What is the appropriate dosing regimen for insulin in a patient with diabetes (Diabetes Mellitus)?

From the Guidelines

Insulin dosing in diabetic patients should start with 10 units, or 0.1 to 0.2 units/kg of body weight, of basal insulin per day, with adjustments made by 10% to 15%, or 2 to 4 units, once or twice weekly until the fasting blood glucose target is met. When initiating insulin therapy, a safe and simple approach is to prescribe basal insulin and advise to increase the dose as needed 1. Insulin is typically used with metformin and sometimes 1 additional noninsulin agent.

Key Considerations

• Cost considerations are important when an insulin product is selected, particularly because of substantial price increases over the past decade 1.
• Newer products cause less hypoglycemia, but intermediate-acting insulin (neutral protamine Hagedorn [NPH]) may be a more affordable option for some patients 1.
• Advancing insulin therapy for patients not achieving HbA1c goals on optimally titrated basal insulin alone often requires premeal insulin dosing, with rapid-acting insulin analogues preferred due to their quick onset of action 1.

Dosing Adjustments

• 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.
• Providers should consider decreasing the basal insulin dose by the same amount of the starting mealtime dose 1.

Alternative Options

• Premixed insulin products containing both basal and bolus insulin are another option for patients who may benefit from simpler dosing 1.
• Concentrated insulin preparations, such as U-500 formulation of regular insulin, are available for patients requiring more than 200 units of insulin per day 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION LEVEMIR can be administered once- or twice-daily. The dose of LEVEMIR should be adjusted according to blood glucose measurements. The dosage of LEVEMIR should be individualized based on the physician’s advice, in accordance with the needs of the patient. For patients with type 1 or type 2 diabetes on basal-bolus treatment, changing the basal insulin to LEVEMIR can be done on a unit-to-unit basis. The dose of LEVEMIR should then be adjusted to achieve glycemic targets For insulin-naïve patients with type 2 diabetes who are inadequately controlled on oral antidiabetic drugs, LEVEMIR should be started at a dose of 0.1 to 0. 2 U/kg once-daily in the evening or 10 units once- or twice-daily, and the dose adjusted to achieve glycemic targets.

The dose of insulin in diabetic patients should be individualized based on the physician's advice and the patient's needs.

• For patients with type 1 or type 2 diabetes on basal-bolus treatment, the dose of LEVEMIR can be changed on a unit-to-unit basis.
• For insulin-naïve patients with type 2 diabetes, the initial dose of LEVEMIR should be 0.1 to 0.2 U/kg once-daily in the evening or 10 units once- or twice-daily. The dose should be adjusted to achieve glycemic targets 2.

From the Research

Insulin Dosing in Diabetic Patients

To determine the appropriate insulin dosing for diabetic patients, several factors must be considered, including the type of diabetes, the patient's weight, and their individual insulin needs.

• The total basal dose (TBD) can be estimated using the formulas TBD = 0.2 x weight (kg) or TBD = 0.33 x total daily dose (TDD) 3.
• The insulin-to-carbohydrate ratio (ICR) and correction factor (CF) can also be estimated using the formula 90/TBD = ICR = CF/4.5 3.
• For patients with type 2 diabetes, continuous glucose monitoring (CGM) can be used to inform insulin titration decisions, with a goal of achieving a glucose level between 70 and 180 mg/dL 4, 5.
• CGM can provide a more accurate picture of a patient's glucose levels and can help identify patterns and trends that may not be apparent with traditional blood glucose monitoring 4, 5, 6.
• Self-monitoring of blood glucose (SMBG) can also be an effective way to manage diabetes, particularly when used in conjunction with structured therapy adjustment 7.

Key Considerations

• The type and severity of diabetes, as well as the patient's individual needs and circumstances, should be taken into account when determining insulin dosing.
• Regular monitoring of glucose levels, either through CGM or SMBG, can help inform insulin titration decisions and improve glycemic control.
• A structured approach to insulin therapy, including regular adjustments based on glucose monitoring data, can help improve outcomes for patients with diabetes 3, 4, 5, 7.