Can a 90 kg patient with diabetes start insulin aspart (Fiasp) and continue basal insulin, metformin, and empagliflozin, and other current medications?

Can You Start Fiasp and Basalog Tomorrow While Continuing Reclimet?

Direct Answer

Yes, you can start Fiasp (insulin aspart) and Basalog (insulin glargine) tomorrow while continuing Reclimet (metformin + empagliflozin), as this combination addresses multiple pathophysiologic defects in type 2 diabetes and metformin should be maintained when initiating insulin therapy. 1

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Foundation Therapy: Continue Reclimet

Metformin must be continued when starting insulin therapy unless contraindicated. 1, 2 The combination of metformin with insulin provides:

• Superior glycemic control with reduced insulin requirements 2
• Less weight gain compared to insulin alone 2
• Complementary glucose-lowering effects 3

The empagliflozin component in Reclimet provides additional benefits when combined with insulin and metformin, addressing multiple pathways without increasing hypoglycemia risk. 3, 4, 5

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Starting Basalog (Basal Insulin)

Initial Dosing

For a 90 kg patient, start with one of these approaches:

• 10 units once daily at the same time each day, OR 1, 2
• 0.1-0.2 units/kg/day (9-18 units for your weight) 1, 2

Administer at bedtime or the same time daily for consistency. 2

Titration Schedule

• Increase by 2 units every 3 days if fasting glucose is 140-179 mg/dL 1, 2
• Increase by 4 units every 3 days if fasting glucose is ≥180 mg/dL 1, 2
• Target fasting glucose: 80-130 mg/dL 1, 2
• If hypoglycemia occurs, reduce dose by 10-20% immediately 1, 2

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Starting Fiasp (Prandial Insulin)

Initial Dosing

Start with 4 units before the largest meal OR 10% of your basal dose (approximately 1-2 units initially). 1

Timing

Administer Fiasp 0-15 minutes before meals for optimal postprandial glucose control. 6, 7 Fiasp has a faster onset of action than regular insulin aspart, reaching peak concentrations in 40-50 minutes versus 80-120 minutes. 6

Titration

• Increase prandial dose by 1-2 units every 3 days based on 2-hour postprandial glucose readings 1, 2
• Target postprandial glucose: <180 mg/dL 2

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Critical Threshold to Monitor

When your basal insulin (Basalog) exceeds 0.5 units/kg/day (45 units for your weight) and approaches 1.0 units/kg/day (90 units), adding or intensifying prandial insulin becomes more appropriate than continuing to escalate basal insulin alone. 1, 2 This prevents "overbasalization" which causes:

• Increased hypoglycemia risk 2
• High glucose variability 2
• Bedtime-to-morning glucose differential ≥50 mg/dL 2

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Monitoring Requirements

Daily Monitoring During Titration

• Check fasting blood glucose every morning 1, 2
• Check pre-meal glucose before administering Fiasp 2
• Check 2-hour postprandial glucose to guide Fiasp adjustments 2

Reassessment Schedule

• Adjust doses every 3 days during active titration 1, 2
• Reassess overall control every 3-6 months once stable 2

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Common Pitfalls to Avoid

Do NOT:

• Discontinue metformin when starting insulin—this leads to higher insulin requirements and more weight gain 1, 2
• Delay insulin initiation—prolonged hyperglycemia increases complication risk 2
• Continue escalating Basalog beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia with Fiasp 1, 2
• Give Fiasp at bedtime—this significantly increases nocturnal hypoglycemia risk 1, 2

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Hypoglycemia Management

Treat any glucose <70 mg/dL immediately with 15 grams of fast-acting carbohydrate (glucose tablets, juice, regular soda). 2 Recheck in 15 minutes and repeat if needed. 2 Always carry a source of fast-acting carbohydrates. 2

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Expected Outcomes

With proper basal-bolus therapy at weight-based dosing combined with metformin and empagliflozin:

• HbA1c reduction of 2-3% is achievable 2
• Better postprandial glucose control with Fiasp versus regular insulin aspart 7
• No increased hypoglycemia risk when properly implemented 2
• Weight reduction from empagliflozin component (2.8-3.8 kg) 5