cause; if no clear reason is identified, lower the dose by 10-20% 1
Assess adequacy of insulin dose at every visit and consider clinical signals to evaluate for overbasalization 1

With an HbA1c of 11.5%, patients may require both basal and prandial insulin coverage 1
If A1c remains above goal after optimizing basal insulin, consider adding prandial insulin, typically starting with one dose with the largest meal or meal with greatest postprandial glucose excursion 1
Initial prandial insulin dose is typically 4 units per day or 10% of the basal insulin dose 1
Titrate prandial insulin based on postprandial glucose measurements, increasing by 1-2 units or 10-15% as needed 1

Regular self-monitoring of blood glucose should be performed, including fasting and postprandial measurements, to guide insulin dose adjustments 2
Re-evaluate HbA1c in 3 months after treatment initiation to assess effectiveness 3
Both fasting plasma glucose (FPG) and postprandial glucose (PPG) significantly impact HbA1c and should be monitored to achieve glycemic goals 4

Failing to start insulin therapy promptly in patients with severely elevated HbA1c (>10%) can lead to prolonged hyperglycemia and increased risk of complications 3
Not prescribing glucagon for emergency hypoglycemia management, especially in patients new to insulin therapy 1
Setting overly aggressive glucose targets without considering the risk of hypoglycemia, particularly in elderly patients or those with comorbidities 3
Neglecting to continue metformin when starting insulin therapy, as the combination is more effective than insulin alone 2

Choice of basal insulin should be based on patient-specific considerations, including cost 1
For patients already on oral medications, maintain metformin if already prescribed and consider discontinuing sulfonylureas when starting insulin to reduce hypoglycemia risk 3, 2
Lifestyle modifications including dietary changes, physical activity, and weight management remain important components of diabetes management even when initiating insulin therapy 3