What is the appropriate dose and type (regular vs. basal) of insulin for a patient with uncontrolled diabetes and an HbA1c (Hemoglobin A1c) level of 8%?

From the Guidelines

For a patient with uncontrolled diabetes and an HbA1c of 8, initiation of insulin therapy is recommended.

Insulin Regimens

A suitable starting regimen may include:

• Basal insulin, such as glargine (Lantus) or detemir (Levemir), at a dose of 10 units once daily 1
• Premixed insulin, such as aspart (NovoLog) or lispro (Humalog), at a dose of 6-8 units before breakfast and dinner 1
• Regular insulin, such as human insulin (Humulin R), at a dose of 4-6 units before meals and 6-8 units at bedtime 1 The choice of insulin and dose should be individualized based on the patient's specific needs and clinical profile.

Dose Titration

Dose titration is important, with adjustments made based on blood glucose levels and the pharmacodynamic profile of each formulation 1.

Treatment Intensification

Further options for treatment intensification include adding a single injection of rapid-acting insulin analogue before the largest meal, adding a GLP-1–receptor agonist, or stopping basal insulin and starting twice-daily premixed insulin 1.

Considerations

Providers should consider regimen flexibility, cost, and potential side effects when devising a plan for the initiation and adjustment of insulin therapy for patients with type 2 diabetes 1.

From the FDA Drug Label

Insulin Lispro was administered by subcutaneous injection immediately before meals and Humulin R was administered 30 to 45 minutes before meals. Humulin® N [NPH human insulin (rDNA origin) isophane suspension] or Humulin U was administered once or twice daily as the basal insulin. The reductions from baseline in HbA1c and the incidence of severe hypoglycemia (as determined by the number of events that were not self-treated) were similar between the two treatments from the combined groups End point Baseline Insulin Lispro +Basal Humulin R+Basal HbA1c (%)a8.9 ± 1.7 8.2 ± 1.3 8.2 ± 1.4 Short-acting insulin dose (units/kg/day)a0.3 ± 0.2 0.3 ± 0.2 0.3 ± 0. 2

The appropriate dose and type of insulin for a patient with uncontrolled diabetes and an HbA1c level of 8% is not explicitly stated in the provided drug label. However, based on the information provided, it can be inferred that:

• Short-acting insulin (such as Insulin Lispro) can be administered immediately before meals.
• Basal insulin (such as Humulin N or Humulin U) can be administered once or twice daily.
• The short-acting insulin dose is approximately 0.3 units/kg/day. It is essential to note that the provided information is not sufficient to determine the exact dose and type of insulin for a specific patient, and a healthcare professional should be consulted to determine the best course of treatment 2.

From the Research

Insulin Therapy for Uncontrolled Diabetes

• For patients with type 2 diabetes and an HbA1c level of 8%, the preferred method of insulin initiation is to begin by adding a long-acting (basal) insulin or once-daily premixed/co-formulation insulin or twice-daily premixed insulin, alone or in combination with other oral antidiabetic drugs (OADs) 3.
• Basal insulin is usually initiated at a conservative dose of 10 units/day or 0.1-0.2 units/kg/day, then titrated thereafter over several weeks or months, based on patients' self-measured fasting plasma glucose, to achieve an individualized target (usually 80-130 mg/dL) 4.
• If the desired glucose targets are not met, rapid-acting or short-acting (bolus or prandial) insulin can be added at mealtime to control the expected postprandial raise in glucose 3.
• The dose of basal insulin should be increased as required up to approximately 0.5-1.0 units/kg/day in some cases, but overbasalization (continuing to escalate dose without a meaningful reduction in fasting plasma glucose) is not recommended 4.

Comparison of Insulin Regimens

• A study comparing the efficacy and safety of treating patients with type 2 diabetes and highly elevated HbA1c levels with basal-bolus insulin or a glucagon-like peptide-1 receptor agonist plus basal insulin found that the latter regimen resulted in better glycemic control and body weight, lower insulin dosage and hypoglycemia, and improved quality of life 5.
• Another study found that insulin degludec/liraglutide fixed-ratio combination (IDegLira) was noninferior to basal-bolus insulin in terms of HbA1c reduction, and was associated with lower hypoglycemia rates and weight loss 6.

Titration and Switching of Basal Insulins

• Basal insulin doses must be titrated to agreed fasting plasma glucose goals, usually 80-130 mg/dL, and a simple rule is to gradually increase the initial dose by 1 unit per day (NPH, insulin detemir, and glargine 100 units/mL) or 2-4 units once or twice per week (NPH, insulin detemir, glargine 100 and 300 units/mL, and degludec) until FPG levels remain consistently within the target range 4.
• Switching between basal insulins can be done using simple regimens, but pharmacokinetic and pharmacodynamic differences between formulations require clinicians to provide explicit guidance to patients 4.