What is the typical starting dose of insulin (MDSS units) for patients requiring insulin therapy?

MDSS Units of Insulin: Starting Dose Recommendations

Standard Starting Doses for Insulin Therapy

For type 2 diabetes patients who are insulin-naive, start with 10 units once daily or 0.1-0.2 units/kg body weight of basal insulin, administered at the same time each day. 1, 2, 3

Type 2 Diabetes Initial Dosing Algorithm

• Standard initiation: 10 units once daily OR 0.1-0.2 units/kg/day of long-acting basal insulin (such as insulin glargine/Lantus) 1, 2, 3
• Severe hyperglycemia (HbA1c ≥9%, blood glucose ≥300-350 mg/dL, or symptomatic/catabolic features): Consider higher starting doses of 0.3-0.5 units/kg/day as total daily dose, requiring immediate basal-bolus therapy rather than basal insulin alone 1, 2
• Continue metformin unless contraindicated when initiating insulin therapy 1, 2

Type 1 Diabetes Initial Dosing Algorithm

For type 1 diabetes, the recommended starting dose is 0.5 units/kg/day as total daily insulin, divided as approximately 50% basal insulin and 50% prandial insulin. 4, 2

• Standard range: 0.4-1.0 units/kg/day total daily dose, with 0.5 units/kg/day typical for metabolically stable patients 1, 4
• Distribution: 40-60% as basal insulin (long-acting), 40-60% as prandial insulin (rapid-acting before meals) 1, 4
• Special populations: Young children and those in "honeymoon period" may require lower doses of 0.2-0.6 units/kg/day 4
• Higher doses needed: During puberty, pregnancy, or acute illness (may approach or exceed 1.0 units/kg/day) 4

Dose Titration Protocol

Increase basal insulin by 2-4 units every 3 days until fasting blood glucose reaches target of 80-130 mg/dL. 1, 2

• If fasting glucose is 140-179 mg/dL: increase by 2 units every 3 days 1
• If fasting glucose is ≥180 mg/dL: increase by 4 units every 3 days 1
• If hypoglycemia occurs: reduce dose by 10-20% immediately 1

Critical Threshold: When to Add Prandial Insulin

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. 1, 2

• This prevents "overbasalization" - a dangerous pattern where excessive basal insulin masks the need for mealtime coverage 1
• Clinical signs of overbasalization include: bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 1
• Start prandial insulin with 4 units of rapid-acting insulin before the largest meal, or use 10% of current basal dose 1

Common Pitfalls to Avoid

• Do not delay insulin initiation in patients not achieving glycemic goals with oral medications - this causes prolonged exposure to hyperglycemia and increases complication risk 1, 2
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia - this leads to suboptimal control and increased hypoglycemia risk 1
• Do not abruptly discontinue oral medications when starting insulin - risk of rebound hyperglycemia; continue metformin unless contraindicated 5, 6
• Do not mix or dilute insulin glargine with any other insulin or solution due to its low pH 3

Administration Guidelines

• Administer subcutaneously into the abdominal area, thigh, or deltoid 3
• Rotate injection sites within the same region to reduce risk of lipodystrophy 3
• Do not administer intravenously or via insulin pump 3
• Administer at the same time each day for consistency 1, 3