From the Guidelines
Insulin dosing for the first time should start with a basal insulin regimen, with a typical starting dose of 0.1-0.2 units/kg/day, as this approach has been shown to be effective in controlling fasting glucose levels and reducing the risk of hypoglycemia 1. When initiating insulin therapy, it is essential to consider the patient's body weight and degree of hyperglycemia to determine the optimal starting dose.
- The starting dose can be estimated based on body weight, with a range of 0.1-0.2 units/kg/day, and individualized titration over days to weeks as needed 1.
- The principal action of basal insulin is to restrain hepatic glucose production and limit hyperglycemia overnight and between meals.
- Control of fasting glucose can be achieved with human NPH insulin or a long-acting insulin analog, with long-acting basal analogs (U-100 glargine or detemir) demonstrating a reduced risk of symptomatic and nocturnal hypoglycemia compared to NPH insulin 1.
- Patients should monitor blood glucose levels frequently when beginning insulin, aiming for fasting levels of 80-130 mg/dL and post-meal levels below 180 mg/dL.
- Hypoglycemia (low blood sugar) is the main risk when starting insulin, so having fast-acting carbohydrates like juice or glucose tablets available is essential.
- Insulin works by allowing glucose to enter cells from the bloodstream, replacing the function that the pancreas can no longer adequately perform, thus reducing blood glucose levels and preventing complications of diabetes.
- A study published in 2017 also supports the use of basal insulin as a starting point, with a recommended starting dose of 10 units, or 0.1 to 0.2 units/kg of body weight, per day, and advises to increase the dose by 10% to 15%, or 2 to 4 units, once or twice weekly until the fasting blood glucose target is met 1.
From the Research
Insulin Dosing for the First Time
- Insulin initiation is a major step in the medical management and life of patients with type 2 diabetes, necessary when a combination of 2 or 3 oral antidiabetic agents fail to achieve target glycemic goals 2.
- Insulin can be initiated with 10 units or 0.2 units/kg, then increased by 2 units every 3 days until fasting levels are consistently in the target range 2.
- If hypoglycemia occurs, the insulin dose will be reduced by 4 units 2.
- Insulin initiation requires a specific educational program for the acceptance of injection and to learn insulin injection, capillary blood glucose test, and adjustment of insulin regimens 2.
Comparison of Insulin Types
- Insulin detemir and insulin glargine have been compared in several studies, with results showing no significant differences in glycemic control 3, 4, 5.
- Insulin detemir was associated with less weight gain compared to insulin glargine 4.
- Treatment with insulin glargine resulted in a lower daily basal insulin dose and a lower number of injection site reactions 4.
- Once-daily dosing with insulin detemir provided glycaemic control similar to that of once-daily insulin glargine in patients with type 2 diabetes 5.
Other Treatment Options
- Glucagon-like peptide-1 (GLP-1) receptor agonists have been compared to insulin glargine, with results showing no significant differences in reducing glycosylated hemoglobin (HbA1c) levels 6.
- GLP-1 receptor agonists were more conducive to reducing weight, postprandial blood glucose, and LDL-C, but had significantly more gastrointestinal adverse effects 6.
- Insulin glargine was significantly better in reducing fasting blood glucose, but exhibited greater incidence of nocturnal hypoglycemia and influenza 6.