From the Guidelines
Rapid-acting insulin doses should be initiated at 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%. When adjusting rapid-acting insulin doses, consider the patient's pre-meal blood glucose levels, carbohydrate intake, and anticipated physical activity 1. The recommended approach is to start with a baseline insulin-to-carbohydrate ratio and a correction factor, and then adjust doses based on individual needs. For example, if the patient's pre-meal glucose is elevated, the dose can be increased accordingly. It is also important to consider decreasing the basal insulin dose by the same amount as the starting mealtime dose to avoid hypoglycemia.
Key Considerations
- Start with a low dose and titrate upward to minimize the risk of hypoglycemia
- Consider using premixed insulin products or concentrated insulin preparations for patients who require simpler dosing or higher doses of insulin
- Keep detailed records of glucose readings, carbohydrate intake, insulin doses, and physical activity to identify patterns requiring adjustment
- Always consult with a healthcare provider before making significant changes to the insulin regimen, as individual needs vary considerably
Adjusting Doses
- Adjust doses downward by 25-50% before exercise and upward during illness or stress
- Consider using a correction factor to adjust doses based on pre-meal blood glucose levels
- Use a basal insulin dose that is evidence-based, such as starting with 10 units per day or 0.1-0.2 units/kg per day, and titrate accordingly 2
Monitoring and Follow-up
- Assess adequacy of insulin dose at every visit
- Consider clinical signals to evaluate for overbasalization and need to consider adjunctive therapies
- Monitor for hypoglycemia and adjust doses accordingly to minimize the risk of hypoglycemia 1, 2
From the Research
Guidelines for Fixing Rapid Acting Insulin Doses
- The American Diabetes Association (ADA) recommends individualizing the treatment approach to glucose control, considering factors such as age, health behaviors, comorbidities, and life expectancy 3.
- When glycosylated hemoglobin (HbA1c) levels remain unmet with maximum doses as recommended by the ADA after adding basal insulin, but fasting blood glucose is at goal, one to three injections daily of rapid-acting insulin are typically added to the treatment plan to be injected prior to meals while continuing all other antihyperglycemic medications 4.
- Intensifying insulin therapy by adding one dose of rapid-acting insulin prior to meals can improve HbA1c to < 7% in patients on maximum doses of basal insulin whose fasting blood glucose is at goal but whose HbA1c is above goal 4.
- Several validated treatment algorithms, such as the FullSTEP, SimpleSTEP, ExtraSTEP, and AUTONOMY algorithms, can be helpful for providing guidance on initiation of rapid-acting insulin while simultaneously considering patient preferences and clinical needs during treatment intensification 3.
- Clinical inertia should be prevented with timely intensification of therapy when HbA1c levels are greater than 7% (or rising above a patient's individual target) according to national guidelines 3.
- Increased personalization in the intensification of type 2 diabetes treatment is necessary to improve HbA1c targets while addressing risk of hypoglycemia, concern about weight gain, and overall health goals 3.
- Healthcare providers are encouraged to address glycemic control with a variety of strategies, including prandial insulin, while developing evidence-based treatment plans on the basis of algorithms discussed in the literature 3.
- New technologies, such as computer algorithms, can be used to analyze a person's blood glucose response to insulin treatment, calculate the person's next recommended insulin dose, and provide alerts regarding glucose control 5.