What is the appropriate insulin dosage?

From the Guidelines

Insulin dosage should be initiated at 10 units or 0.1-0.2 units/kg of body weight per day for type 2 diabetes, with adjustments made by 10% to 15% or 2 to 4 units once or twice weekly until the fasting blood glucose target is met, as recommended by the 2017 American Diabetes Association standards of medical care in diabetes 1.

Key Considerations for Insulin Dosage

• The dosage should be individualized based on a person's specific needs, medical history, and blood glucose levels.
• For type 2 diabetes, basal insulin can be started at 10 units daily or 0.1-0.2 units per kilogram, with mealtime insulin added as needed to achieve HbA1c goals.
• The recommended starting dose of mealtime insulin is 4 U per meal, 0.1 U/kg per meal, or 10% of the basal insulin dose per meal if the HbA1c level is less than 8% 1.
• Premixed insulin products containing both basal and bolus insulin can be used for simpler dosing, but require a relatively fixed meal schedule and carbohydrate content per meal.
• Concentrated insulin preparations, such as U-500 regular insulin, are available for patients requiring high doses of insulin.

Important Factors to Consider

• Cost considerations are important when selecting an insulin product, particularly due to substantial price increases over the past decade.
• Newer insulin products may cause less hypoglycemia, but intermediate-acting insulin (neutral protamine Hagedorn [NPH]) may be a more affordable option for some patients.
• Regular blood glucose monitoring is necessary to adjust insulin dosage and prevent hypoglycemia.
• Patients should be educated on self-titration algorithms based on self-monitoring to improve glucose control.
• Hypoglycemia is a serious risk, and patients should always have fast-acting carbohydrates available.

From the FDA Drug Label

1. 2 General Dosing Instructions Administer Insulin Glargine subcutaneously once daily at any time of day but at the same time every day. Individualize and adjust the dosage of Insulin Glargine based on the patient's metabolic needs, blood glucose monitoring results and glycemic control goal.

2. 3 Initiation of Insulin Glargine Therapy Recommended Starting Dosage in Patients with Type 1 Diabetes The recommended starting dosage of Insulin Glargine in patients with type 1 diabetes is approximately one-third of the total daily insulin requirements. 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 insulin dosage should be individualized and adjusted based on the patient's metabolic needs, blood glucose monitoring results, and glycemic control goal.

• For patients with type 1 diabetes, the recommended starting dosage is approximately one-third of the total daily insulin requirements.
• For patients with type 2 diabetes who are not currently treated with insulin, the recommended starting dosage is 0.2 units/kg or up to 10 units once daily 2.

From the Research

Insulin Dosage

• Insulin therapy is recommended for patients with type 2 diabetes mellitus and an initial A1C level greater than 9 percent, or if diabetes is uncontrolled despite optimal oral glycemic therapy 3.
• Insulin therapy may be initiated as augmentation, starting at 0.3 unit per kg, or as replacement, starting at 0.6 to 1.0 unit per kg 3.
• When using replacement therapy, 50 percent of the total daily insulin dose is given as basal, and 50 percent as bolus, divided up before breakfast, lunch, and dinner 3.
• The dose of insulin glargine can be titrated according to fasting blood glucose levels, with a target of <5.5 mmol/L (<100 mg/dL) to achieve glycosylated hemoglobin (HbA1c) <7% 4.
• A simple titration regimen for insulin glargine, where the daily dose is increased by 0-2,4, or 6-8 IU based on mean fasting plasma glucose levels, can help patients reach HbA1c <7% without nocturnal hypoglycemia 4.

Types of Insulin

• Premixed insulin analogues, such as biphasic insulin aspart, can provide improved postprandial glucose control compared to conventional insulins 5.
• Ultrafast-acting insulins, such as faster-acting insulin aspart, can reduce postprandial hyperglycemia and improve flexibility in insulin dosing 6.
• Biosimilar insulins, such as LY2963016 and MK-1293, have comparable efficacy and safety to original insulins at a lower price, making them available for more people with diabetes 6.

Titration Algorithms

• Patient-managed dose titration of insulin glargine can result in greater reductions in HbA1c compared to clinic-managed titration 4.
• Clinic-managed titration can result in fewer patients experiencing hypoglycemia compared to patient-managed titration 4.
• The choice of titration algorithm may depend on clinical circumstance and a patient's willingness and ability to become more involved in management of therapy 4.