From the FDA Drug Label
- 3 Initiation of Insulin Glargine Therapy 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 appropriate starting dose of insulin in a patient with 14% A1C and type 2 diabetes is 0.2 units/kg or up to 10 units once daily. However, since the patient has liver failure, dosage adjustments may be needed due to changes in hepatic function, and this should be done under medical supervision with appropriate glucose monitoring 1.
From the Research
For a patient with type 2 diabetes, 14% HbA1c, and liver failure, I recommend starting with a conservative insulin regimen of 0.3 units/kg/day of total insulin, divided between basal and bolus insulin, as this approach prioritizes minimizing the risk of hypoglycemia while attempting to control severe hyperglycemia 2. For example, in a 70kg patient, this would be approximately 21 units total daily, with about 10-12 units as basal insulin (like insulin glargine or detemir once daily) and the remainder as prandial insulin (like insulin lispro or aspart) divided before meals.
Key Considerations
- Patients with liver failure require careful insulin dosing due to impaired insulin metabolism and increased risk of hypoglycemia, as highlighted by the complex relationship between cirrhosis and type 2 diabetes mellitus 2.
- The extremely high HbA1c (14%) indicates severe hyperglycemia requiring insulin therapy, but the liver dysfunction necessitates starting at a lower dose than the typical 0.5-0.6 units/kg/day to avoid exacerbating liver injury or causing hypoglycemia.
- Close monitoring of blood glucose is essential, with frequent adjustments every 2-3 days based on patterns, to ensure that the patient's glycemic control improves without increasing the risk of hypoglycemia.
- Aim for gradual improvement rather than rapid normalization to avoid hypoglycemia, considering the patient's liver condition and the potential for altered glucose metabolism.
- Consider inpatient initiation if the patient has complications or is at high risk for adverse events, to closely monitor and adjust the insulin regimen as needed.
Underlying Principles
- The management of type 2 diabetes in patients with liver failure involves a multidisciplinary approach, including nutritionists, obesity management teams, endocrinologists, hepatologists, and others, to address both the glycemic control and the underlying liver disease 2.
- The choice of insulin regimen should consider the patient's specific needs, including the severity of hyperglycemia, the presence of liver dysfunction, and the risk of hypoglycemia, as well as the potential benefits and drawbacks of different insulin types, such as insulin glargine or detemir 3.
- Recent studies have highlighted the importance of the liver in achieving sustained glycemic normalization, emphasizing the need for careful management of liver disease in patients with type 2 diabetes 4.