What are the guidelines for initiating insulin therapy in a patient?

From the Guidelines

Starting a patient on insulin requires initiating basal insulin at 10 units daily or 0.1-0.2 units/kg/day, preferably at bedtime, and adjusting the dose by 10% to 15%, or 2 to 4 units, once or twice weekly until the fasting blood glucose target is met, as recommended by the American Diabetes Association standards of medical care in diabetes 1. When starting insulin therapy, it is essential to consider the patient's specific needs and the type of diabetes they have. For type 2 diabetes, basal insulin alone is the most convenient initial insulin regimen, and it is usually prescribed in conjunction with metformin and sometimes one additional noninsulin agent. The choice of insulin product should take into account cost considerations, as there have been substantial increases in the price of insulin over the past decade 1. Some key points to consider when starting a patient on insulin include:

• Initiating basal insulin at a dose of 10 units daily or 0.1-0.2 units/kg/day, depending on the degree of hyperglycemia 1
• Adjusting the dose by 10% to 15%, or 2 to 4 units, once or twice weekly until the fasting blood glucose target is met 1
• Using long-acting basal analogs (U-100 glargine or detemir) instead of NPH insulin when adding basal insulin to antihyperglycemic agents in patients with type 2 diabetes 1
• Providing comprehensive education regarding self-monitoring of blood glucose, diet, and the avoidance of and appropriate treatment of hypoglycemia 1
• Regular follow-up to ensure appropriate dose adjustments and address any concerns or complications 1

From the FDA Drug Label

1. 3 Initiation of Insulin Glargine Therapy Recommended Starting Dosage in Patients with Type 1 Diabetes The recommended starting dosage of Insulin Glargine in patients with type 1 diabetes is approximately one-third of the total daily insulin requirements. Recommended Starting Dosage in Patients with Type 2 Diabetes The recommended starting dosage of Insulin Glargine in patients with type 2 diabetes who are not currently treated with insulin is 0.2 units/kg or up to 10 units once daily.

The recommended starting dosage of Insulin Glargine is:

• For patients with Type 1 Diabetes: approximately one-third of the total daily insulin requirements.
• For patients with Type 2 Diabetes who are not currently treated with insulin: 0.2 units/kg or up to 10 units once daily 2.

From the Research

Initiating Insulin Therapy

• Insulin is often indicated for patients with suboptimally controlled type 2 diabetes mellitus, despite lifestyle modification and oral antidiabetic agents 3.
• Basal insulin is usually initiated at a conservative dose of 10 units/day or 0.1-0.2 units/kg/day, then titrated thereafter over several weeks or months, based on patients' self-measured fasting plasma glucose, to achieve an individualized target (usually 80-130 mg/dL) 4.
• The dose of basal insulin should be increased as required up to approximately 0.5-1.0 units/kg/day in some cases 4.

Titration and Adjustment

• Basal insulin should be titrated regularly on a prophylactic basis (eg. fasting glucose <4.4 mmol/L: -2U, 4.4-7.0: +0 U, 7.1-10.0: +2 U, >10.0: +4 U) or increased by 1 U/day until fasting glucose of 5.5 mmol/L is reached 3.
• A simple rule is to gradually increase the initial dose by 1 unit per day (NPH, insulin detemir, and glargine 100 units/mL) or 2-4 units once or twice per week (NPH, insulin detemir, glargine 100 and 300 units/mL, and degludec) until FPG levels remain consistently within the target range 4.
• Overbasalization (continuing to escalate dose without a meaningful reduction in fasting plasma glucose) is not recommended; rather re-evaluation of individual therapy, including consideration of more concentrated basal insulin preparations and/or short-acting prandial insulin as well as other glucose-lowering therapies, is suggested 4.

Alternative Therapies

• Glucagon-like peptide 1 receptor agonist or bolus insulin with optimized basal insulin can be considered for patients with type 2 diabetes 5.
• Exenatide resulted in similar glycemic control as adding lispro and was well tolerated, with fewer nonnocturnal hypoglycemic episodes but more gastrointestinal adverse events 5.
• Basal-bolus therapy using insulin detemir and insulin aspart is an effective and well-tolerated insulin regimen in people with type 2 diabetes, resulting in glycaemic control comparable to that of NPH + HSI, but with the advantages of less weight gain and a lower day-to-day within-person variation in FPG 6.