Insulin Regimen for a 70kg Male with Hyperglycemia
Start with basal insulin at 7-14 units once daily at bedtime, using either insulin glargine (Lantus) or detemir (Levemir), and titrate upward by 2-4 units every 3-7 days based on fasting glucose levels until target is achieved. 1
Initial Insulin Selection and Dosing
For this 70kg patient, initiate basal insulin at 0.1-0.2 units/kg/day, which translates to 7-14 units once daily. 1 The lower end of this range (7-10 units or 0.1 units/kg) is preferred if the patient has risk factors for hypoglycemia including age >65 years, renal impairment, or poor oral intake. 1
Recommended Basal Insulin Options:
- Long-acting analogs (glargine U-100, detemir, or degludec) are preferred over NPH insulin because they reduce nocturnal and symptomatic hypoglycemia risk. 1
- Insulin glargine (Lantus) or insulin detemir (Levemir) provide 24-hour basal coverage with minimal peak activity. 2, 3, 4
- Longer-acting formulations (glargine U-300 or degludec) may further reduce hypoglycemia risk compared to glargine U-100. 1
How to Prepare and Administer
Preparation:
- Inspect the insulin vial or pen visually before each use—it should appear clear and colorless. 5
- Do not mix basal insulin with any other insulin in the same syringe. 5
- If using a vial, draw up the prescribed dose using an insulin syringe (typically U-100 syringes for standard insulin concentrations). 5
Administration Technique:
- Inject subcutaneously into the thigh, abdomen, or upper arm. 5
- Rotate injection sites within the same anatomical region to prevent lipohypertrophy. 5
- Administer at the same time each day for consistency—typically at bedtime or with the evening meal for once-daily dosing. 1, 5
- For detemir, if twice-daily dosing becomes necessary, give the second dose 12 hours after the morning dose or with the evening meal. 5
Disposal:
- Remove and dispose of the needle immediately after injection in a puncture-resistant sharps container without recapping. 5
When to Give Insulin
Administer basal insulin once daily at bedtime (or with the evening meal) to control fasting glucose and provide 24-hour basal coverage. 1, 5 This timing optimally suppresses overnight hepatic glucose production and controls fasting hyperglycemia. 1
If the patient requires twice-daily basal insulin dosing (uncommon initially but may be needed in insulin-resistant patients), the evening dose can be given at bedtime or 12 hours after the morning dose. 5
Titration Protocol
Increase the basal insulin dose by 2-4 units every 3-7 days until fasting blood glucose consistently reaches 80-130 mg/dL (4.4-7.2 mmol/L). 1, 6 Use the following systematic approach:
- If mean fasting glucose over 3 days is ≥180 mg/dL (≥10 mmol/L): increase by 6-8 units 7
- If 140-180 mg/dL (7.8-10 mmol/L): increase by 4 units 7
- If 120-140 mg/dL (6.7-7.8 mmol/L): increase by 2 units 7
- If 100-120 mg/dL (5.6-6.7 mmol/L): increase by 0-2 units 7
- If <100 mg/dL (<5.6 mmol/L): maintain current dose 7
Hold titration if any blood glucose reading is <72 mg/dL (<4.0 mmol/L) and consider reducing the dose by 10-20%. 7, 6
When to Add Prandial Insulin
If fasting glucose is controlled but A1c remains elevated (typically >8%), add rapid-acting insulin at the largest meal starting at 4 units or 10% of the basal insulin dose. 1, 6 This addresses postprandial hyperglycemia that basal insulin alone cannot control. 1
Rapid-acting insulin options include aspart (NovoLog), lispro (Humalog), or glulisine (Apidra), given immediately before meals. 1 Titrate prandial doses by 1-2 units twice weekly based on 2-hour postprandial glucose readings. 6
Critical Monitoring Requirements
- Check fasting blood glucose daily during titration to guide dose adjustments. 1, 7
- Monitor for hypoglycemia symptoms (tremor, sweating, confusion, palpitations), especially 2-4 hours after rapid-acting insulin if added. 6
- Recheck A1c every 2-3 months to assess overall glycemic control. 6
- Educate the patient on hypoglycemia recognition and treatment with 15g fast-acting carbohydrate. 1
Common Pitfalls to Avoid
Do not use sliding scale insulin alone as the primary regimen—this reactive approach is ineffective and strongly discouraged. 1, 6 Basal insulin provides the foundation for glycemic control. 1
Avoid overbasalization (basal dose >0.5 units/kg without adequate glycemic control), which signals the need for prandial insulin rather than further basal increases. 1 Clinical clues include high bedtime-to-morning glucose differentials (>50 mg/dL) or controlled fasting glucose with elevated A1c. 1
Do not delay insulin intensification if A1c remains >9% despite optimized basal insulin—prolonged severe hyperglycemia increases complication risk. 6
If the patient is on sulfonylureas and requires complex insulin regimens beyond basal insulin alone, discontinue the sulfonylurea to reduce hypoglycemia risk. 6