Is starting insulin with 10 units of glargine (insulin glargine) and 22 units of bolus (8-8-6) a correct approach, given that it doesn't follow the traditional 50/50 basal to bolus insulin ratio?

Is the 10 Units Glargine + 22 Units Bolus (8-8-6) Approach Wrong?

Yes, this approach is fundamentally flawed and violates evidence-based insulin dosing principles. The regimen you describe provides only 31% basal insulin (10 units) versus 69% bolus insulin (22 units), which is the inverse of physiologic insulin requirements and contradicts established guidelines.

Why This Approach Is Problematic

The 50:50 Basal-Bolus Principle

• The American Diabetes Association explicitly recommends that basal-bolus insulin therapy requires approximately 50% of total daily insulin as basal and 50% as bolus (prandial) insulin for type 1 diabetes. 1
• For type 2 diabetes patients requiring both basal and prandial coverage, the physiologic distribution should similarly approximate 50:50, though type 2 diabetes may tolerate some variation. 2
• The fundamental approach emphasizes that basal insulin controls fasting and between-meal glucose, while prandial insulin addresses postprandial excursions—both components require balanced dosing. 2

What the Guidelines Actually Recommend

For insulin initiation in type 2 diabetes:

• Start with basal insulin alone at 10 units once daily or 0.1-0.2 units/kg/day, NOT with simultaneous basal-bolus therapy. 3
• Basal insulin should be titrated by 2-4 units every 3 days until fasting blood glucose reaches 80-130 mg/dL. 3
• Metformin should be continued unless contraindicated. 3

Only advance to basal-bolus when:

• Basal insulin has been optimally titrated (fasting glucose 80-130 mg/dL) but A1C remains above target after 3-6 months. 3, 1
• Basal insulin dose approaches 0.5-1.0 units/kg/day without achieving glycemic goals. 3, 1, 2

When Adding Prandial Insulin: The Correct Approach

If basal-bolus therapy is truly indicated, the starting algorithm should be:

• Start prandial insulin at 4 units per meal, 0.1 units/kg per meal, OR 10% of the basal dose per meal. 3
• If starting with 10 units of glargine, the initial prandial dose would be approximately 1 unit per meal (10% of basal), NOT 8-8-6 units. 3
• Consider decreasing the basal insulin dose by the same amount as the starting mealtime dose if A1C is <8%. 3

The Correct 50:50 Distribution

For a patient requiring 32 units total daily dose (as in your example):

• Basal insulin: 16 units glargine once daily
• Bolus insulin: 16 units total, divided as approximately 5-5-6 units before meals
• This maintains the physiologic 50:50 distribution. 1, 2

Critical Threshold: Overbasalization vs. Under-Basalization

The Danger of Excessive Bolus Insulin

• When bolus insulin dominates the regimen (as in the 10 glargine + 22 bolus example), patients experience:
  • Inadequate fasting glucose control (insufficient basal coverage)
  • Excessive postprandial insulin exposure
  • Increased hypoglycemia risk between meals
  • Poor overnight glucose control 1, 2

Recognizing Overbasalization (The Opposite Problem)

• Clinical signals of overbasalization include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia episodes, and high glucose variability. 1, 2
• When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, add prandial insulin rather than continuing to escalate basal insulin alone. 3, 1, 2

The Correct Algorithmic Approach

Step 1: Start with Basal Insulin Alone

• Initial dose: 10 units glargine once daily or 0.1-0.2 units/kg/day. 3, 1
• Continue metformin unless contraindicated. 3
• Titrate by 2-4 units every 3 days based on fasting glucose. 3

Step 2: Optimize Basal Insulin First

• Target fasting glucose: 80-130 mg/dL. 3, 1
• If fasting glucose ≥180 mg/dL, increase by 4 units every 3 days. 1
• If fasting glucose 140-179 mg/dL, increase by 2 units every 3 days. 1

Step 3: Add Prandial Insulin Only When Indicated

• Add prandial insulin when basal insulin is optimized but A1C remains elevated after 3-6 months. 3, 1
• Start with 4 units before the largest meal or 10% of basal dose. 3
• Maintain approximately 50:50 basal-bolus distribution as you titrate. 1, 2

Step 4: Recalculate and Redistribute

• When basal insulin is increased, recalculate the total daily dose (TDD) and redistribute bolus insulin to maintain the 50:50 ratio. 2
• Recalculate insulin sensitivity factor (ISF) using 1500/new TDD. 2
• Do not continue using the same bolus doses from Day 1 when basal insulin has been escalated. 2

Common Pitfalls to Avoid

• Never start with simultaneous high-dose basal-bolus therapy in insulin-naive type 2 diabetes patients unless they have severe hyperglycemia (A1C ≥10-12% with symptomatic/catabolic features). 1
• Do not skip the basal-only optimization phase—this is the foundation of insulin therapy. 3
• Avoid continuing to use fixed bolus doses without recalculating when basal insulin changes—this violates the physiologic 50:50 principle. 2
• Do not delay treatment intensification, but also do not over-intensify prematurely. 3, 1

Evidence from Clinical Trials

• The RABBIT 2 trial demonstrated that basal-bolus insulin therapy (glargine + glulisine) starting at 0.4-0.5 units/kg/day total (split appropriately between basal and bolus) achieved superior glycemic control compared to sliding scale insulin in hospitalized type 2 diabetes patients. 4
• A Latin American study showed equivalent glycemic control with mean insulin doses of 0.76 units/kg/day (glargine 22 units/day + glulisine 31 units/day), demonstrating approximately 42% basal and 58% bolus distribution in hospitalized patients. 5
• Recent real-world data from 306 patients with type 2 diabetes followed for 3.4 years challenges the rigid 50:50 rule, showing that three-quarters of patients maintaining stable glycemic control had basal insulin fractions <50%, with half having <41.2% basal. 6

Reconciling Guidelines with Real-World Evidence

While the 2023 real-world study 6 shows variation from 50:50 in established patients, this does NOT justify starting with 31% basal (10 units) and 69% bolus (22 units). The study examined patients after prolonged titration and optimization, not initial dosing strategies. The key principles remain:

• Start with basal insulin alone in most type 2 diabetes patients. 3
• When adding prandial insulin, start conservatively (4 units per meal or 10% of basal). 3
• Allow individualized titration over time to find the optimal basal-bolus distribution for each patient. 6
• The 50:50 ratio serves as a starting framework, not a rigid endpoint. 6

The approach of starting with 10 units glargine + 22 units bolus (8-8-6) bypasses evidence-based initiation protocols and exposes patients to unnecessary hypoglycemia risk and suboptimal glycemic control.