From the Guidelines
Insulin therapy should be initiated in patients with diabetes with a starting dose of 10 units or 0.1 to 0.2 units/kg of body weight of basal insulin per day, as recommended by the American Diabetes Association standards of medical care in diabetes 1. When initiating insulin therapy, it is essential to consider the patient's individual needs and medical history. The goal of insulin therapy is to achieve optimal blood glucose control, reducing the risk of complications associated with diabetes.
Key Considerations for Insulin Initiation
- The initial dose of basal insulin should be adjusted by 10% to 15%, or 2 to 4 units, once or twice weekly until the fasting blood glucose target is met 1.
- Insulin is typically used with metformin and sometimes 1 additional noninsulin agent, taking into account cost considerations and the potential for hypoglycemia 1.
- For patients not achieving HbA1c goals on optimally titrated basal insulin alone, premeal insulin dosing with rapid-acting insulin analogues may be necessary, starting at 4 U per meal, 0.1 U/kg per meal, or 10% of the basal insulin dose per meal 1.
Insulin Products and Regimens
- Basal insulin products, such as insulin glargine, insulin detemir, or insulin degludec, are commonly used as the initial insulin regimen 1.
- Premixed insulin products containing both basal and bolus insulin may be an option for patients who require simpler dosing, but this approach requires a relatively fixed meal schedule and carbohydrate content per meal 1.
- Concentrated insulin preparations, such as U-500 regular insulin, may be indicated for patients requiring more than 200 units of insulin per day 1.
From the FDA Drug Label
Individualize dosage based on metabolic needs, blood glucose monitoring, glycemic control, type of diabetes, and prior insulin use. See Full Prescribing Information for the recommended starting dosage in patients with type 2 diabetes (2.3) and how to change to Insulin Glargine from other insulins (2.4)
The recommended approach for initiating insulin with glargine (SQ) is to individualize the dosage based on the patient's metabolic needs, blood glucose monitoring, glycemic control, type of diabetes, and prior insulin use. The full prescribing information should be consulted for the recommended starting dosage in patients with type 2 diabetes and for guidance on changing to Insulin Glargine from other insulins 2.
From the Research
Initiation of Insulin Therapy for Diabetes
- Insulin therapy is often necessary for patients with type 2 diabetes to achieve near-normal glycemic targets and avoid complications 3.
- The initiation of insulin therapy is a major step in the medical management and life of patients with type 2 diabetes 4.
- Insulin is usually initiated at a conservative dose of 10 units/day or 0.1-0.2 units/kg/day, and then titrated thereafter based on patients' self-measured fasting plasma glucose 5.
- The dose of basal insulin should be increased as required up to approximately 0.5-1.0 units/kg/day in some cases, but overbasalization should be avoided 5.
When to Initiate Insulin Therapy
- Insulin therapy should be initiated when combination of 2 or 3 oral antidiabetic agents fail to achieve target glycemic goals, especially if HbA1c are superior to 1% from target or weight loss 4.
- Insulin therapy should be considered when oral antidiabetic drugs (OADs) no longer confer adequate glycemic control 6.
- The decision to initiate insulin therapy should be made through a shared decision-making process, taking into account the patient's individual needs and goals 5.
Treatment Regimen Options
- Treatment regimens available for insulin initiation include once-daily basal insulin, sometimes with addition of prandial insulin, or premix/biphasic insulin 6.
- Insulin analogs, such as long-acting basal insulins, offer greater stability and flexibility than older preparations and improved delivery systems 5, 7.
- The choice of insulin regimen should be individualized based on the patient's specific needs and lifestyle 6.