Which basal insulin stocked in [LOCATION] should be initiated, what initial dose and administration schedule are recommended, how should metformin be continued (dose and timing), and which SGLT2 inhibitor (brand and generic) and dose/schedule should be added?

Insulin Therapy Initiation and Management for Type 2 Diabetes

Basal Insulin Selection and Initial Dosing

Start with insulin glargine (Lantus) 10 units once daily at bedtime, or calculate 0.1–0.2 units/kg body weight as the initial dose. 1, 2 Long-acting basal analogs (glargine U-100, detemir, or degludec) are preferred over NPH insulin because they reduce nocturnal and overall hypoglycemia risk when titrated to the same fasting glucose target. 1, 3

• Administer at the same time each day—bedtime is traditional, though any consistent time works for glargine. 1, 2
• For elderly patients (>65 years), those with renal impairment (eGFR <60 mL/min), or poor oral intake, start conservatively at 0.1–0.25 units/kg/day to minimize hypoglycemia risk. 1
• If the patient presents with severe hyperglycemia (HbA1c ≥9%, fasting glucose ≥300 mg/dL, or symptomatic), consider starting at 0.3–0.4 units/kg/day or immediately initiating basal-bolus therapy. 1, 2

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Systematic Basal Insulin Titration Protocol

Increase the basal insulin dose by 2 units every 3 days if fasting glucose is 140–179 mg/dL, or by 4 units every 3 days if fasting glucose is ≥180 mg/dL, targeting a fasting glucose of 80–130 mg/dL. 1, 2

• Check fasting glucose daily during titration to guide dose adjustments. 1, 2
• If more than two fasting glucose values per week fall below 80 mg/dL, decrease the basal dose by 2 units. 1
• If any unexplained hypoglycemia (glucose <70 mg/dL) occurs, reduce the current dose by 10–20% immediately. 1, 2
• An alternative approach is to increase the dose by 10–15% once or twice weekly until the target is reached. 1, 2

Critical threshold: Stop escalating basal insulin when the dose approaches 0.5–1.0 units/kg/day without achieving glycemic targets; at this point, add prandial insulin or a GLP-1 receptor agonist instead. 1, 2 Clinical signs of "overbasalization" include basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia episodes, and high glucose variability. 1, 2

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Metformin Integration: Dosage and Timing

Continue metformin at the maximum tolerated dose (up to 2,000–2,550 mg daily, typically 1,000 mg twice daily with meals) when initiating or intensifying insulin therapy. 1, 2

• Metformin reduces total insulin requirements by 20–30% and provides superior glycemic control compared to insulin alone. 1, 2
• Never discontinue metformin when starting insulin unless specific contraindications exist (e.g., acute infection with tissue hypoxia, renal impairment with eGFR <30 mL/min, or contrast administration). 1
• Metformin should be taken with meals to minimize gastrointestinal side effects. 1

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SGLT2 Inhibitor Selection: Brand, Dosage, and Schedule

For patients with established cardiovascular disease, heart failure, or chronic kidney disease, add empagliflozin 10 mg once daily in the morning (can increase to 25 mg if needed) or canagliflozin 100 mg once daily before breakfast (can increase to 300 mg). 1, 4, 5

• SGLT2 inhibitors provide cardio-renal protection and lower HbA1c by 0.5–0.7% when added to metformin and insulin. 1, 4, 5
• Empagliflozin 25 mg is particularly effective for HbA1c reduction. 5
• Administer in the morning to minimize nocturnal polyuria. 4
• Monitor for genital mycotic infections, volume depletion, and rare euglycemic diabetic ketoacidosis (especially if insulin dose is reduced too aggressively or during illness). 4
• The combination of metformin and SGLT2 inhibitors carries a theoretical increased risk of metabolic acidosis, though this remains rare; monitor for symptoms of lactic acidosis (nausea, vomiting, abdominal pain, hyperventilation). 4

Alternative SGLT2 inhibitors: Dapagliflozin 5–10 mg once daily is also effective, though empagliflozin and canagliflozin have stronger cardiovascular outcome data. 1, 5

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When to Add Prandial Insulin

Add prandial insulin when basal insulin has been optimized (fasting glucose 80–130 mg/dL) but HbA1c remains above target after 3–6 months, or when basal insulin dose approaches 0.5–1.0 units/kg/day without achieving HbA1c goals. 1, 2

• Start with 4 units of rapid-acting insulin (lispro, aspart, or glulisine) before the largest meal, or use 10% of the current basal dose. 1, 2
• Administer prandial insulin 0–15 minutes before meals for optimal postprandial control. 1
• Titrate each meal dose by 1–2 units (≈10–15%) every 3 days based on 2-hour postprandial glucose, targeting <180 mg/dL. 1, 2

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Alternative to Prandial Insulin: GLP-1 Receptor Agonist

When basal insulin exceeds 0.5 units/kg/day without reaching targets, consider adding a GLP-1 receptor agonist (e.g., semaglutide 0.25 mg weekly, titrated to 0.5–1.0 mg weekly) instead of prandial insulin. 1, 2

• This combination provides comparable postprandial control with less hypoglycemia and weight loss rather than weight gain. 1, 2
• GLP-1 receptor agonists should be evaluated in all eligible patients before starting prandial insulin. 3
• Transient nausea occurs in ≈21–22% of patients; start at the lowest dose and titrate gradually. 1

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Essential Patient Education and Monitoring

Provide comprehensive education on:

• Blood glucose self-monitoring techniques (check fasting glucose daily during titration). 1, 2
• Hypoglycemia recognition (symptoms: shakiness, sweating, confusion) and treatment (15 g fast-acting carbohydrate, recheck in 15 minutes). 1, 2
• Proper insulin injection technique and site rotation to prevent lipohypertrophy. 1, 2
• "Sick day" management: continue insulin even if not eating, check glucose every 4 hours, maintain hydration. 1, 2
• Insulin storage and handling. 1, 2

Monitoring schedule:

• Daily fasting glucose during titration. 1, 2
• HbA1c every 3 months during intensive titration. 1, 2
• Assess insulin dose adequacy at every clinical visit. 1, 2

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Common Pitfalls to Avoid

• Do not delay insulin initiation in patients failing to achieve glycemic goals on oral medications; prolonged hyperglycemia increases complication risk. 1, 2
• Never use insulin as a threat or describe it as punishment; explain the progressive nature of type 2 diabetes objectively. 1, 2
• Do not continue escalating basal insulin beyond 0.5–1.0 units/kg/day without addressing postprandial hyperglycemia; this leads to overbasalization with increased hypoglycemia risk and suboptimal control. 1, 2
• Never discontinue metformin when starting insulin unless contraindicated; omission increases insulin requirements and worsens outcomes. 1, 2
• Avoid relying solely on correction (sliding-scale) insulin without scheduled basal doses; this reactive strategy is condemned by major diabetes guidelines. 1

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Expected Clinical Outcomes

• Basal insulin optimization alone can produce an HbA1c reduction of 1.5–2.0%. 1
• Adding prandial insulin or a GLP-1 receptor agonist can yield an additional 2–3% HbA1c reduction. 1
• Approximately 68% of patients achieve mean glucose <140 mg/dL with properly implemented basal-bolus therapy, versus 38% with inadequate dosing. 1
• Properly executed regimens do not increase hypoglycemia risk relative to under-dosed insulin. 1